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Management of Special Populations > Vulnerable Foot & Epidemiology & Levels of Amputation > Flashcards

Vulnerable Foot & Epidemiology & Levels of Amputation Flashcards

1
Q

What is ABI and what does it stand for

A
  • Ankle Brachial Index
  • Ankle systolic pressure ÷ Brachial systolic pressure
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2
Q

Describe the compression systems

A
  • Inelastic: low resting pressure, high working pressure, safer for arterial disease, rapid loss of compression over time
  • Elastic: high resting & working pressure, not for material disease, little pressure is lost over time
  • Single layer: delivers constant pressure
  • Multilayer: delivers graded pressure
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3
Q

Describe the ankle brachial index (ABI)

A
  • Noninvasive vascular screening test to identify large vessel, peripheral arterial disease by comparing systolic BPs in the ankle to the brachial which is the best estimate of central systolic BP
  • Measured via continuous wave doppler; pulse palpation or automated BP devices are considered unreliable for ABI
  • If blood flow is normal in the lower extremities, the pressure at the ankle should equal or be slightly higher than that in the arm with an ABI of 1.0 or more
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4
Q

What characteristics would you expect to find in a wound caused by venous insufficiency vs arterial disease vs diabetes?

A
  • Venous: weeping, moist, wet, a lot of drainage, edema, wound with irregular borders
  • Arterial: dry, not a lot of exudate, can be pale, more defined borders, associated with possible ischemia
  • Diabetic: wounds commonly on the heel or plantar aspects of the feet/callus around wound hyperkeratinize
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5
Q

How would you manage a wound caused by venous insufficiency

A
  • Need an absorbing dressing to manage it along with moving the edema out of the area to get the good nutrients in and the bad stuff out
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6
Q

How would management of an arterial wound be different

A
  • A dressing that provides moisture
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7
Q

What are some ways that you are able to assess peripheral arterial circulation

A
  • Capillary refil
  • Rubor on dependency
  • Pitting edema
  • ABI
  • BP in the toe
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8
Q

ABI graded scale for BP ratios

A
  • > 1.3 = elevated, incompressible vessels
  • > 1.0 = normal
  • ≤0.9 = LEAD
  • ≤0.6 to 0.8 = boderline
  • ≤0.5 = severe ischemia
  • <0.4 = critical ischemia, limb threatened
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9
Q

Indications for urgent referral to a vascular surgeon or emergency room

A
  • Gangrene: toes or foot is black
  • Wound infection or cellulitis in an ischemic limb: concern for sepsis
  • Sudden onset of 6 Ps: pain, pulselessness, pallor, parathesia, paralysis, polar (coldness) which indicates acute limb ischemia associated with a thrombosis
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10
Q

Why is it important to monitor distal pulses in patients following traumatic lower limb injury? Following a revascularization procedure?

A
  • Make sure there isn’t a blood clot
  • Can get edema/compartment syndrome from too much blood
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11
Q

Where can you palpate for pedal pulses

A
  • Dorsalis pedis
  • Posterior tibial
  • Popliteal
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12
Q

Describe a vascular exam

A

-Pulses: presence and quality of the most distal pulses should be documented on each visit
- Color: cyanotic limbs may represent continued tissue ischemia due to poor arterial flow; globally erythematous residual limbs may indicate an issue with venous drainage that is DVT or may be a sign of infection
- Temperature: as indicated by color, cold limbs may indicate poor arterial supply while warm limbs may have underlying issues with venous drainage or infection

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13
Q

**Describe the differences between vascular and neurogenic claudication

A
  • Vascular: symptoms are relieved by rest
  • Neurogenic: most commonly seen in spinal stenosis (narrowing of hole)
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14
Q

Describe vascular claudication Slide 17

A
  • Arterial vessel narrowing restricts blood flow to levels insufficient to match the metabolic demands of the lower extremity musculature
  • Only about half of people with positive ABI’s havesymptomsof vascular claudication
  • Symptoms that are relieved with standing alone and located below the knees are often associated with vascular claudication
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15
Q

