Q: 1 out of every ______ Americans will undergo an amputation.
T/F: Amputations rates decrease with age and are twice as common in women.
False: increase, men
Q: Over ____% of lower extremity amputations are due to ___________ disease and/or _________.
80, vascular, neuropathy
Q: Over ____% of upper extremity amputations are due to _____
Q: What are 3 other causes of amputation?
1. Cancer 2. Infection 3. Congenital limb defects
Q: Who is peripheral vascular disease (PVD) most common in?
African Americans followed by Native Americans and Hispanics, then Caucasians
T/F: Peripheral vascular disease is associated with diabetes and/or smoking.
Q: Diabetes alone increases the risk of intermittent claudication by _______x, even after controlling for HTN, smoking, and cholesterol
Q: What comorbidities increase risk for PVD and amputation? (4)
1. Obesity 2. HTN 3. Hyperlipidema 4. Nephropathy
T/F: 40% of amputations in those with diabetes are preceded by a foot ulceration.
False, Most ~85%
Q: ____% of those with PVD results in amputation will eventually undergo _________ amputations.
Q: What is the 30 day mortality rate follow a major leg amputation?
As high as 40%
Q: What is the 5 year mortality for amputation?
As high as 70%
Q: Who is traumatic amputation more common in?
Q: Within what window must re-plantation of a traumatic amputation occur?
12 hour window
Content: Traumatic Amputation Causes (4)
1. MVA 2. Violence related combat injuries 3. Severe burns 4. Electrocution
Q: The lifetime cost of amputation is as much as ___ times higher than salvage.
T/F: The risk of subsequent hospitalization is lower after salvage.
T/F: Amputations may result in better functional outcomes
T/F: Amputation may be more psychologically acceptable.
Content: Malignancy and Amputation (2)
1. Can be due to primary cancer or metastatic disease 2. More commonly involve the lower limbs
Q: Why are amputation rates declining? (3)
1. Earlier diagnoses 2. Improved chemotherapy 3. Limb salvage/reconstruction techniques
T/F: Children are miniature adults.
Q: What is ratio of male to female pediatric amputations?
Q: _____% of pediatric amputations are congenital and _____% are acquired.
Content: Acquired pediatric amputations (3)
1. 90% are single limb 2. 60% are LE 3. Most result from trauma
Content: Pediatric amputation (4)
1. Disarticulation minimizes growth plate disruption 2. Must consider longitudinal and circumferential growth 3. Excellent circulation enhances wound healing 4. Superior tissue tolerance may allow early post-op prosthetic fitting
LE Amputation Term: Excision of portion of 1 or more toes
LE Amputation Term: Disarticulation at MTP joint
LE Amputation Term: Resection of 3rd, 4th, and/or 5th, MTs and digits
Partial foot/ray resection
LE Amputation Term: Amputation through long axis of all MTs
LE Amputation Term: Ankle disarticulation with preservation of heel pad
LE Amputation Term: Retains > 50% of tibial length
LE Amputation Term: Retains < 50% of tibial length
LE Amputation Term: Amputation through knee with intact femur
LE Amputation Term: Retains > 50% of femoral length
LE Amputation Term: Retains < 50% of femoral length
LE Amputation Term: Amputation through hip joint, pelvis intact
LE Amputation Term: Resection of half of the pelvis
LE Amputation Term: Amputaiton of both LEs and pelvis below L4-5
UE Amputation Term: Excision of one or more fingers
UE Amputation Term: Disarticulation at MCP joint
UE Amputation Term: Resection through long axis of MTCs
UE Amputation Term: Amputation of hand with preservation of wrist
UE Amputation Term: Amputation of hand and carpals
UE Amputation Term: Amputation through radius and ulna
UE Amputation Term: Disarticulation of elbow
UE Amputation Term: Amputation through humerus
UE Amputation Term: Amputation through shoulder joint
UE Amputation Term: Amputation of humerus, scapula, and clavicle
Content: Surgical Principles of Amptuation (5)
1. Maintain adequate circulation for wound/incision healing 2. Remove damaged or involved tissues 3. Preserve as many anatomical joint as possible, esp. knee 4. Preserve maximal bone length 5. Provide residual limb that will accept prosthesis and tolerate WB
Content: Surgical considerations for dysvascular patients often present with (4)
1. Comorbidities 2. Neuropathy 3. Vascular compromise 4. Infection/osteomyelitis
Content: Surgical considerations for traumatic injuries often involve (2)
1. Open, comminuted fx with soft tissue loss 2. Vascular/nerve disruption
Content: Surgical considerations for cancer-related amputation is indicated in (4)
1. High grade neoplasms 2. Proximal lesions 3. Risking pathologic fx or neurovascular involvement 4. Recurrent disease
T/F: Amputation is among the oldest medical procedures
Q: Why must muscle length be preserved with amputation?
To prevent contracture and atrophy
Content: Muscle Stabilization (Closure) Techniques (5)
1. Myodesis 2. Tenodesis 3. Myofascial 4. Myopasty 5. Open (guillotine), provisional, or delayed closure
Term: Transected muscles are re-attached by suturing through drill holes at distal end of the bone.
