Chapter 04 Amputations and Prosthetics Flashcards
Amputation due to _________ disease accounts for 54% of cases, and of these, two-thirds have a diagnosis of _________. Trauma accounts for 45% of cases and cancer for the remaining less than 2%.
Amputation due to dysvascular disease accounts for 54% of cases, and of these, two-thirds have a diagnosis of DM. Trauma accounts for 45% of cases and cancer for the remaining less than 2%.
The Chopart is _______; the Lisfranc is _______.
The Chopart is shorter; the Lisfranc is longer.
Transhumeral – _______ appendage with retention of the _______ tuber-osity. Generally, the longer the better (up to 90% of normal length).
Transhumeral – Cylindrical appendage with retention of the deltoid tuber-osity. Generally, the longer the better (up to 90% of normal length).
Transradial – Ideal shape follows the contours of the natural limb. Longer appendages provide better _______ arms and more _______/_______ and are optimal for _______-powered prostheses and heavy labor. Retention of the _______ improves elbow flexion. Medium length limbs are optimal for externally powered prostheses.
Transradial – Ideal shape follows the contours of the natural limb. Longer appendages provide better lever arms and more pronation/supination and are optimal for body-powered prostheses and heavy labor. Retention of the brachioradialis improves elbow flexion. Medium length limbs are optimal for externally powered prostheses.
Transfemoral – Ideal shape is _______. Longer residual limbs improve seating balance and tolerance. For shorter limbs, maintaining the _______ _______ and its attachment to the hip _______ is key.
Transfemoral – Ideal shape is conical. Longer residual limbs improve seating balance and tolerance. For shorter limbs, maintaining the greater trochanter and its attachment to the hip abductors is key.
Transtibial – Ideal shape and length is a _______ appendage about one-third the original tibial length, with retention of the patellar tendon attachment to the _______ _______. The _______ should be shorter than the _______. In vascular disease, longer limbs may not have adequate circulatory supply and fitting of the below-knee socket may be problematic. The ideal length recommended from medial tibial plateau to bony end is 5″ to 7″.
Transtibial – Ideal shape and length is a cylindrical appendage about one-third the original tibial length, with retention of the patellar tendon attachment to the tibial tuberosity. The fibula should be shorter than the tibia. In vascular disease, longer limbs may not have adequate circulatory supply and fitting of the below-knee socket may be problematic. The ideal length recommended from medial tibial plateau to bony end is 5″ to 7″.
Post-Amputation Pre-Prosthetic Wound Care – Keep limb clean and protected and debride any nonviable tissue.
Edema Control
• Elastic wraps: Most commonly _________. Must use figure-of-8 elastic wrapping, which should begin immediately after surgery and should ideally be rewrapped qid. May be time consuming.
• Elastic socks: Alternative to wraps. Not expensive and easy to apply.
• _________ dressings: Protective. Allow for weight bearing to desensitize the limb. Examples include the immediate postoperative-fitting prosthesis, which is not removable and therefore inhibits ability to check and desensitize the skin. The removable rigid dressing is custom made and allows for wound inspection and desensitization.
_______ _______ massage should be instituted as soon as tolerated to help prevent adherence of the scar to the underlying soft tissues and bone. Once the sutures are removed, the massage can be performed more aggressively.
Post-Amputation Pre-Prosthetic Wound Care – Keep limb clean and protected and debride any nonviable tissue.
Edema Control
• Elastic wraps: Most commonly Ace bandages. Must use figure-of-8 elastic wrapping, which should begin immediately after surgery and should ideally be rewrapped qid. May be time consuming.
• Elastic socks: Alternative to wraps. Not expensive and easy to apply.
• Rigid dressings: Protective. Allow for weight bearing to desensitize the limb. Examples include the immediate postoperative-fitting prosthesis, which is not removable and therefore inhibits ability to check and desensitize the skin. The removable rigid dressing is custom made and allows for wound inspection and desensitization.
Scar mobilization massage should be instituted as soon as tolerated to help prevent adherence of the scar to the underlying soft tissues and bone. Once the sutures are removed, the massage can be performed more aggressively.
Anticontracture Management – Due to muscle imbalance. AKA commonly develop ______, hip ______, and hip ______ rotation contractures. In addition, BKA develop KF contractures. Prevent with a firm mattress, prone lying 15 minute tid, and promoting knee extension while resting. A posterior splint to maintain knee extension can be considered for patients at higher risk.
Anticontracture Management – Due to muscle imbalance. AKA commonly develop HF, hip abduction, and hip external rotation contractures. In addition, BKA develop KF contractures. Prevent with a firm mattress, prone lying 15 minute tid, and promoting knee extension while resting. A posterior splint to maintain knee extension can be considered for patients at higher risk.