Describe neurogenic claudication

A
  • An extended lumbar posture narrows a degenerative stenotic spinal canal to a critical threshold, leading to direct mechanical compression or indirect vascular compression of the nerve roots and/or cauda
  • The presence of Lumbar Spinal Stenosis on magnetic resonance imaging (MRI) or computed tomography (CT) scans has been shown to poorly correlate with lower extremity symptoms
  • Symptoms that are triggered with standing, relieved with sitting and located above the knees and that have a positive shopping cart sign are typically associated with neurogenic claudication
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16
Q

As we get older our chances of peripheral arterial disease ___________ (increases/decreases)

A
  • Increases
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17
Q

Describe intermittent claudication (IC) and exercise

A
  • Exercise improves both pain-free and max walking distance in people with leg pain from IC when compared to placebo
  • Exercise did not improve ABI
  • No evidence of an effect of exercise on amputation or mortality.
  • Exercise may improve quality of life
  • No clear evidence of differences b/w supervised walking & alternative exercise modes in improving max pain-free walking distance
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18
Q

Major risk factor for peripheral arterial disease (PAD)

A
  • Poorly managed hypertension
  • High serum cholesterol & triglyceride levels
  • History of tobacco use & smoking
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19
Q

Define critical limb ischemia (CLI)

A
  • Slide 22
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20
Q

What is the probability of healing using toe pressure

A
  • Healing is unlikely if toe pressure is <55 mmHg
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21
Q

Society for Vascular Surgery Lower Extremity Threatened Limb Classification System (SVS WIFI)- Wound Clinical Category

A
  • Grade 0: no ulcer or gangrene
  • Grade 1: small, shallow ulcer on distal leg/foot, no exposed bone, unless limited to distal phalanx
  • Grade 2: deeper ulcer, exposed bone/joint/tendon, gangrenous changes limited to digits
  • Grade 3: ulcer involves forefoot and/or midfoot, full thickness heel ulcer +- calcanea involvement and extensive gangrene
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22
Q

Society for Vascular Surgery Lower Extremity Threatened Limb Classification System (SVS WIFI)- Ischemia Clinical Category

A
  • Grade 0: ABI = ≥0.80; Ankle systolic = >100mm Hg; TP = ≥60mm Hg
  • Grade 1: ABI = 0.6-0.79; Ankle systolic = 70-100mm Hg; TP = 40-59mm Hg
  • Grade 2: ABI = 0.4-0.59; Ankle systolic = 50-70mm Hg; TP = 30-39mm Hg
  • Grade 3: ABI = ≤0.39; Ankle systolic = <50mm Hg; TP = <30mm Hg
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23
Q

When are toe pressures preferred

A
  • TPs are preferred for classification of ischemia (I) in patients with diabetes mellitus, since ABI is often falsely elevated
24
Q

Mean wound healing timelines & incidence of amputation

A
  • Stage 1 = 94 days
  • Stage 2 = 115 days
  • Stage 3 = 163 days
  • Stage 4 = 264 days
25
Q

Revascularization procedures

A
  • Thrombolytic therapy
  • Angioplasty
  • Bypass surgery
  • Amputation is often best option for some individuals with dysvascular or neuropathic disease when bypass won’t work and persons with complex medical conditions at high risk for intraoperative & postoperative complications
  • Arterial bypass or thrombolytic therapy may be used as adjuncts to amputation of more distal amputation
26
Q

How does hyperglycemia effect wound healing

A
  • Increased leukocyte adhesiveness
  • Release of cytokines contributes to a pro-inflammatory environment
  • Such changes are likely to increase oxidative damage, decrease proper responsiveness of vascular endothelial cells, & impede neoangiogenesis & other repair responses during the tissue regenerative phase of wound healing
27
Q

How to offload for a diabetic for ulcer

A
  • Use a non-removable knee-high device with an appropriate foot-device interface; if contraindicated/not tolerated use a removable knee-high walker with an appropriate foot-device interface
28
Q

When a knee-high device is contraindicated or cannot be tolerated by the patient, consider offloading with a

A
  • Forefoot offloading shoe
  • Cast shoe
  • Custom-made temporary shoe to heal a neuropathic plantar forefoot ulcer in a patient with diabetes, but only when the patient can be expected to be adherent to wearing the shoes
29
Q