Term: Intact tendon(s) re-attached to bone
Term: Fascial envelope is sutured over transected muscles
Term: Suturing of one muscle group to its antagonist
Content: Osteomyoplasty (3)
1. Used in transtibial amputation 2. Bone bridge harvested from tibia 3. Bridge connects distal ends of tibia and fibula
Q: What are the benefits osteomyoplasty? (2)
1. Prevents chopsticking of distal bone ends 2. Improves WB on residual limb
Content: Post-Op complications of amputation (5)
1. Contracture 2. Edema 3. Phantom limb sensation or pain 4. Personal grief/depression 5. Sx complications (i.e. pain, infection, respiratory compromise, DVT, etc)
Content: Acute Post-Sc Exam (14 - general idea)
1. Medical history 2. Social situation 3. Pain level 4. Sensation / Proprioception 5. A/AROM or PROM 6. Strength 7. Bed mobility 8. Sitting / Standing balance 9. Transfers 10. Locomotion: gait and/or wheelchair 11. Endurance 12, Home and work environment 13. Barriers to care or adjustment 14. Knowledge: limb care and prosthetic use
Content: Goals of acute rehab (5)
1. Prevent complications and allow healing 2. Develop limb strength and ROM for prosthesis 3. Maximize independence in mobility and ADLs 4. Pre-prostehtic training and limb preparation 5. Endurance training and initiation of HEP
Content: Amputation Education (5)
1. Positioning 2. Residual limb care 3. Protection of contralateral limb 4. Prosthetic info and time frame 5. Support smoking cessation
Content: Post-surgical phase (4)
1. Compression 2. ROM 3. Positioning 4. Endurance
Q: When does the post-surgical phase end?
When pt. is provided with a definitive prosthesis
Content: Post-op Dressing - Rigid dressing (2)
1. Immediate Post Op Prosthesis (IPOP) 2. Plaster socket with removable pylon and foot
Content: Advantages of Rigid Dressing (6)
1. Limits edema 2. Reduces pain 3. Prevents contracture 4. Allows early WB/gait 5. Easier move to definitive prosthesis
Content: Disadvantages of Rigid Dressing (3)
1. Difficult to apply 2. Requires very close supervision 3. Cannot visualize wound or residual limb
Content: Post-op Dressing - Rigid Removable Dressing (RRD) (2)
1. After suture/staple removal, a polypropylene or cast is fist from an impression of the residual limb 2. The RRD is worn over the wound dressing or compression socks
Content: Advantages of RRD (4)
1. Allows skin inspection 2. Provides consistent pressure 3. Easily donned 4. Protects residual limb
Content: Disadvantages of RRD
May require frequent refitting
Content: Post-Op Dressing - Semi-Rigid Dressing (2)
1. Zinc-oxide, gelatin, glycerin, and calamine compound 2. Applied in OR or PACU
Content: Advantages of Semi-Rigid Dressing (6)
1. Controls edema 2. Adheres to skin 3. Allows some ROM 4. Breathable 5. Inexpensive 6. Easy to contour
Content: Disadvantages of Semi-Rigid Dressing (3)
1. Loses effectiveness as edema resolves 2. Not as protective 3. May permit contracture formation
Content: Post-Op Dressing - Soft Dressing (2)
1. Incision dressed with 4x4s and Kerlix 2. Compression provided with ACE bandages or elastic shrinker
Content: Advantages of Soft Dressing (3)
1. Inexpensive 2. Lightweight 3. Readily available
Content: Disadvantages of Soft Dressing (4)
1. Inconsistent, weak compression 2. Requires frequent re-wrapping and replacement 3. Does not prevent contracture 4. Difficult for pt. to self apply
Content: ACE Wrapping Amputations (4)
1. Must be rewrapped every 4-6 hrs 2. distal to proximal pressure gradient 3. Figure 8 pattern to prevent tourniquet effect 4. Pt. and caretaker education
Q: How should an ACE wrap be applied to a BKA?
Pull in medial to lateral, posterior to anterior direction
Q: How should an ACE wrap be applied to AKA?
Include adductor tissue (prevent adductor roll) and pull into extension and adduction
Defn: Limb Shrinkers
Elastic socks that help decrease edema and assist in shaping the residual limb
Q: What is the pressure gradient for limb shrinkers?
Distal to proximal
T/F: AKA socks do not require waist belts.
T/F: Intermittent claudication is very predictable.
Not enough vascular supply to support the demand, results in pain typically in the calf
Defn: Limb socks
Used between residual limb and prosthetic socket for protection, friction absorption, and to fill socket volume
Content: Limb sock (4)
1. Absorbs perspiration 2. Allows optimal socket fit and contact 3. Cotton, wool, or blended fabric 4. 1, 3, and 5 ply socks can be layered up to 15 ply
Video: AKA Post-Op Bandaging
Video: Residual Limb Care
Video: BKA Prosthetics
Video: AKA Prosthetics
Video: Bilateral AKA
T/F: Phantom sensation is normal.
