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Flashcards in Amputation Deck (23):
1

In the United States, upper extremity amputations are

(a) most often due to vascular disease.
(b) more common in males than females.
(c) rarely caused by workplace injuries. Page 6 of 23

(d) increasing due to the relaxing of occupational safety standards.

Answer: (b) Commentary: Of all upper extremity amputations, 90% are due to trauma. The majority of these are related to workplace injuries involving saws or blades. Males account for 75% of all upper extremity amputations. Trauma related amputations have decreased over the last 20 years and they are expected to remain flat or decrease, due to ongoing enforcement of safety standards.

Reference: Sheehan TP. Rehabilitation and prosthetic restoration in upper limb amputation. In: Braddom RL, editor. Physical medicine and rehabilitation. 4th ed. Philadelphia: Elsevier
Saunders; 2011. p 257

2013

2

You see a patient in clinic with what appears to be a non-infected diabetic foot ulcer over the first
metatarsal head and order an ankle-brachial index (ABI) study. The patient’s ABI is 1.4. What is
your next step in treatment?

(a) Proceed with off loading the ulcer, since blood flow is normal.
(b) Order additional testing, such as an arterial duplex.
(c) Refer for to vascular surgery for urgent revascularization.
(d) Refer for consideration of a transmetatarsal amputation.

Answer: (b)
Commentary: Evaluation of vascular status is critical in any patient presenting with diabetic ulcer. The ABI is considered a useful screening tool to look for peripheral arterial disease. Values under 0.91 are considered consistent with peripheral arterial disease. However, calcified vessels can lead to higher values and possibly false negative test results. If ABI is >1.3, this most likely due to calcified, non-compressible vessels; therefore, other means of testing vascular status should be used.

Reference: Salameh MJ, Ratchford EV. Update of peripheral arterial disease and claudication rehabilitation. Phys MedRehabil Clin N Am 2009;20:632.

2013

3

Comparing lower limb amputations to upper limb amputations in the United States, lower limb
amputations are

(a) most often due to trauma.
(b) expected to significantly increase over the next 20 years due to increasing rates of
diabetes mellitus.
(c) less common than upper extremity amputations.
(d) expected to decrease over time due to improved prenatal care leading to less congenital
malformations.


Answer (b)
Commentary: The prevalence of diabetes mellitus continues to increase in the United States and this trend is expected to cause increasing rates of lower extremity amputation. Lower extremity amputations are more common than upper extremity amputations and are more likely to be related to dysvascular causes. Despite improvements in prenatal care enabling more births, rates
of amputations due to congenital defects have not changed significantly. The most common cause of upper extremity limb loss is trauma-related injury

2012

4

Of the following modalities, which is the most effective in treating phantom limb pain?

(a) Iontophoresis
(b) Transcutaneous electrical nerve stimulation
(c) Short wave diathermy
(d) Paraffin baths


Answer: (b)
Commentary: Of the options listed, transcutaneous electrical nerve stimulation (TENS) is the
modality that may be useful in treating phantom limb pain. Iontophoresis is generally used for
dispersion of medications. Short wave diathermy is a method of deep heat. Paraffin bath is a
superficial heat modality.

2011

5

A patient with a left transfemoral amputation demonstrates a lateral trunk lean towards his
prosthetic side. What is the most likely cause?

(a) Prosthesis too long
(b) Long residual limb
(c) Prosthesis aligned in adduction
(d) Hip abduction contracture


Answer: (d)
Commentary: Causes of lateral trunk lean towards the prosthetic side include: prosthesis too
short, hip abduction contracture, prosthesis lined in abduction, and short residual limb

2011

6

Comparing lower limb amputations to upper limb amputations in the United States, lower limb
amputations are
(a) most often due to trauma.
(b) expected to significantly increase over the next 20 years due to increasing rates of
diabetes mellitus.
(c) less common than upper extremity amputations.
(d) expected to decrease over time due to improved prenatal care leading to less congenital
malformations.

Answer (b)
Commentary: The prevalence of diabetes mellitus continues to increase in the United States and
this trend is expected to cause increasing rates of lower extremity amputation. Lower extremity
amputations are more common than upper extremity amputations and are more likely to be
related to dysvascular causes. Despite improvements in prenatal care enabling more births, rates
of amputations due to congenital defects have not changed significantly. The most common cause
of upper extremity limb loss is trauma-related injury.

2012

7

What is the primary benefit of using a postoperative, rigid, non-removable dressing in a new
transtibial amputee?
(a) Improved monitoring of postoperative wounds
(b) Protection of the wound and edema control
(c) Prevention of hip flexion contractures
(d) Improved strength in the residual limb

Answer (b)
Commentary: The primary benefits of a rigid dressing include wound protection, edema control
and prevention of knee flexion contractures (not hip flexion contractures). Monitoring the wound
may be more difficult with a non-removable rigid dressing. The dressing should be removed for
wound check regularly and if there is a concern for infection. Type of postoperative dressing has
no effect on residual limb strength.