Preprosthetic and Prosthetic Training – Hip AROM and strengthening exercises are key. A good test to determine cardiovascular tolerance for prosthesis use is ambulation with a ______ (without a prosthesis). Prosthetic gait training should begin with ______ ______ and progress to walkers or canes. Crutches should be avoided since they promote poor gait patterns. The definitive prosthesis is usually created at ______ to ______ months.
Preprosthetic and Prosthetic Training – Hip AROM and strengthening exercises are key. A good test to determine cardiovascular tolerance for prosthesis use is ambulation with a walker (without a prosthesis). Prosthetic gait training should begin with parallel bars and progress to walkers or canes. Crutches should be avoided since they promote poor gait patterns. The definitive prosthesis is usually created at 3 to 6 months.
TRANSTIBIAL PROSTHETICS: Socket Designs: The socket connects the residual limb to the rest of the prosthesis and plays an important role in the transfer of body weight to the ground (Fig. 4-4).
The PTB socket is an old term for the ______ ______ ______. The ______ tendon actually only bears a moderate load. Weight is distributed over many areas (see “pressure-tolerant areas” in Fig. 4-5), but not over the bony prominences.
For any socket, soft inserts made of polyethylene foam or silicone gel provide extra protection, e.g., for cases of PVD or extensive scarring. The inserts, however, reduce the intimacy of contact between the limb and prosthesis, which is important for ______. A soft foam distal end discourages ______ ______ formation.
TRANSTIBIAL PROSTHETICS: Socket Designs: The socket connects the residual limb to the rest of the prosthesis and plays an important role in the transfer of body weight to the ground (Fig. 4-4).
The PTB socket is an old term for the total contact socket. The patellar tendon actually only bears a moderate load. Weight is distributed over many areas (see “pressure-tolerant areas” in Fig. 4-5), but not over the bony prominences.
For any socket, soft inserts made of polyethylene foam or silicone gel provide extra protection, e.g., for cases of PVD or extensive scarring. The inserts, however, reduce the intimacy of contact between the limb and prosthesis, which is important for proprioception. A soft foam distal end discourages verrucous hyperplasia formation.
TRANSTIBIAL PROSTHETICS: Selected Suspension Options
Differential Pressure (Silicone Suction with Shuttle Lock) – A flexible, molded silicone liner is rolled directly onto the residual limb and secured to the socket with a pin. This provides optimal suspension and proprioception, but requires stable limb volumes and good hand dexterity for donning/doffing.
Anatomic – A _______ _______ is an extension of the socket over the femoral epicondyles. This design is easy to don/doff, provides mediolateral knee stability, and is useful for _______ limb lengths.
The supracondylar cuff clips on above the epicondyles and is a common suspension option. This design is not indicated in patients with very short residual limbs or with mediolateral knee instability. A supracondylar cuff with fork strap and waist belt suspension provides additional stability for very active patients, e.g., manual laborers.
Sleeve – An elastic sleeve can serve as a primary or secondary suspension via longitudinal tension and negative pressure during swing phase. It can provide additional security for short residual limbs, when medio-lateral knee stability is questionable, or when hyperextension control is required (Fig. 4-6).
TRANSTIBIAL PROSTHETICS: Selected Suspension Options
Differential Pressure (Silicone Suction with Shuttle Lock) – A flexible, molded silicone liner is rolled directly onto the residual limb and secured to the socket with a pin. This provides optimal suspension and proprioception, but requires stable limb volumes and good hand dexterity for donning/doffing.
Anatomic – A brim suspension is an extension of the socket over the femoral epicondyles. This design is easy to don/doff, provides mediolateral knee stability, and is useful for short limb lengths.
The supracondylar cuff clips on above the epicondyles and is a common suspension option. This design is not indicated in patients with very short residual limbs or with mediolateral knee instability. A supracondylar cuff with fork strap and waist belt suspension provides additional stability for very active patients, e.g., manual laborers.
Sleeve – An elastic sleeve can serve as a primary or secondary suspension via longitudinal tension and negative pressure during swing phase. It can provide additional security for short residual limbs, when medio-lateral knee stability is questionable, or when hyperextension control is required (Fig. 4-6).
Solid Ankle Cushioned Heel Foot – SACH feet are light, durable, inexpensive, and stable. The _____ heel simulates _____ during heel strike (Fig. 4-7A).
Solid Ankle Cushioned Heel Foot – SACH feet are light, durable, inexpensive, and stable. The soft heel simulates PF during heel strike (Fig. 4-7A).
Single-Axis Foot – These feet are heavier but less _____ than the SACH feet. They are most commonly used for _____ amputees, i.e., when knee _____ is desired (a quick foot flat improves knee stability). Only _____ axis movement is allowed.
Single-Axis Foot – These feet are heavier but less durable than the SACH feet. They are most commonly used for TF amputees, i.e., when knee stability is desired (a quick foot flat improves knee stability). Only sagittal axis movement is allowed.
