PTA Acute Care - Amputation Flashcards
Name three causes of Amputation
Peripheral Vascular Disease - #1
Osteogenic Sarcoma
Trauma
Name the Levels of Amputation
- Partial Toe
- Toe Disarticulation
- Partial Foot / Ray Resection
- Transmetatarsal
- Syme’s (ankle, keep calcaneus)
- BKA long transtibial
- BKA transtibial
- BKA short transtibial
- Knee Distarticulation
- AKA long transfemoral
- AKA transfemoral
- AKA short transfemoral
- Hip Disarticulation
- Hemipelvectomy
- Hemicorporectomy
Describe surgical procedures relating to amputation
- Skin Flap
- Stabilization of major muscles
- Formation of a neuroma
- Hemostasis
- Sharp bone smoothed
- With trauma have to work with what is preserved
- Avoid infection
- Vascular amputations are elective
what is Partial Toe amputation?
excision of any part of one or more toes
what is toe disarticulation?
separation of the toe at the metatarsal phalageal joint (MTP)
what is partial foot/ray resection?
removal of the 3rd, 4th, and 5th metatarsals and toes
what is a Syme amputation?
- Ankle disarticulation with attachment of heel pad to distal end of tibia; may include removal of malleoli and distal tibial/fibular flares
- removes the dysfunctional part of the foot while saving the heel pad – that unique, resilient tissue at the bottom of the foot that acts as a shock absorber while we’re walking
What are the differences between transtibial, long transtibial and short transtibial amputation?
how much of the tibial length is preserved:
transtibial - preserves between 20% and 50%
long transtibial - preserves more than 50%
short transtibial - preserves less than 20%
(25%, 50% and 75%)
What is a knee disarticulation amputation?
- removal of LLE below femur/patella
- Knee disarticulation which leaves the femur and patella untoched offers many advantages. The surgical technique is simple and non-traumatic since no bone or muscle tissue is to be dissected. The thigh muscles are completely preserved and thus there is no muscular imbalance. The stump permits total end bearing and its bulbous shape permits easy and firm attachment of the prosthesis.
What are the differences between transfemoral, long transfemoral and short transfemoral amputations?
how much of the femoral length is preserved:
transfemoral - preserves between 35% and 60%
long transfemoral - preserves more than 60%
short transfemoral - preserves less than 35%
(25%, 50% and 75%)
What is a hip disarticulation?
- the surgical removal of the entire lower limb at the hip level
- pelvis remains intact, femur is removed
What is a hemipelvectomy?
- transpelvic amputation
- removal of entire LE and resection of lower half of the pelvis
- occurs in a skeletal zone that can include, from the socket on the outside to the spinal column in the middle, the acetabulum, ischium, rami, ilium and sacrum
What is a hemicorporectomy?
- translumbar amputation
- corporal transection
- hemisomato-tmesis
- “halfectomy”
- radical surgery in which the body below the waist is amputated, transecting the lumbar spine
- this removes the legs, the genitalia (internal and external), urinary system, pelvic bones, anus, and rectum
describe the Skin Flap procedure in amputation
• as broad as possible
• scar should be pliable, painless, non-adherent
• for most transfemoral and transtibial amputations without vascular impairment:
o equal length anterior and posterior flaps
o scar at distal end of bone
• for transtibial with vascular impairment:
o long posterior flaps
o posterior tissues have better blood supply than anterior
o scar anterior over distal end of tibia
o extra care to avoid scar adhering to bone
• skew flap:
o angular medial-lateral incision
o scar away from bony prominence
describe the Stabilization of Major Muscles in amputation
Allows for maximum retention of function • Myofascial closure – muscle to fascia • Myoplasty – muscle to muscle • Myodesis – muscle attached to periosteum or bone • Tenodesis – tendon attached to bone
describe the Formation of Neuroma in amputation
- Neuroma – collection of nerve cells
- Must be well surrounded by soft tissue so as not to cause pain and interfere with prosthetic wear.
- Surgeon pulls major nerves with some tension to allow for clean cut
- Cut nerves retract into soft tissue of residual limb
- Prefer neuroma to form away from scar tissue or bone
describe the Hemostasis in amputation
Achieved by ligating (tie off or bind with ligature) major veins and arteries
- Cauterization used only for small bleeders
describe Sharp Bone Smoothed in amputation
- Smoothed and rounded
- In transtibial, anterior portion of distal tibia is beveled to reduce pressure between end of bone and prosthetic socket
- Need bone to be physiologically prepared for pressures of prosthetic wear
Discuss trauma and amputation
- Surgeon attempts to save as much bone length and viable skin as possible and preserve proximal joints
- Secondary closure allows surgeon to shape the residual limb appropriately
How does surgeon attempt to avoid infection after amputation?
- In “dirty” amputation, may leave incision open for 5-9 days to prevent infection
- Because infection is the greatest post-operative concern (from internal or external sources)
How is the level of amputation determined?