2012

8

A 45-year-old man with a history of transtibial amputation secondary to trauma presents to your
office 6 months following surgery. He is successfully ambulating independently with his
prosthesis. His chief complaint today is new mild phantom limb pain. Evaluation does not reveal
any significant problems with his prosthesis or gait. What treatment would you recommend to
decrease his phantom limb pain?
(a) Cryotherapy
(b) Ultrasound
(c) Desensitization
(d) Paraffin wax

Answer (c)
Commentary: First line treatment for phantom limb pain should include use of desensitization
techniques (massage, friction rubbing, wrapping, etc.) The other types of therapeutics listed
would not be effective in phantom limb pain management. Phantom limb pain is one of many
sources of pain in an amputee and is difficult to treat. It affects anywhere from 67% to 79% of
amputees. For patients whose pain interferes with function and quality of life, a biopsychosocial
approach to pain management is crucial.

2012

9

In a transfemoral amputee, a circumducted gait pattern, on the prosthetic side, could be caused by
which factor?
(a) Insufficient prosthetic knee friction
(b) Long prosthetic limb
(c) Hip flexion contracture
(d) Poor balance

Answer (b)
Commentary: When observing gait deviations in an amputee, one should consider both the
prosthetic issues and amputee compensatory maneuvers as a potential cause for the deviation. A
circumducted gait pattern can have various causes, including a long prosthetic limb, excessive
prosthetic knee friction (making it difficult to bend the knee), and hip abduction contracture. Poor
balance is usually associated with excessive lateral trunk bending, uneven arm swing, and short
stance phase on the prosthetic side.

2012

10

A 65-year-old woman with diabetes who will be undergoing an elective transtibial amputation due to a nonhealing wound consults you regarding her upcoming surgery. Which postoperative dressing would you recommend to promote wound healing and prevent postoperative complications?

A. Elastic bandages
B. Nonadhesive gauze
C. Stump shrinker compressive bandage
D. Removable or nonremovable postoperative cast

Option d is correct.

The major tenets of postoperative wound management following transtibial amputation are edema control, wound protection and prevention of knee flexion contracture. This is best done with a rigid dressing. Elastic bandages and stump shrinkers can help control edema but may be applied inappropriately. They also do not protect the wound from trauma or prevent knee flexion contracture.

2014

11

Which lower extremity amputee group has the highest probability of successful mobility?

a. Dysvascular bilateral transtibial over age 85
b. Dysvascular unilateral transtibial under age 85
c Traumatic unilateral transtibial under age 85
d Traumatic unilateral transtibial over age 85

Option c is correct.

The person with a traumatic lower extremity amputation has higher mobility success: 97% of traumatic amputees are ambulating at 3 months. Dysvascular amputees can be successful ambulators but at a lower rate than traumatic amputees. Mobility success in bilateral amputees is less than unilateral amputees. Two studies report that 70% of bilateral transtibial amputees use their prostheses for ambulation. Age greater than 85 years is associated with very low rate of mobility success (2% success in 1 study).

2014

12

What is the 5-year mortality rate for persons with diabetes after sustaining a major lower limb amputation?
(a) 15%
(b) 25%
(c) 33%
(d) 50%

(d)
At least 50% of persons with diabetes and peripheral arterial disease who undergo major limb amputation will die within 5 years of sustaining major lower limb amputation.

2008

13

An advantage of a knee disarticulation compared to a transfemoral amputation is that the knee disarticulation offers
(a) more options for a prosthetic knee.
(b) enhanced ability to create power during ambulation or running.
(c) better soft tissue coverage within the zone of injury.
(d) better prosthetic cosmesis.

(b)
Disarticulation results in a bulbus distal residual limb, which may complicate prosthetic fitting. Choice of prosthetic knee options for a person with a knee disarticulation, therefore, is limited and potentially excludes the newer, more advanced knee-joint designs. Benefits of a knee disarticulation over a transfemoral approach include greater tolerance to distal limb weight bearing, a longer lever arm to create power during ambulation and running, and improved sitting balance. Of note, functional outcome studies of trauma-related lower extremity amputees concluded that persons with through knee amputations had significantly poorer outcomes. These poorer outcomes are attributed to complications arising from soft tissue failure within the zone of injury.

2008

14

The most common congenital limb deficiency is
(a) right transtibial limb deletion.
(b) right transradial limb deletion.
(c) left transtibial limb deletion.
(d) left transradial limb deletion.

(d)
The most common congenital limb deficiency is the left midlength transradial deficiency.
Ref: Gaebler-Spira D, Uellendahl J. Pediatric

2008

15

In adults, the prevalence of phantom limb pain, phantom sensation or residual limb pain after amputation is
(a) approximately 70% at 6 months postamputation.
(b) dependent on age at the time of amputation.
(c) directly related to surgical technique.
(d) primarily dependent upon the level of amputation.