Peripheral neuropathy in a diabetic foot is suspected when one or more of the following clinical signs are present:

A
  • Deficits of sensation (loss of Achilles and patellar reflexes, decreased vibratory sensation, and loss of protective sensation)
  • Motor impairments (weakness and atrophy of the intrinsic muscles of the foot)
  • Autonomic dysfunction (inadequate or abnormal hemodynamic mechanism, tropic changes of the skin, and distal loss of hair).
30
Q

What is a major contributor to diabetic amputations

A
  • Neuropathy
  • The resulting loss of thermal, rain, & protective sensation increases the vulnerability of the foot to acute, high-pressure & repetitive, low-pressure trauma
31
Q

Diabetes related amputation

A
  • Approximately 50% of persons undergoing diabetes-related amputation will have contralateral amputation within 3 to 5 years.
  • Between 25% and 45% of persons with amputations have had amputations of both lower extremities, most often at the transtibial level in both limbs, or a combination of transtibial amputation of one limb and transfemoral amputation of the other.
32
Q

How is nutritional status and wound healing related

A
  • Protein deficiency can contribute to poor healing rates; may also decrease fibroblast activity, delaying angiogenesis and reducing collagen formation
  • High exudate loss can result in a deficit of as much as 100g of protein in one day
  • Protein and energy requirements of chronic wound patients may rise by 250% and 50%, respectively
  • Holistic assessment of nutrition and early detection of malnutrition are essential to promote effective wound healing
33
Q

Why does wound healing require adequate blood supply

A
  • Transports nutrients
  • Transports cells involved in wound healing
  • Oxygenates wound bed
  • Removes waste products
  • BLEEDING IS GOOD!
34
Q

What can you educate a diabetic at risk patient on to help protect their feet

A
  • Instruct them not to walk barefoot, in socks only, or in thin-soled standard slippers, whether at home or when outside
  • Instruct them to wear properly fitting footwear to prevent a 1st foot ulcer
  • Consider prescribing therapeutic shoes, custom made insoles, or toe orthosis when a foot deformity or a pre-ulcerative sign is present
35
Q

What are the 2 principles to consider when deciding when & where to amputate

A
  • Must have adequate circulation to ensure healing of incision & surgical reconstruction
  • Preserve as many anatomical joints as possible
36
Q

Amputation levels terminology for the lower extremity

A
  • Toe = phalangeal
  • Forefoot = ray resection (≥1 complete metatarsals) or transmetatarsal (across the metatarsal shaft)
  • Midfoot = partial foot
  • At the ankle = syme
  • Below the knee = transtibial
  • At the knee = knee disarticulation
  • Above the knee = transfemoral
  • At the hip = hip disarticulationn
  • At the pelvis = hemipelvectomy
37
Q

Functional implications of great toe amputation

A
  • Display a lower walking speed & greater variability & lower ankle, knee, & hip ROM values
  • Tend to have more flexed hip profile
  • Complained of increased pain & lower QOL
38
Q

When is a metatarsal head resection typically performed

A
  • When there is a non-healing plantar ulcer, especially if there is osteomyelitis of the metatarsal head
39
Q

What is the adverse consequence of a ray resection

A
  • Amputation leaves a narrow foot
40
Q

Pros and cons of a transmetatarsal amputation

A
  • Pros: Walking involves less work. Functional results may be better than with higher levels. It potentially provides lower morbidity and mortality when compared with results for transtibial (TT) amputations.
  • Cons: The possibility of reamputation is potentially greater than with a higher level amputation chosen for the same situation
41
Q

What are the cons to a mid foot disarticulation

A
  • High risk for contracture development
  • Prosthetic fitting can be challenging
42
Q

What are the 3 levels/types of mid foot disarticulations

A
  • Transmetatarsal
  • Lisfranc
  • Chopart
  • In order from distal to proximal
43
Q

Describe a Syme amputation

A
  • Disarticulates the talocrural, trims the malleoli to create a flat WBing surface, & repositions the fat pad & soft tissue of the heal under the distal tibia & fibula
  • Prosthetic fabrication can be challenging due to the low build height for the prosthetic foot
44
Q

