Week 4- Rehabilitation And The Managemnt Of Amputation Flashcards
What are the causes of amputation
- PVD 63%
- Diabetes 20%
- Trauma 10%
- Malignacy 5%
- Infection/ other 1%
- Congenital deformities 1%
What are the common states of amputation (male/female, age, location)
- 65-79yr
- male:female= 2:1
- LL> UL —> 3-15% of all amputation
- NT highest rates
What is the most common amputation level
Transtibial
What is conservative management (limb preservation)
- smoking cessation
- diabetes management
- control high BP/ high cholesterol
- weight loss/ diet/ exercise modification
- medications
- sympathectomy
- vascular surgery
- trauma cases: limb salvage attempts
Failed conservative management or poor patient prognosis leads to amputation
What are the amputation types?
• Primary amputation
-Performed without attempting salvage procedures
• Secondary amputation
-Performed after salvage procedures have failed
• Traumatic amputation
-Occurs at time of injury
• Minor amputation —> toe or part of foot, finger
• Major amputation —> part of the leg/arm removed
Labels these amputations
A = Forequarter B = Shoulder disarticulation (through shoulder) C = Trans-humeral (above elbow D = Elbow disarticulation (through elbow) E = Trans-radial (below elbow) F = Wrist disarticulation (through wrist) G = Trans-carpal (partial hand) H = Hemipelvectomy (hindquarter) I = Hip disarticulation (through hip, HAD) J = Trans-femoral (above knee, AKA/TFA) K = Knee disarticulation (through knee, KD) L = Trans-tibial (below knee, BKA/TTA) M = Ankle disarticulation (Syme, ADA) N = Partial Foot (Chopart, TMA)
What is the transtibial amputation (TTA) technique?
- Most common= burgess technique
- posterior flap is made from lateral and medial gastrocnemius and some soleus muscle
- flap fixed anterior by sutures
- also referred to as “below knee amputation” (BKA)
What is a transfemoral amputation (TFA) technique
- “fish mouth” incision
- myopexy of posteriomedial musculature to shape stump
- scar line sits at the base of the stump
- also referred to as “above knee amputation” (AKA)
What are acute care principles for physios
Aim: always aim for prosthesis and mobility
Standard Post-Op care • Consider effects of anaesthetics • Pulmonary co-morbidities • Circulation exercises for other limb • Sit out of bed early post-op • Progress to W/C transfers, standing, mobility with aids -Vascular patients have strict no hopping orders • check bloods (Hb) and vitals
Stump Management
• Oedema reduction and prevention —> compression therapy
• Wound cares, promotion of wound healing
• Pain management and desensitisation
• Early prosthetic fitting
• Prevention of contractures
• Exercise rehabilitation
What is ongoing stump assessment/cares
-Check the limb in mirror
-acute wound care
• Suture splitting
• Malodour, pus
• Redness, heat, swelling
• Febrile, unwell, chest pain, dizziness • Intense pain
• Other leg is cold
-ongoing stump care
•Swelling
• Rash
• Cysts, boils
• Lumps under skin
• Inflammation of skin
• Itching
• Rough, dark skin
• Flaking skin
> daily washing, thorough drying, moisturise stump
manage perspiration; baby powder, regular bandage/ sock changes
What is scar massage
- 5 - 10 min, 3-4 times/ day
- decrease oedema
- Reduce scar tissue
- Reduce contractures
- Improves healing
- Assists desensitisation of stump
- Can help with phantom pain
- Helps to prepare for prosthesis
- May require massage on intact limb
What are intact limb cares
- Important, particularly if PVD or diabetes is present
- Encourage regular inspection by professionals
- Control diabetes, stop smoking
- Daily hygiene, skin moisturiser, good footwear
- Check skin condition, particularly heels
What are new sensations and pain
-Stump pain • Wound healing • Requires good pain control • May occur later in healing stages - Phantom pain • 20-50% of patients • “crushing, toes twisting, hot iron, burning, tingling, cramping, shocking, shooting, pins and needles” • Decrease in severity and frequency over time • Requires specialised pain control • Can change with emotional state -Phantom sensation/Phantom limb syndrome
What are causes of ongoing stump pain