(a)
Phantom sensation, phantom pain, and residual limb pain have all been reported about equally in over 70% of amputees 6 months or more after lower limb amputation. This is typically not dependent upon the person's age at the time of amputation, the level of amputation, or surgical technique.

2008

16

Proper positioning for a transtibial amputee should include use of a
(a) pillow underneath thigh.
(b) pommel between legs.
(c) limb board underneath knee.
(d) wedge cushion underneath buttocks.

Answer: (c)
Commentary: A limb board placed underneath the knee will help to prevent knee flexion
contractures. Placing a pillow underneath the thigh would encourage the development of a hip
flexion and possibly a knee flexion contracture. A pommel between the legs may encourage a hip
abduction contracture. A wedge cushion would promote hip flexion contractures.

2011

17

In a transtibial amputee, ambulation with a prosthesis, instead of unilateral non-weight bearing (with crutches) results in
(a) higher rate of energy expenditure.
(b) lower heart rate.
(c) higher respiratory exchange rate.
(d) equivalent amounts of energy to walk the same distance.

(b) Transtibial amputees have a lower rate of energy expenditure, heart rate and oxygen consumption when using a prosthesis (vs. non-weight bearing crutch gait). The cardiovascular demand of crutch walking is high, with increased rate of oxygen consumption, increased heart rate, increased energy costs, and respiratory exchange rate in the anaerobic range

2007

18

You have just finished admitting a 60-year-old man with diabetes who has recently undergone a
right below-knee amputation. The patient's son stops you in the hallway and inquires about his
father's health status and prognosis for walking again. You have never met the patient's son before,
and before answering the questions, you would first
(a) further review the patient's medical record and determine the patient's cardiac status.
(b) perform a literature review of outcomes research in individuals with below-the-knee
amputations.
(c) ask the patient for permission to discuss his health status with his son.
(d) ask the son if the patient has a living will or a health care power-of-attorney

(c) Maintaining confidentiality of patient information is important even when discussing health
information with family members. Before discussing the patient's health status with his son, the
appropriate first step would be to ask the patient for permission. The other options listed would not
be appropriate initial management strategies.

2006

19

Which factor is a known risk for the development of depression following amputation?

A. Higher income levels
B. Dysvascular etiology
C. Phantom limb pain
D Paucity of comorbid conditions

C

depression is noted in 21 - 35% of persons with limb loss regardless of etiology. Posttraumatic stress disorder is more associated with traumatic etiology. Phantom limb pain and back pain are risk factors for developing clinical depression in persons with limb loss. Other risk factors include low income levels and more comorbid conditions.

2015

20

What is the main advantage of a wrist disarticulation over a shorter transradial amputation?

a. Pronation and supination preserved
b. simpler socket fabrication
c. easier to fit myoelectric components
d. More prosthetic options for wrist units.

a

One of the main advantages of wrist disarticulation is preservation of supination and pronation. Wrist disarticulation creates a more complicated situation in socket fabrication. Most wrist units do not fit on wrist disarticulation prostheses making options more limited. There also tends to be less room for myoelectric components in wrist disarticulation.

2015

21

You are evaluating a patient who may require a transtibial amputation. Which factor would be associated with poor postsurgical healing?

a. ankle-brachial index higher than 0.90
b. monophasic arterial doppler ultrasound measurement
c. warm limb temperature
d. capillary refill time of 1-2 seconds.

b.

Blood flow plays a critical role in healing of the residual limb. An ankle-brachial index (ABI) greater than 0.9 is normal and values less than 0.5 are associated with wounds that are unlikely to heal. NOrmal Doppler ultrasound should reveal triphasic waveforms; monophasic recordings indicate impaired blood flow and would predict poor healing. Cold limb temperature (not warm) would be more associated with poor healing. Capillary refill time of 2 seconds or less is considered normal.

2015.

22

Of the following modalities, which is the most effective in treating phantom limb pain?

a. Iontophoresis
b. Transcutaneous electrical nerve stimulation
c. short wave diathermy
d. paraffin baths

b

Of the options listed, TENS is the modality that may be useful in treating phantom limb pain. Iontophoresis is generally used for dispersion of medications. Short wave diathermy is a method of deep heat. Paraffin bath is a superficial heat modality.

2015

23

A patient with a left transfemoral amputation demonstrates a lateral trunk lean towards his prosthetic side. What is the most likely cause?

a. prosthesis too long
b. long residual limb
c. prosthesis aligned in adduction
d. hip abduction contracture

d

causes of lateral trunk lean towards the prosthetic side include: prosthesis too short, hip abduction contracture, prosthesis aligned in abduction, and short residuall limb.

2015