Multiaxis Foot (Greissinger, Endolite Multiflex, SAFE II, TruStep) – The multiaxis foot allows _____/_____, inversion/eversion, and rotation, which improve balance and coordination. It provides good shock absorption and is good for uneven ground, but is heavy, costly, and needs relatively frequent adjustments or repairs.
Multiaxis Foot (Greissinger, Endolite Multiflex, SAFE II, TruStep) – The multiaxis foot allows PF/DF, inversion/eversion, and rotation, which improve balance and coordination. It provides good shock absorption and is good for uneven ground, but is heavy, costly, and needs relatively frequent adjustments or repairs.
DER Foot (Seattle Light, Carbon Copy II, Quantum Foot, Flex-Foot, SpringLite) – These feet were formerly called “energy-storing feet,” but they have not demonstrated a reduction in the energy cost or rate of energy expenditure during level walking, compared with the SACH foot.3 They may, however, be more efficient than other feet at _____ speeds. _____ amputees benefit from the light weight of these feet (Fig. 4-7B).
DER Foot (Seattle Light, Carbon Copy II, Quantum Foot, Flex-Foot, SpringLite) – These feet were formerly called “energy-storing feet,” but they have not demonstrated a reduction in the energy cost or rate of energy expenditure during level walking, compared with the SACH foot.3 They may, however, be more efficient than other feet at higher speeds. Geriatric amputees benefit from the light weight of these feet (Fig. 4-7B).
Traditional Socket Designs
TF sockets are often fitted in slight (5°) _______ and _______ to stretch the hip _______ and _______ and give them a mechanical advantage.
Traditional Socket Designs
TF sockets are often fitted in slight (5°) flexion and adduction to stretch the hip extensors and abductors and give them a mechanical advantage.
QUADRILATERAL DESIGN
This ischial–gluteal weight–bearing, narrow _______ design was originally designed by Inman and Eberhart at UC Berkeley in the 1950s. It has four sides and four corners. It is easy to make and fit but less stable for _______ residual limbs and less comfortable when sitting than the ischial containment design (Fig. 4-8A).
QUADRILATERAL DESIGN
This ischial–gluteal weight–bearing, narrow anteroposterior design was originally designed by Inman and Eberhart at UC Berkeley in the 1950s. It has four sides and four corners. It is easy to make and fit but less stable for shorter residual limbs and less comfortable when sitting than the ischial containment design (Fig. 4-8A).
ISCHIAL CONTAINMENT DESIGN
A “bony lock” incorporates the ischial _______, _______ _______, and greater trochanter. The posterior rim provides ischial–gluteal weight bearing and is contoured for the ischial tuberosity and gluteal muscles. These features improve stability, particularly for shorter residual limbs. The narrow medio-lateral design also provides a more efficient energy cost of ambulation than the narrow anteroposterior design at high _______ (Fig. 4-8B).
ISCHIAL CONTAINMENT DESIGN
A “bony lock” incorporates the ischial tuberosity, pubic ramus, and greater trochanter. The posterior rim provides ischial–gluteal weight bearing and is contoured for the ischial tuberosity and gluteal muscles. These features improve stability, particularly for shorter residual limbs. The narrow medio-lateral design also provides a more efficient energy cost of ambulation than the narrow anteroposterior design at high speeds (Fig. 4-8B).
Suction – ________ socket pressure maintains prosthetic attachment during swing phase. The ________ ________ is pulled through a one-way valve hole. Its use is indicated in active amputees with well-shaped, nonfluctuating residual limbs.
Suction – Subatmospheric socket pressure maintains prosthetic attachment during swing phase. The sock bandage is pulled through a one-way valve hole. Its use is indicated in active amputees with well-shaped, nonfluctuating residual limbs.
Silesian Belt or Bandage – A belt that attaches from the socket at the greater trochanter and wraps around the ________ ________ ________ (Fig. 4-9A).
Silesian Belt or Bandage – A belt that attaches from the socket at the greater trochanter and wraps around the opposite iliac crest (Fig. 4-9A).
Total Elastic Suspension (Belt) – Wraps around the proximal prosthesis and waist, enhancing ________ control. It retains body heat and has limited durability (Fig. 4-9B).
Total Elastic Suspension (Belt) – Wraps around the proximal prosthesis and waist, enhancing rotational control. It retains body heat and has limited durability (Fig. 4-9B).
Pelvic Band and Belt Suspension – A rigid belt is connected to a metal hip joint on the lateral side of the socket. It is indicated for improving rotational and mediolateral pelvic stability in ________ patients with significant redundant tissue or weak abductors with short or poorly shaped amputations. It is heavy and bulky and tends to interfere with ________ (Fig. 4-9C).
Pelvic Band and Belt Suspension – A rigid belt is connected to a metal hip joint on the lateral side of the socket. It is indicated for improving rotational and mediolateral pelvic stability in obese patients with significant redundant tissue or weak abductors with short or poorly shaped amputations. It is heavy and bulky and tends to interfere with sitting (Fig. 4-9C).