• Abscess, infection, skin conditions • Ill-fitting prosthesis • Muscle contractures - Neuromas • Nerves cut in operation • Scar sensitivity • Localised, very tender, electric shock • Can trigger phantom limb pain - Bony spurs • Cut end of the bone —> nerve irritation • May require surgical removal
What is pain management
- Contracture prevention
- Oedema management
- Adequate post-op analgesia
- Desensitisation —> massage, tapping, bandaging
- Get moving —> distraction helps
- Early prosthetic training
- TENS, vibration, acupuncture, hypnosis, biofeedback, ECT, mirror therapy, CBT
What is oedema management: compression therapy
• Removable Rigid Dressing (RRD): put in surgery
• Post op silicone liners
• Stump bandaging
• Stump shrinkers – tubigrip or socks
—> Controls oedema, stump shape (dog ear, adductor roll)
What is removable rigid dressing (RRD)
- a cast that can be removed
- usually applied immediately post op (20mins) for TTAs
- can take for showering or ROM assessment but limit to 10mins
- is the most effective form of post op dressing in TTAs
- good prosthetic warm up indicator
- wool socks should be added as the volume of the stump decreases (with swelling, and after time will loose muscle mass)
- when the patients require 3 or more wool socks or if there are problems fitting the case therefore get a new cast
- worn 24/7, except showering or limb inspections
Advantages
- decrease oedema —> facilitate wound healing
- allows wound inspection
- stump shaping —> earlier time to prosthetic fitting
- pain management
- prevent knee contracture
- stump protection from trauma (falls)
Disadvantages
- specialist skill/ therapist required for application
- close monitoring required
- can be heavy and affect bed mobility
- lack of progressive compression
What is a joint line RRD
- Cast created up to knee joint line
- Held in place by suspension cuff
PROs
• Allows knee flex/ext
• Can easily pad up with socks
• Easy to make
CONs • Suspension cuff – risk of tourniquet • Does not prevent knee flexion contracture • Difficult to align when donning • Harder to shape stump • Soft tissue can be pinched
What is a thigh high RRD
- Knee fixed into extension
- No suspension cuff required
PROs • Easier alignment when donning • Prevents flexion contracture • Don’t need to pack socket • Less soft tissue pinching • Better fit
CONs
• Harder to make
• Requires more materials
• Needs removing for knee exercises
What are bandaging/ Shriner socks
- ↑ pressure tolerance
- Encourages conical shape
- ↓ swelling and readiness for casting
- Maintains constant volume
- Provides sensory feedback → minimising phantom sensations
Advantages • Low cost • Washable • Easy to don / doff • Easy to monitor wound
Disadvantages • May slip off, loosen easily • Slower healing, longer hospital stay • Elastic bandage can be inconsistent with application causing pressure problems • Shearing over wound with shrinkers
What are bandaging guidelines
- Check stump first, dressing over wound
- All bandage turns should be diagonal (not spiral) to avoid tourniquet (figure 8 dressing)
- Never restrict blood flow —> pain = reduced circulation
- Should be applied with extended knee
- Graduated pressure, firm at end of stump, apply pressure on upwards turns. Should be able to fit fingers under top
- Re-apply every 4 hr
- No folds, creases, windows
- No pins to secure, use only tape
- Worn 24/7
What are shrinkers
- Should be tight but not painful or restrict blood flow
- Make sure the top does not roll – can reduce blood supply
- When starting to use a prosthesis the shrinker should be worn whenever the prosthesis is off
- Seam should not shear over wound
Note:are tight and hard to get on, make sure are smooth so no pressure areas
When is the right time for shrinkers stocks
Ideal world
• RRD applied in theatre and to be worn for up to 2 weeks
• Progress then onto shrinker socks
Next best if no RRD applied
• Commence stump bandaging or tubigrip 2-4 days post op, once wound dressings are minimized and pain allows
• Progress to shrinker socks after 7-10days when the stump is starting to form nice conical shape
What are contractures
A fixed tightening of muscles, tensions, ligaments or skin
What are the main contractures that develop in LL amputees
Most often in the joints closest to the amputation.
