Management of the pt with LE amputation Flashcards
Diabetes
There is a 15 x greater rate of amputation in pts with DM than those without
Leading cause of amputation
Impaired vascular system
Pre-operative care issues
Determine pt level of activity Identify the pt support system Identify the support medical team and the roles each - SOCIAL WORKER IS CRITICAL Pt expectations Explain sequence of events Identify realistic expectations Answer questions Listen to the pt Determine functional level Determine impairments Practice transfer skills! CRITICAL Begin proper bed positioning
Goals of pre prosthetic phase
Dec edema Promote healing Inc strength Promote mobility and self care! CRITICAL Promote sound limb care Assist with adjustment to limb loss
Medical info
Vitals
Condition of other limb
Lab results
Medications (narcotics)
Things that can be done with dressing on
Examine uninvolved extremity - general condition, sensation, ROM, strength
Balance (make sure to look at sitting B)
ADL
Condition of dressing
Pain
Things that can be done with dressing removed
Pain Condition of surgical site Residual limb shape and size ROM/flexibility Balance Strength Sensation
Things that can be done with dressing removed - residual limb shape and size
two lengths (using non movable landmarks)
- Ischial tub to soft tissue end
- Ischial tub to bony end of TF amputation
SHOULD BE A DIFFERENCE
TT - tibial tubercle to soft tissue and bony ends too – Bony end will be tibia! (fibular should be shorter)
Phantom pain, phantom sensation, residual limb pain - how many experience these
85% of all pts with amputations
Difficult to predetermine which pt is likely to experience which type of pain
Phantom sensation
Non painful sensation that gives form and substance to areas distal to the level of amputation
Can be a safety issue
3 categories - kinesthetic, kinetic, exteroreceptive
Phantom sensation - categories
Kinesthetic - posture, length, volume
Kinetic - movements
Exteroreceptive - temp, pressure, touch
Residual limb pain
Within the residual limb
Specific anatomic structures can usually be identified as source (neuroma is common)
10% continue to report residual pain 2 years after surgery
57% within 8 days post surgery
Residual limb pain - how does a neuroma cause it
Tension on nerves and BVs when they make the flap - nerve can retract and cause a neuroma which can be the source of their pain - it is getting weird signals from pain fibers
Phantom pain
Painful sensation experienced below the level of amputation
Etiology is unknown
Phantom sensation - table
Touch Pressure Cold Itching Phantom movement Crawling
Phantom pain - table
Dull aching Burning Stabbing knife-like Leg being pulled off Pre-operative pain Electric shock Unnatural position
Residual limb pain - table
Neuroma Referred Abnormal tissue Joint pain Soft tissue pain Bone pain
Treatment of phantom pain
Sensory stimulation, overload (pounding with wooden mallet, rub with towel) Surgery (ok short) Spinal cord stimulation (ok short) TENS Vibration Mirror therapy Psych counseling Analgesics
Strength
12 to 16 wks before getting prosthesis so early strengthening is important
When we see them will likely already be deconditioned
Need UE and LE strengthening program
Dynamic, Functional, Isometirc/Isotonic, Manual Resistane
Positioning - Transtibial
AVOID knee flex, hip abd, hip flex, hip ER
Positioning - Transfemoral
AVOID hip abd, flex, ER
Skin condition and sensory system
Education - sensory loss, care of sound limb, care of residual limb
Activities to desensitize limb
Scar mobilization
Balance
Pt has lost up 10% of weight - balance will be impacted!!!
Functional progressive exercise
Developmental sequence
Equipment
Ambulation devices
Bathroom equipment
WC - anti-tips, wheels more post, stump board for residual limb
Post op day 1
Bed mobility Positioning PROM/AROM to uninvolved joints Glut sets Sound side exercises Breathing exercises
Post op day 2
Transfer training Sitting endurance AROM to uninvolved joints Glut sets, quad sets Sound side exercises Resp as needed
Post op day 3
Ambulation
Sitting endurance
Continue AROM, isometrics, exercises
Dressing education
Post op day 4
Ambulation with discharge device
Education regarding contracture prevention and protection of limbs
Continue other parts of program
Post op day 5
Continue program
HEP given
Discharge
Post op day 10-14
Rigid dressing changed
Dynamic strengthening exercises (avoid knee F/E TTA, avoid hip abd/add TFA)
Limited stretching (PROM) of involved side
Review and adjust HEP
Pt ed as needed
Staples are removed when
Week 3
21 days for vascular
14 days for traumatic
Week 6 to 8
Cast for temporary prosthesis, AKA diagnostic socket
Week 10-12
Ready for prosthetic gait training
K0
Will not ambulate
K1
Transfer
K2
limited community ambulator
single speed
K3
typical community ambulator
variable speed
K4
child, active adult/athlete
SACH
Solid ankle cushion heel
Match amount of heel cushion to pt weight
If heel too soft - will get foot slap
Probably need a new socket - at what plie
12
TES
Total elastic suspension
Goes around the waist
Carbon foot =
dynamic response
Thigh lacer - often used when
Skin breakdown from pressure - thigh lace can help take weight off of the residual limb
Knee disarticulation adv
End WB
Can do hands and knees stuff
All thigh muscles still intact
Knee disarticulation disadv
Long thigh to deal with
Cosmetic - when sit, knee will always protrude out longer - Can use polycentric knee with manual unlocking mechanism to prevent this
