P&O Lower Extremity Flashcards
1/3 of LE amputations were of teh ___
toe
Top four causes of LE amputation
- PVD/infection 70%
- Trauma 22%
- tumor 5%
- Congenital deformity 3%
Most common locations of LE amputation (top 2)
- transtibial 59%
2. Transfemoral 35%
What is a normal ABI?
PAD ABI?
Normal 0.91 - 1.30
Mild PAD 0.71 - 0.90
Moderate PAD 0.41 - 0.70
Severe PAD 0.00 to 0.40
ABI > 1.30 may suggest _____
calcified, noncompressible vessels which can produce falst negative results
- common in DM
what is the gold standard imaging test for PAD?
interarterial contrast angiography
Describe the difference between myodesis and myoplasty
myodesis - muscles and fasciae are sutured directly to bone through drill holes. Residual limb is more structurally sound. Contraindicated in severe dysvascularity in which the blood supply to the bone may be compromised
myoplasty - opposing muscles are sutured to each other and to the periosteum at the end of the cut bone with minimal tension. Generally takes less operating time. May be the procedure of choice in severe dysvascular residual limbs.
What is a symes ampuation
ankle disarticulation with attachment of heel pad to the distal end of tibia and may include the removal of malleoli and distal tibial/fibular flares
standard BKA is ____% of tibial length
20-50%
If amputation line is within _____ below tibial tubercle, might as well do a disartic
1cm
standard transfemoral AK is ____% of femur length
35-60%
Short BK are at risk for ____
knee flexion contractures. If above 1cm below tibial tubercle, might as well do knee disartic.
Very high AKAs are at risk for ____
flexion and abduction contractures at the hip joint
____- amputation is through the transmetatarsal junction
lisfranc
____ is an amputation at the midtarsal line. Only talus and calcaneus remain
chopart
_____ is a resection of a portion of up to three metatarsals and digitis
partial foot/ray resection
_____ is an amputation of both lower limbs and pelvis below L4/5 level
hemicorporectomy
Transmetatarsal amputations are important because they preserve:
the attachment of the dorsiflexors and plantar flexors and their function.
_____ amputaiton is a vertical calcaneal amputation
pirogoff
___ amputation is a horizontal calcaneal amputation
boyd
In both lisfranc and chopart amputations, the remaining foot often ____
develops significant equinovarus deformity resulting in excess anterior weight bearing with breakdown.
adequate dorsiflexor tendon reattachment with achilles tendon lengthening has been advocated to prevent this deformity.
4 “pros” of symes amputation
- maintains limb length
- there is preservations of the heel pad, providing excellent weight bearing residual limb
- early fitting of prosthesis is possible with excellent results
- partial weight bearing of the residual limb is possible almost immediately after the procedure with a proper rigid casting (approx within 24H)
Healing rate for dysvascular BK is ____%
80-90%
In a BKA, fibula should be cut _____ and the tibia should be _____
2-3cm shorter than the tibia
beveled anteriorly
4 advantages of a knee disartic
- less traumatic to tissue
- blood loss is minimal
- a long strong residual limb with excellent end-bearing quality is produced
- prosthetic suspension is facilitated by the bulbous contour of the residual limb end.
Hip flexion contractures are common with AK’s. Paticularly with _____limbs. ____ degrees of hip flexion can be accomodated in the socket
shorter limbs
20 degrees.
During transfermoral amputation use of myodesis of _______ helps to maintain adduction position of the femur in the prosthetic socket
adductor muscles
Ideal shape for TT residual limb is _____ and TF residual limb is ____
cylindrical
conical
in residual limbs, a chronically draining sinus may be the result of (3)
- superficial abscess
- bone spur
- localized osteo
A postoperative plaster or fiberglass rigid dressing does what? 3
- prevents edema - occurs within a few minutes
- protects from trauma
- decreases post-op pain
a rigid removable dressing for TT amputee consists of a plaster or fiberglass cast suspended by ______ and _____. Adjusted by ______. Provides good edema control with advantage of ____.
stocking & supracondylar cuff
adding or removing socks to maintain compression.
allowing daily inspection
When using elastic bandages in figure-8 pattern, ____ should be used for TT limb, and _____ for TF limb
double length 4-inch bandages
double length 6-inch bandages
May use shrinker socks after _____
staple/suture removal
In the K0 non-prosthesis candidate ____ may help edema and pain with facilitated healing
shrinkage device
Amputees should prone ____ to prevent hip flexion contractures
15 minutes TID
an amputee who cannot lie prone should lie supine and actively extend the residual limb while flexing the contralateral limb.
_______ with or without a prosthesis promotes good ROM and when feasible, is preferred over wheelchair mobility.
crutch walking
appropriate cleaning of residual limb?
daily with bland soap and warm water, pat completely dry before application of shrinker.
