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*Complex Patient - Physiotherapy > Week 4- Rehabilitation And The Managemnt Of Amputation > Flashcards

Week 4- Rehabilitation And The Managemnt Of Amputation Flashcards

1
Q

What are the causes of amputation

A
  • PVD 63%
  • Diabetes 20%
  • Trauma 10%
  • Malignacy 5%
  • Infection/ other 1%
  • Congenital deformities 1%
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2
Q

What are the common states of amputation (male/female, age, location)

A
  • 65-79yr
  • male:female= 2:1
  • LL> UL —> 3-15% of all amputation
  • NT highest rates
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3
Q

What is the most common amputation level

A

Transtibial

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4
Q

What is conservative management (limb preservation)

A
  • 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

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5
Q

What are the amputation types?

A

• 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

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6
Q

Labels these amputations

A 
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)
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7
Q

What is the transtibial amputation (TTA) technique?

A
  • 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)
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8
Q

What is a transfemoral amputation (TFA) technique

A
  • “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)
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9
Q

What are acute care principles for physios

A

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

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10
Q

What is ongoing stump assessment/cares

A

-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

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11
Q

What is scar massage

A
  • 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
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12
Q

What are intact limb cares

A
  • 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
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13
Q

What are new sensations and pain

A 
-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
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14
Q

What are causes of ongoing stump pain

A 
• 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
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15
Q

What is pain management

A
  • 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
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16
Q

What is oedema management: compression therapy

A

• 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)

17
Q

What is removable rigid dressing (RRD)

A
  • 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
18
Q

What is a joint line RRD

A
  • 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
19
Q

What is a thigh high RRD

A
  • 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

20
Q

What are bandaging/ Shriner socks

A
  • ↑ 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
21
Q

What are bandaging guidelines

A
  • 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
22
Q

What are shrinkers

A
  • 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

23
Q

When is the right time for shrinkers stocks

A

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

24
Q

What are contractures

A

A fixed tightening of muscles, tensions, ligaments or skin

25
Q

What are the main contractures that develop in LL amputees

A

Most often in the joints closest to the amputation.

  • hip: transfemoral
  • knee: transtibial
26
Q

Why do contractures occur

A

Inactivity

27
Q

What is important about positioning amputees

A 
• 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
28
Q

What are exercises for amputees

A 
• 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
29
Q

What are transfers for amputees

A 
• 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

30
Q

Wheelchairs for amputees

A

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
31
Q

What are mobility aids for gait re-education

A

• 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)

32
Q

What is a PPAM aid

A

• 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)

33
Q

What is the flow chart from amputation surgery to artificial limb manufacturers

A
34
Q

What is the suitability for a prosthesis

A 
• 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
35
Q

What are prosthetic considerations

A
  • 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
36
Q

If a patient is a prosthetic candidate…

A

• 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)

37
Q

What are interim prostheses

A
  • 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

38
Q

What are definitive prosthesis

A
  • 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

*Complex Patient - Physiotherapy (13 decks)

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