Content: Phantom Limb Sensation (4)
1. Painless awareness of the amputated body part 2. Incomplete sensation, often mild tingling 3. Occurs in over 90% of the traumatic/Sx amputees 4. Usually persists throughout life
Defn: Phantom Limb Pain
Painful sensation of amputated body part, described as cramping, squeezing, burning, or shooting
Content: Phantom Limb Pain (4)
1. Can be consistent or intermittent, with varying intensity 2. 30-75% incidence 3. Uncommon in individuals with congenital amputation 4. More common after crush injury or amputation in later life
Content: Interventions for Phantom Pain (6)
1. Desensitization and massage 2. Compression 3. Exercise 4. Limb handling and use 5. Modalities: TENS, US, icing 6. Psychological counseling
Content: Mirror Therapy (3)
1. Pt. performs a movement with the unaffected limb 2. Movement is viewed in mirror positioned in front of pt. 3. Simultaneously, pt. attempts to perform the movement with their residual or phantom limb
Q: How long does scar maturation continue?
Up to 1 year
Q: Skin integrity andpressure tolerance is only ____% of normal.
Content: Desensitization and MAssage (3)
1. Initiate gentle touch and textural stimulation after wound is closed 2. Initiate scar and deep friction massage after the incision is fully healed 3. Massage to residual limb should be used as an adjunct to daily skin inspection and care routine
Content: Positioning - Initiate the following as soon as allowable (3)
1. ROM 2. Prone positioning 3. Wrapping/shrinker
Content: Positioning (3)
1. Should start immediately 2. Optimize both in and out of bed 3. Monitor edema and limb volume fluctuation
Content: Modern Amputation Technique (5)
1. Skin/muscle flaps made anterior and posterior 2. dissect, clamp, cut A&V 3. Dissect nerve and retract back into tissue 4. Severe bone, make a smooth edge 5. Close muscle and skin flaps
Content: TherEx (4)
1. Maintain full ROM 2. Strengthen hip ext, add, and knee ext 3. CC exercise and functional activites 4. CV endurace
Q: Unilateral BKA increases energy cost of ambulation by ____%.
Q: Unilateral AKA increases energy cost of ambulation by ____%.
Q: Energy cost for ambulation of a bilateral BKA is ______ than a unilateral AKA.
Q: Hip disarticulation increases energy cost of ambulation by ____%.
Q: Bilateral AKA increases energy cost of ambulation by ____%.
Q: When should you begin transfer training?
POD1 if medically stable
T/F: Transfer prosthesis is not useful for non-ambulatory pts.
False, may be useful
Q: How should position roller walker?
Pts. elbow in full extension
Q: What is the largest factor in determining WC use for amputees?
Energy cost of ambulation
Content: WC setup considerations (3)
1. Offset rear axis 2. Power system 3. Anti-tip system
Q: What is dehissing?
When an amputation incision reopens
Q: What are the 2 best predictors of prosthetic potential?
1. Level of amputation 2. Pre-Sx function
Q: What 2 types of amputations can be functionally independent with prosthesis?
Unilateral BKA Bilateral BKA
T/F: Most bilateral AKA amputees are prosthetic users.
Content: Contraindications to prosthetic use (5)
1. Dementia 2. Institutionalization 3. Adv cardiopulm or neurologic disease 4. Bilateral transfemoral amputation with inability to transfer/stand 5. Unacceptable energy expenditure for ambulation
T/F: You can develop contractures with amputations no matter how far out you are.
Content: Residual Limb Requirements (5)
1. Fully healed incision 2. No signs of infection 3. No drainage from incision site 4. Ability to tolerate to WB 5. Frequent skin inspection
Content: Components to selection of prosthetic parts (4)
1. Age 2. Activity level/vocational demands 3. Funding sources 4. Compliance
T/F: Pt. and PT must have understanding of selected components and their functional implications.
T/F: Temporary prostheses are intended for full time wear until the permanent prosthesis is available.
Q: When is the definitive socket provided?
Content: Temporary Prosthesis (5)
1. Shapes residual limb 2. Allows early gait training and independence 3. Evaluation for potential prosthetic use 4. Allows endurance training 5. Discourages contracture development
Content: Progression of gait training (3)
1. Parallel bars: sit to stand, SLB, weight shifting 2. Walker: stand to stand, hopping, stepping 3. Functional tasks: reaching, bending, turning
Q: What should be emphasized with gait training?
Stance and stability on prosthesis
Content: Advanced Gait Training (8 - general idea)
1. Step up/downs onto prosthetic leg 2. Resisted ambulation 3. Running and jumping 4. Transfers to and from the floor 5. Uneven terrain, congested community ambulation 6. Curb and stair training 7. Reaching 8. Lifting and carrying objects
Content: When to refer to the prosthetist (4)
1. Weight gain 2. Volume changes 3. ROM 4. Functional changes
T/F: As a PT you can make significant adjustments to prosthesis without input from the prosthetist
Q: What 2 types of prostheses are typically used with UE?
1. Harness 2. body powered cable control systems
Q: What is often and issue with UE prosthetics, esp. with pediatric pts.
Q: What type of control systems are becoming increasingly prevalent in UE prosthetics?
Term: indicated if severe infection or toxicity are present