Gentle massage to residual limb decreases _____
Deep friction massage perpendicular to the scar prevents ____
sensitivity to pressure
prevents scar adhesions
What are the K levels for amputees
K0 - nonambulatory (bedbound)
K1 - limited to transfers or limited household ambulator
K2 - Unlimited household but limited community ambulator
K3 - Unlimited community ambulator
K4 - High energy activities (sports, work)
Name the prosthesis/components allowed for the different K levels
K0 - no prosthesis allowed
K1 - Manual lock or stance-control knee, SACH or single-axis foot
K2 - Pneumatic or polycenctric knee, multi-axis foot
K3/4 - hydralic knee, energy-storing foot
Name the 3 prosthetic feet available for Syme’s amputation
- syme solid ankle cushion heel (SACH)
- Syme stationary ankle flexible endoskeleton (SAFE)
- Energy-storing carbon fiber foot (low profile)
Components of a BKA prosthesis usually include what 4 things?
socket
suspension
shank
prosthetic foot
the standard socket for BKA is
total-contact patellar tendon bearing (PTB) socket
characterized by bar in the anterior wall designed to apply pressure on the patellar tendon
Trim line of PTB
Anteriorly:
medially/laterally
Posteriorly
extends anteriorly to mid-patellar level
may extend medially and laterally to femoral condyles,
extends posteriorly to the level of the PTB bar
In BKA
Name the pressure tolerant areas in PTB socket (5)
Name the pressure relief areas in PTB socket (5)
- Patella ligament
- pretibial muscles (anterior compartment)
- popliteal fossa (posterior compartment; gastroc-soleus muscles via gastroc depression)
- Medial tibial flare
- Lateral shaft of fibula
- Tibial crest, tubercle, and condyles
- Patella
- Anterior tibial tubercle
- Crest of tibia
- Distal end of tibia
- Head of fibula and peroneal nerve
- distal end of fibula
- Hamstring tendons
A PTB socket is arranged on the shank in 5 degrees of flexion. What advantages? 4
- enhance loading of the patellar ligament
- prevent genu recurvatum
- resist tendency of the residual limb to slide down the socket
- place quads in more efficient and mechanically advantageous position, facilitating its contraction
a maximum of _____ degrees of flexion is possible to accommodate knee flexion contracture in PTB socket
25 degrees
purpose of the liner (4)
- protect fragile or insensate skin
- reduce shear forces
- provide more comfortable socket for tender residual limbs
- accommodate for growth
Lateral tilt of the socket alignment is needed for:
reduce pressure on the fibularhead
liners can be made of (3)
Customs are better for ____
- closed-cell thermal plastic foams
- rubber covered with leather
- silicone gels
custom gels without suspension pin have been helpful in managing shear problems that can occur with residual limbs covered in split thickness skin grafts or boney prominences
Name the most freqently used suspension systems for BKA (6)
- Supracondylar cuff suspension socket - consists of a cuff or strap that wraps circumferentially around the thigh, fitted immediately above the femoral epicondyles
- Brim suspension - supracondylar vs supacondylar/suprapatellar which add proximal brim usually for short residual limbs or controlling recurvatum (patellar)
- Rubber or neoprene sleeve
- Pin suspension - used for patients with greater suspension demands such as athletes and short RL. expensive bc usually requires replacement annually
- Suction suspension - silicone or other gel insert or liner with use of one-way expulsion valve in distal aspectof the socket.
- Thigh corset - connects a leather thigh corset to PTB through metal joints and side bars to decrease distal residual limb weight bearing by 40-60%
For what three reasons is neoprene sleeve suspension inadequate for BKA
- decreased mediolateral knee stability
- Very short residual limbs
- when hyperextension control is required.
Name the 5 types of prosthetic feet
- SACH (solid ankle cushion heel)
- Single-axis foot - PF/DF axis
- multi-axis foot
- Flexible keel foot
- Energy storing/dynamic response foot
Most common locations of boney overgrowth in peds with acquired amputation
- humerus
- fibula
- tibia
4 femur
5 indications for cane
improve balance decrease pain reduce weight-bearing forces on injured structures compensate for weak muscles scan the immediate environment
Name the two types of wrist units
friction control
locking
name the two types of wrist flexion units
add on
combination
failure of total contact of residual limb in the distal socket wall may lead to:
distal residual limb choking syndrome. If untreated for a long period may then lead to verrucous hyperplasia which is wartlike skin overgrowth, usually of the residual distal limb, resulting from inadequate socket wall contact with subsequent edema formation
in TF AKA, what occurs if a balanced myodesis is not achieved?
the femur may extrude through the muscle and present subcutaneously. If prosthetic adjustments, such as a flexible socket, are inadequate for extruded femur, then surgical intervention might be needed.
Phantom pain appears to be related to neuron _____
deafferentiation hyperexcitability.
In a symes amputation, gait speed is typically decreased by _____% and oxygen consumption increased _____%
32
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