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
What are some important considerations for post-amputation mobility?
- Special care to residual limb - avoid shear and drag
- Will need to instruct patient in special care
- Early: walk on crutches with three point gait pattern (to get ready for prosthesis)
- Elderly may need a walker
- Earlier walking is better outcome
When would a Temporary Prosthesis be used?
While waiting for edema to be completely resolved
While waiting for limb to shrink completely/properly
While waiting for the socket to be fabricated
Allows for early weight bearing - better outcomes with earlier weight bearing
To help with phantom pain or sensation
(but, used rarely. mainly for trauma patients)
What is necessary for patient education?
- learn care of residual limb
- learn care of remaining limb, especially in diabetic patients
- learn information about the disease process, especially for patients who have undergone amputation due to diabetes (diet and exercise)
What are the goals or desired outcomes in the acute setting?
Patient will:
- be independent in bed mobility and w/c to/from bed transfers
- be independent in w/c mobility and self-care
- demonstrate proper residual limb positioning, bandaging, and care
- be knowledgeable of basic ROM and strengthening exercises
- walk with at least minimal assistance with crutches or walker
What emotional or psychosocial adjustments do the patient and rehab team need to be aware of?
- Initially grief and depression
- If trauma = disbelief or denial
- Socially feel lonely
(so, offer help)
Name some special things to consider regarding Bilateral Amputation
- All care the same except gait
- All Bilateral amputations will need a wheelchair
- Balance a larger issue
- Will need more upper body strength
- Increased risk of contracture
- Start walking on stubbies
How would you educate the patient in residual limb care?
- look at it
- use a mirror to see the bottom and back
- monitor healing status - check incision/scar
- touch it, to work on desensitization (make it less sensitive, ready for prosthesis)
- friction massage to break up scar tissue
- how to wrap
- avoid drag and shear during bed mobility and transfers
- no razors - avoid cuts
- keep skin and clean and dry
- phantom sensation/pain
How would you educate the patient in care of the sound limb?
- especially if amputation was due to peripheral vascular disease or diabetes *
- no razors
- use the mirror to check bottom of foot
What is the most important thing to educate your patient about her amputation?
Do Not Drag It Across Anything
What is phantom pain?
generalized noxious sensation in the absent limb that is so strong as to interfere with prosthetic fitting
What is phantom sensation?
itching, tingling, burning, or pressure sensation
or sometimes a numbness
something not painful - makes it feel like their limb is there
What does the prosthesis for transtibial amputation include?
foot-ankle assembly (articulated or non-articulated)
shank/pylon (lower leg)
socket
suspension
What is the difference between an articulated and a non-articulated foot-ankle assembly?
articulated has moving joint (single-axis or multi-axis)
non-articulated has no ankle joint (no space between foot and shank)
Name 5 types of non-articulated foot-ankle assembly
SACH SAFE Seattle Energy storing/Dynamic Flex-lite (Springlite)
Describe the SACH foot
Solid Ankle Cushion Heel
- non-articulated
- Longitudinal portion is wooden or metal keel, ending at MTP joints
- Keel covered in rubber
- Posterior is resilient to absorb shock and permit PF in early stance
- Anterior junction of keel and toe allows foot to hyperextend in late stance
Describe the SAFE foot
Stationary Attachment Flexible Endoskeleton
- non-articulated
- Rigid ankle block joined to posterior portion of keel at 45-degree angle
- Comparable to subtalar joint
- Permits wearer to maintain contact with moderately uneven terrain
- Relatively great range of medial-lateral motion in rear foot
Describe the Seattle foot
- non-articulated
- Full length, split composite keel for increased stability
Describe the Flex-foot and Springlite foot
- non-articulated
- Energy storing or dynamic or energy releasing
- Long band of carbon fiber, extending from toe to proximal shank – leaf spring, enabling the foot to store considerable energy in early and midstance
- Posterior heel section
- for active wearers
Describe Energy Storing/Dynamic foot
- Springy sole that stores energy in early and midstance as wearer moves over the foot
- Spring recoils in late stance as wearer transfers loading to opposite foot
What is the scale used to determine eligibility for prosthetic prescription?
K0: not a candidate
K1: household ambulation
K2: limited community ambulation
K3: community ambulation and the ability to vary cadence with vocational, therapeutic or exercise needs
K4: high levels of activity such as demonstrated by active adults and athletes
Name the two types of articulated foot-ankle assembly.
Single-axis
Multi-axis
describe single-axis foot-ankle assembly
- Most common example of articulated foot
- Rear bumper absorbs shock, controls plantarflexion excursion (more bumper for heavier person)
- Early stance, weight-bearing on heel causes plantarflex for stable foot-flat position
- Does not allow medial-lateral or transverse motion (this means only plantarflexion)
describe multi-axis foot-ankle assembly
- Components move slightly in all planes to aid the wearer in maintaining maximum contact with the walking surface
- Some include electronic sensors to detect when the wearer needs dorsiflexion
- Heavier and less durable than single-axis or non-articulated (more parts, break down more quickly)
- DF, PF, Inversion and Eversion
name and describe the 2 types of shank/pylon
Exoskeletal
- rigid exterior shaped to simulate the contour of the anatomical leg
- does not permit changes in alignment of the prosthesis
Endoskeletal
- Central aluminum or plastic pylon with a removable cover
- Pylon has a mechanism that permits adjustment in alignment
What is the shank (pylon)?