- hip: transfemoral
- knee: transtibial
Why do contractures occur
Inactivity
What is important about positioning amputees
• No pillows under stump or thigh • No crossing legs in bed • Maintain knee extension (stump board) in sitting • Prone lying to maintain hip extension • Early ambulation/standing • Active strengthening/AROM - Hip extension - Knee extension • RRD
What are exercises for amputees
• Prone lying • Maintain joint range of motion • Increase muscle strength - Reduce LL atrophy as a result of poor positioning/reduced use of muscles - Don’t forget the intact limb - Remember the upper limb • Balance retraining – transfers • ↑ CV endurance - Self propelling in wheelchair and/or walking with prosthesis
What are transfers for amputees
• Key to independence • Reduces complications of bed rest • Practice bed mobility • Transfer practice -Pivot transfers -Stand transfer -Slide board (also helps to protect stump) • STS transfer onto frame • Floor to chair transfer – in case of fall
Note: vascular patients can’t hop
Wheelchairs for amputees
Note: after time amputee, they have less weight on the front and are easier to tip in the wheelchair
- Anti-tippers – increase safety when transferring and negotiating ramps
- Rear wheel brackets set the wheels further back and allow more space to transfer if using a slide-board and made the whole chair more stable
- Stump boards should be used for all TTA to control stump oedema and knee extension
What are mobility aids for gait re-education
• Hopper
- Stable but slow and does not allow step through gait
• Two single sticks
-Less stable but allows step through gait and reciprocal gait pattern
• One single stick
-Enables good balance but need even WB and requires ↑ strength and balance
• Crutches
-Encourage stooping and does not allow effective use of glutes (major stability muscles when walking)
What is a PPAM aid
• Pneumatic Post Amputation Mobility Aid
• Used for transtibial and transfemoral amputees
• Aluminium support frame with air bags to hold limb
• Partial weight bearing aid only
• Used primarily in parallel bars
• Use >7 days post-op (depends on wound healing)
• Can be applied over stump dressings, shrinkers etc
• Air bags cup around stump
- 40mmHG for mobilising
• Worn for 5-10 minutes initially – stump must be examined
• Gradually build up wearing time
Advantages: • Psychological boost • Patient is upright and weight bearing • Provides total stump contact • Aids in oedema reduction • Can give indication about whether suitable for prosthesis • Can be re-used for other amputees
Disadvantages:
• No natural knee movement during use
• Gait tricks – circumduction
• Time consuming set-up (can take around 30mins)
What is the flow chart from amputation surgery to artificial limb manufacturers
What is the suitability for a prosthesis
• Good stump condition • Adequate ROM and strength • Able to hop • No medical issues preventing training • Intact cognitive function -Ability to learn complicated task of gait retraining and safety in using a prosthesis -Medical issues affecting cognitive function eg. dementia, stroke may limit ability • Social situation • Attitude and motivation
What are prosthetic considerations
- TTA require 40% more energy to walk with a prosthesis than walking with 2 legs
- TFA require 100% more energy to walk again
- Can preserve energy by slowing down when walking and/or using a walking aid
If a patient is a prosthetic candidate…
• PWB as soon as surgeon allows (PPAM Aid / interim)
• FWB as soon as wound is healed with no open lesions which varies from 14 days to ~months
• Compression therapy is extremely important
- Stump volume decreases rapidly in first 3months, then gradually for next 15 months
• Refer to Queensland Amputee Limb Service (QALS)
What are interim prostheses
- Once the wound must be healed (at least 8/52 post op)
- Allows modifications to be made in the learning phase and while the stump stabilises in size
Note: prostheses is dependent on services available
What are definitive prosthesis
- Fitted once learning phase is completed
- Finished to look like the intact leg
- Usually provides ~3 years of use to an amputee before replacement
Can be more creative with real looking muscles and moving joints