Level determined by examining tissue viability
• Doppler systolic blood pressure to measure segmental limb blood pressures – quite accurate in predicting viable level of amputation
• Transcutaneous oxygen measurement
• Radioisotope or plethysmography to measure skin blood flow
What is plethysmography?
Plethysmography is used to measure changes in volume in different parts of the body. This can help check blood. The test may be done to check for blood clots in the arms and legs, or to measure how much air you can hold in your lungs.
What are the surgeon’s goals in amputation surgery?
o Preserve as much viable tissue as possible
o Must allow for primary or secondary wound healing
o Construct a residual limb for optimal prosthetic fitting and function
o Avoid/Prevent infection
What are 6 factors that would affect healing from amputation surgery?
o Infection – internal or external sources
o Smoking—higher rate of infection and re-amputation
o Severity of vascular problems
o Diabetes
o Renal disease
o Cardiac disease
Who are on the Rebiliation Team for a person who has had an amputation?
▪ The patient and the family ▪ PT ▪ OT ▪ MD ▪ Nurse ▪ Psychologist
What are the 3 kinds of Post-Op Dressings?
- Rigid
- Semi-rigid
- Soft
describe the Rigid dressing used after amputation
** Immediate Postoperative Prosthesis (IPOP)
▪ Cast-like (plaster of Paris)
▪ Not adjustable or removable
** Removable Rigid Dressings (RRDs)
▪ Plaster or prefabricated
▪ Come in different sizes
▪ Adjustable
▪ May be removed
Not for vascular patient
Most efficient to keep swelling awaydescribe the Semi-rigid dressing used after amputation
- Better control than soft dressing
- Removable
- Custom made (more costly)
- Superior to soft dressing in enhancing healing and reducing edema
describe the Soft dressing used after amputation
- Elastic wrap/Ace bandage
- Easy to remove and reapply
- Downside – needs frequent rewrapping
- Shrinker sock
- I would not put it on a fresh incision
What is important about ROM and amputation? Which ROMs would be best?
**Avoid contractures to ensure good range for standing, weight bearing Transtibial - Knee flexion, extension - Hip flexion, extension Transfemoral - Hip flexion, extension - Hip abduction, adduction Sound limb - Especially: Dorsiflexion, Hip extension
What is important about MMT and amputation?
BUE and uninvolved LE
• Gross MMT as part of initial examination
• Need to be strong enough to take on workload of missing limb
Transtibial amputation: Need good strength of
• hip extensors
• hip abductors
• knee extensors
• knee flexors
Transfemoral amputation: Need good strength of
• Hip extensors
• Hip abductors
When are post-amputation measurements taken?
- after postsurgical edema has diminished
* regularly throughout pre-prosthetic period
How are post-amputation measurements taken?
• at regular intervals over the length of the residual limb
• landmarks carefully noted
• in centimeters for uniformity
• transtibial :
o circumferentially every 5-8 cm starting at medial tibial plateau
o longitudinally from medial tibial plateau to end of bone, then end of skin
• transfemoral :
o circumferentially every 8-10 cm starting at ischial tuberosity or greater trochanter
o longitudinally from ischial tuberosity or greater trochanter to end of bone, then end of skin
What are shapes might you expect of the residual limb? Which is the preferred?
conical
cylindrical - preferred
bulbous
What might you assess on residual limb?
skin condition - healing sensation joint proprioception shape length and circumference
discuss pain resulting from amputation
• At incision site
• Surgical pain
• Phantom pain
o Generalized noxious sensation
o Strong enough to interfere with prosthetic fitting
o May be localized or diffuse
o May be continuous or intermittent
o May be triggered by external stimuli
o Important to distinguish phantom pain from phantom sensation, residual limb pain or neuroma pain
what is included and documented in the assessment of the unaffected limb?
Determine and document • Vascular status • Condition of skin • Presence of pulses • Sensation • Temperature • Edema • Pain on exercise • Pain at rest • Presence of wounds • Ulceration
What are some “whole person” considerations after amputation?
- ADLs
- transfer status
- pt’s home situation
- goals
- emotional status
What early treatment is needed for the residual limb care?
- Proper hygiene and skin care
- Avoid trauma to the limb—scratches, abrasions, no use of razor
- Begin friction massage once wound closed, staples removed to prevent scar adhering and desensitize
- Teach limb inspection to make sure no sores or pressure areas
Why do we do residual limb wrapping?
- to reduce post-surgical swelling
- to reduce pain
- to improve circulation and healing
- to shape limb for prosthesis
What is important to remember when wrapping a residual limb?
▪ Use of ACE wraps or Shrinkers
(Shrinkers easier to use)
▪ Avoid circular motion when wrapping
▪ Use Velcro or tape instead of clips
▪ Apply most pressure distallyWhat is the main goal with positioning?
prevent contractures
Which muscle groups would you focus on for stretching?
hip flexors
knee flexors
(preventing contractures)
What strengthening exercises are important for post-amputation?
- Pre-gait training
- Hip extension and abduction; knee extension and flexion
- Core strengthening
- prone to back pain once begins walking
- Upper body strengthening
- Cardiovascular conditioning and endurance
- Standing balance
- COG has changed