- the substitute for the human leg
- restores leg length
- transmits body weight from the socket to the prosthetic foot.
What is the socket?
the plastic receptacle into which the residual limb fits
Name and describe the 2 types of socket.
Lined
- Polyethylene foam, polyurethane, silicone or some such
- Cushions the residual limb
- Facilitates alteration of socket size
Unlined
- Soft interface is provided by sock or sheath on wearer
- Easier to clean
What are reliefs in prostheses?
Concavities in the socket over areas contacting sensitive structures, such as bony prominences
What are build-ups in prostheses?
Convexities in the socket over areas contracting pressure-tolerant tissues, such as the belly of the gastroc, patellar ligament, tibial and fibular shafts
What is suspension?
how the prosthesis stays in place during non-weight-bearing moments (such as swing phase of walking)
describe Cuff Variant suspension
Cuff variant
- Leather, flexible plastic or fabric-webbing strap to encircle the thigh above the femoral condyles
describe Distal Attachment suspension
Distal attachments
- Silicone sheath (clings to skin) with distal metal pin
- Vacuum-assisted – pump, liner and sleeve
- Osseointegration – implanted metal post in distal bone (in Europe)
describe Brim Variant suspension
Brim Variant
- medial and lateral walls extend above femoral condyles or the patella
- supracondylar suspension
- supracondylar/suprapatellar (SC/SP)
describe Vacuum-Assisted Suspension
- Combines a pump, liner, and sleeve to achieve elevated vacuum in an airtight environment
- Vacuum promotes
- fluid exchange
- reduces moisture buildup
- regulates volume fluctuations
- increases proprioceptive awareness of the limb’s position in space.
describe Sleeve Suspension
tubular component that covers the proximal socket and the distal thigh
provides excellent suspension
describe Thigh Corset Suspension
- Metal hinges attach distally to the medial and lateral aspects of the socket and proximally to a flexible plastic corset.
- Corset heights vary and may reach the ischial tuberosity for maximum weight relief on the amputation limb.
- hinges increase frontal plane stability
- corset increases area for weight-bearing load distribution
- The resulting prosthesis, however, is heavier and apt to foster piston action because the hinges have a single pivot joint that does not articulate collinearly with the anatomical knee.
The Above the Knee Prosthesis has these three components (in addition to the the foot-ankle assembly and shank):
knee unit
socket
suspension
What comprises the knee unit in the transfemoral prosthesis?
axis
friction mechanisms
extension aid
stabilizers
What is the axis of the transfemoral prosthesis?
it is where the knee rotates
- single axis
- polycentric linkage
What does the friction mechanism do?
- controls the swing rate of the knee
- modifies the pendulum action of the leg to reduce asymmetry between the motions of the sound and the prosthetic limbs
- Not enough friction for rapid walker means excessive knee flexion and knee extension
- Constant
- Variable (Sliding, fluid (hydraulic or pneumatic))
What does the extension aid do?
- the spring or motor to help the knee go into extension during later part of swing phase
- Assist knee extension during latter part of swing phase
- Elastic webbing in front of the knee axis
microprocessor
What does the mechanical stabilizer do?
- helps increase stability so the knee doesn’t buckle
Manual lock – a rod lodges in a receptacle and is released when the wearer unlocks it
Friction brake – high friction during weight-bearing
(stance control knee is stabilizer controlled by hip movement)
What are the 3 type of sockets used in transfemoral prostheses?
Quadrilateral
Ischial Containment
Comfort Flex (fit and alignment)
How does the Quadrilateral socket fit?
- Anteromedial relief for adductor longus tendon and obturator nerve
- Posteromedial relief for hamstring tendons and sciatic nerve
- Posterolateral relief for gluteus maximus
- Anterolateral relief for rectus femoris
How does Ischial Containment socket fit?
- sometimes called “Contoured adducted trochanter-controlled alignment method”
- Covers ischial tuberosity, ischiopubic ramus to augment socket stability
- Anterior wall lower than on quadrilateral
- Lateral wall covers greater trochanter
How does the ComfortFlex socket fit?
- Soft flexible socket placed in carbon graphic frame
- Structural support with intimate fit that allows muscle contraction and improved control
What are the 4 types of suspension used in a transfemoral prosthesis?
Total suction - Socket brim must fit very snugly Partial suction - Suction + auxiliary suspension (silesian belt) No suction - Socks and pelvic band Pin Suspension - Osseus Integration
Why is prosthetic maintenance important?
- for Optimal Function optimal function is dependent on proper care of - socks/sheaths - prosthesis - amputated limb
What are socks, sheaths and liners for?