Describe a Guillotine amputation

A
  • Extensive gangrene of the foot which is complicated by infection, is an indication for an open distal transtibial amputation
  • Time is given for the infection to be controlled by antibiotics & local wound care of the open surgical construct
  • The residual limb is then revised more proximally & a formal transtibial or transferal amputation with standard closure techniques is done
45
Q

Describe transtibial amputations

A
  • Generally 5 to 7 inches below the joint line through the tibia and fibula.
  • With decreased length of residual limb the likelihood of discomfort, skin irritation, and limited use of a transtibial prosthesis increases.
  • A longer residual limb has larger total surface area to distribute pressures within the socket and long lever arm potentially enhance prosthetic control
46
Q

Define myodesis

A
  • Holes are drilled through the tibia about 1 cm proximal to the distal end. The posterior and anterior flaps are sutured to the marrow cavity.
47
Q

Define myoplasty

A
  • The flexor and extensor muscles are sutured together and to the tibial periosteum to allow the muscles to contract against resistance, and preserve blood and lymphatic return, and muscle bulk and action.
48
Q

Describe a modified Burgess posterior flap

A
  • Transtibial surgery option
  • Preserves the Gastroc and anterior compartment muscles beyond the distal tibia
  • Brings the flap of the gastroc-soleus forwards with the suture line being anterior distal below that of the tibia cut line
49
Q

Describe a modified Bruckner procedure

A
  • Transtibial surgery option
  • Designed for dysvascular patients to remove the most susceptible ischemic muscles during the surgery – thus less post-op complications
  • Anterior & Lateral compartment and the Soleus and Lateral gastroc removed
  • Also removes the fibula
50
Q

Describe a modified Ertl procedure

A
  • Periosteal flaps from the tibia and fibula are sutured together to form a bridge across the distal tibia and fibula.
  • This bridge helps provide a pressure tolerant weight bearing surface and prevents rotation of the fibula
  • Increased use in young traumatic amputation pts b/c improves distal end bearing capacity
  • Also longer OR time thus better for younger patients more tolerant of longer time under anesthesia
  • Benefit is also the prevention of heterotopic ossification
51
Q

Describe a knee disarticulation

A
  • Creates several important challenges to prosthetic fit & function in terms of choice & placement of the prosthetic knee unit, which affects energy cost, as well as efficiency of prosthetic gait
52
Q

Describe a transferal amputation

A
  • Preservation of femoral length & of muscle mass via myoplasty or myodesis, rather than trisection through muscle belly, results in a stronger residual limb that is more easily fit & has better prosthetic control
53
Q

Preservation or reattachment of what muscles provide sufficient power for stabilization of the residual limb in adduction in stance to keep the pelvis level during prosthetic gait

A
  • Adductor brevis
  • Adductor longus
  • Especially adductor magnus
54
Q

Considerations for osseointegration

A
  • Utilizes a single stage procedure with rapid rehab & immediate WBing as per the principles of joint replacement surgical procedure
  • Rehab can take 4-18 months
  • Skin area surrounding the abutment requires daily hygiene, with skin irritation & mild infection being the most commonly reported adverse events
  • Less common risks of deeper soft tissue infection, Fx from falls, & loosening of the implant
  • Users are advised to avoid high-impact activities such as running or jumping and the use of public swimming pools to prevent infection
  • Permanent abutment may be considered less than desirable by some patients for cosmetic reason
55
Q

Levels of amputation for the upper extremity

A
  • Hand/partial hand: fingers or portion of the hand below the wrist
  • Wrist disarticulation: limb is amputated at wrist level
  • Transradial (below elbow): amputationn of the forearm from elbow to wrist
  • Elbow disarticulation: amputation through elbow joint preserving the entire humerus
  • Transhumeral (above elbow): amputation of the upper arm from elbow to shoulder
  • Shoulder disarticulation: preserving the shoulder blade, collarbone may or may not be removed
  • Forequarter: amputation at the level of the shoulder; both shoulder blade & collarbone are removed

Management of Special Populations (13 decks)

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