Cushion residual limb Create smooth surface to reduce risk of chafing Comfort Help prosthetic fit Help prosthetic stay in place Protect the skin Absorb perspiration
Why would the patient have excellent prosthetic with a knee disarticulation?
(1) thigh leverage is maximum
(2) most of the body weight can be borne through the distal end of the femur
(3) the broad condyles provide rotational stability.
For which amputations would a hip disarticulation prosthesis be used?
very short transfemoral
hip disarticulation
hemipelvectomy (transpelvic amputation)
What are the 3 possible outcomes of the initial prosthetic evaluation?
Pass – no changes needed to prosthesis, patient proceeds to training
Provisional Pass – one or more minor problems require correction, none of which should interfere with training
Fail – teams’ judgment that the prosthesis has a major fault that should be corrected to the team’s satisfaction before commencement of prosthetic training
In preparation for prosthetic prescription, what will be included in the physical exam?
- Examine joint mobility, AROM, PROM in all joints on both LEs – contracture may require alternate socket design
- Measure length of residual (amputation) limb – to determine best suspension
- Assess strength of all limb and trunk muscles – marked debility may interfere with prosthetic use
- Inspect the skin on the amputation limb – may require sheath for smooth interface
- Examine sensory function on amputation limb – impaired proprioception or neuroma will dictate changes to design and timing of fitting
- Assess patient’s ability to learn and retain new info – maybe need different training strategies
- Assess circulation, size and proportions of amputation and sound limbs – free of wounds, edema
- Assess aerobic capacity – to formulate realistic goals, related to exercise tolerance and level of conditioning
- Note body weight – likelihood of fluctuation will necessitate making provision for alternate liners and socks
- Note arthritis, arthroplasty, hand and wrist function - affect design and alignment
- Assess transfer ability – reasonable strength, balance, coordination and comprehension are needed
In preparation for the prosthesis prescription, what pyschosocial items would be assessed?
- Since PT will see patient more frequently than other members of the team, she may be most attuned to changes in psychosocial status
- Note fear, depression
- Determine motivation, but guard against unrealistic expectations
- Enlist support from family and from other persons with similar situations
For a BKA, what do you look for when assessing static standing and sitting?
Standing
- in parallel bars
- bear equal weight on both feet
- assess comfort
- assess alignment – pelvis, both feet flat on floor
Sitting
- posterior brim should not impinge into popliteal fossa
- hamstring reliefs should be adequate
- assess placement of tabs of the cuff, joints of the corset for comfort
For an AKA, what do you look for when assessing static standing and sitting?
Knee unit should be stable enough to withstand a blow delivered by the therapist to the posterior aspect of the unit when the patient is standing
What is involved in learning to use a prosthesis effectively?
- be able to don it correctly
- develop good balance and coordination
- walk in a safe and reasonably symmetricalmanner, and perform other ambulatory and self-care activities
In gait, what causes lateral bending of the trunk?
prosthetic causes
- prosthesis too long or short
- inadequate lateral wall adduction
- sharp or high medial wall
anatomical causes
- weak abductors (glute medius)
- pain
- anxiety
In gait, what causes circumduction?
prosthetic causes
- Prosthesis too long
- Locked knee unit
- Loose friction
- Inadequate suspension
- Small socket
- Loose socket
- Foot plantarflexed
human causes
- Abduction contracture
- Poor knee control
- Insufficient knee flexion
- Weak hip flexors
- reluctant to allow knee to bend
In gait, what causes vaulting?
prosthetic causes
- Prosthesis too long
- Posterior ankle stop eroded
- Knee lock in use
- Insufficient knee flexion
- Sliding friction unit
human causes
- Excessive plantarflexion on sound ankle
- Weak hip flexion
- Fast pace (vigorous walker)
In gait, what causes unequal step time?
prosthetic causes
- Improper socket fit
- Knee buckle
- Alignment instability
- Decreased weight acceptance
human causes
- Pain
- Weak hip extension
- Poor balance
- Fear, anxiety, insecurity
In gait, what causes uneven arm swing?
- Poor balance
- Fear, anxiety, insecurity
- Habit pattern
In gait, what causes terminal swing impact?
prosthetic causes
- Abrupt knee extension (can be abrupt, noisy)
- Insufficient knee friction
- Knee extension aid too strong
human causes
- Uncertainty – patient forcibly extends limb to assure himself that knee is fully extended
In gait, what causes medial and lateral whips?
- Knee unit rotated; incorrect donning; poor suspension
- Abrupt rotation upon unload at end of stance phase
- Malroration of the knee unit or foot-ankle assembly
- socket does not fit well
In gait, what causes unequal step length?
prosthetic causes
- Uncomfortable socket
- Insufficient socket flexion
human causes
- decreased weight acceptance on prosthetic limb
- hip flexion contracture
- inadequate balance
What causes toe drag?
the leg is too long
weak hip flexors
decreased confidence in bending the knee
What causes toe walking/early heel rise in the BKA?
walking too fast
too much flexion in the socket
a knee flexion contracture
What causes abducted gait in AKA?
the prosthesis is too long
have a high medial wall
pain
fear
