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PTRS 746 > Amputation > Flashcards

Amputation Flashcards

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1
Q

how many americans will undergo amputation

A

1 in 200
rates increase with age
twice as common in men

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2
Q

What is the estimated cost of amputation?

A

over $8.3 billion dollars

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3
Q

over 80% of lower extremity amputations are due to…

A

vascular disease and/or neuropathy

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4
Q

over 70% of upper extremity amputations are due to…

A

trauma

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5
Q

what are some other causes of amputation

A

cancer (especially adolescent bone malignancies), infection, and congenital limb defects

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6
Q

In what populations is vascular disease more common, and what is it associated with?

A

Most common African americans; more common in native americans and Hispanics than Caucasians

associated with diabetes and/or smoking

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7
Q

What are some comorbidities that increase risk for PVD and amputation?

A

obesity, HTN, HLP, nephropathy

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8
Q

What does diabetes increase risk for?

A

increases risk of intermittent claudication by 4-5 times, even after controlling for HTN, smoking, and cholesterol level

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9
Q

85% of amputations in those with diabetes are preceded by…

A

foot ulceration

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10
Q

55% of those whose PVD result in amputation….

A

will eventually undergo bilateral amputations

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11
Q

what is the 30 day mortality following a major leg amputation

A

it is as high as 40%

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12
Q

what is 5 year mortality?

A

as high as 70%

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13
Q

Causes of traumatic amputation? who most likely has them?

A

MVA, work or violence related combat injuries, severe burns, electrocution

more common among younger men

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14
Q

When does reimplantation have to occur?

A

must occur within 12 hour window

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15
Q

What is also associated with traumatic amputation?

A

psychological trauma and an extended period of adjustment

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16
Q

What are advantages and disadvantages of amputation vs. salvage

A

lifetime cost of amputation as much as 3 times higher
risk of subsequent hospitalization is greater after salvage
amputation may result in better functional outcomes
salvage may be more psychologically acceptable

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17
Q

When is malignancy involved with amputation?

A

can be due to primary cancer (osteosarcoma) or metastatic disease
more commonly involved the lower limbs
declining amputation rates due to earlier diagnoses, improved chemotherapy, and limb salvage/reconstruction techniques

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18
Q

What are causes for pediatric amputation?

A

3:2 male to female ratio
60% are congenital
40% are acquired: 90% are single limb, 60% are LE, most result from trauma

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19
Q

What must be considered with pediatric amputation?

A

Disarticulation minimizes growth plate disruption

Must consider longitudinal and circumferential growth

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20
Q

What make pediatric amputations different than adult?

A

Excellent circulation enhances wound healing
Superior tissue tolerance may allow early post-op prosthetic
Children are NOT miniature adults

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21
Q

What are surgical principles that must be considered?

A

maintain adequate circulation for wound/incision healing

remove damaged or involved tissues

preserve as many anatomical joints as possible, especially the knee

preserve maximal bone length

provide residual limb that will accept prosthesis and tolerate weight bearing

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22
Q

What are surgical considerations with dysvascular patients

A

often present with comorbidities, neuropathy, vascular compromise, infection, or osteomyelitis

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23
Q

What are surgical considerations for traumatic injuries?

A

often involved open, comminuted fractures with soft tissue loss and vascular/nerve disruption

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24
Q

What are surgical considerations for cancer related amputation?

A

indicated in high-grade neoplasms, proximal lesions, those risking pathologic fractures or neurovascular involvement, or recurrent disease

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25
What is the modern technique for amputations
Skin and muscle are divided to form anterior and posterior flaps Primary arteries and veins are dissected, clamped, and severed Major nerves are dissected, severed, and allowed to retract into soft tissue Bone is severed, distal end I filed and beveled to produce smooth surface Muscle and skin flaps are sewn together, forming the residual limb
26
Why must there be muscle stabilization techniques?
muscle length must be preserved to prevent contracture and atrophy
27
What is myodesis
transected muscles are re-attached by suturing through drill holes at distal end of the bone
28
tenodesis technique
intact tendons reattached to bone
29
myofascial technique
fascial envelope is sutured over transected muscles
30
myoplasty technique
suturing of one muscle group to its antagonist
31
open (guillotine), provisional, or delayed closure technique
indicated if severe infection or toxicity are present
32
What is osteomyoplasty?
Ertl procedure, developed in 1920s and 30s used in transtibial amputation osteoperiosteal flap (bone bridge) is harvested from amputated tibia flap is implanted, bridging distal tibial and fibular ends incision is closed over bone bridge
33
Why is it important to stabilize distal tibia and fibula?
prevents chopsticking of distal bone ends | improves weight bearing on residual limb
34
What are post-operative complications
contracture, edema, phantom limb sensation or pain, personal grief and depression surgical complications: pain, infection, respiratory compromise, DVT, etc
35
What are components of acute post-surgical examination?
medical history, social situation, pain level, sensation/proprioception, A/AROM or PROM, strength, bed mobility, sitting/standing balance, locomotion (gait and/or wheelchair), endurance, home and work environment, barriers to care or adjustment, knowledge (limb care and prosthetic use)
36
What are the goals of acute rehab?
prevent complications and allow healing develop limb strength and ROM for prosthesis maximize independence in mobility and ADLs pre-prosthetic training and limb preparation endurance training and initiation of HEP
37
What must you as a PT consider when educating a patient?
consider their level of understanding and readiness to accept information you may already know them from wound care or by-pass grafting prioritize
38
What can you educate the patient on?
``` post-op goals and expectations positioning pain relief residual limb care, inspection, and handling protection of contralateral leg prosthetic information and time frame stop smoking ```
39
What is important in post surgical phase?
compression, ROM, positioning, endurance
40
What must be considered in post surgical phase?
consider vascular factors in determining time frames for wound healing and prosthetic fittings time until a temporary prosthesis can be tolerated is variable, depends largely on skin tolerance and healing ends when patient is provided with a definitive prosthesis
41
What is a IPOP?
immediate post op prosthetic | plaster socket with removable pylon and foot
42
What are advantages of IPOP?
Limits edema, reduces pain, prevents contracture, protects limb, allows early weight bearing and gait, easier move to definitive prosthesis
43
What are disadvantages of IPOP?
Difficult to apply, requires very close supervision, cannot visualize wound or residual limb
44
What is a RRD?
Rigid Removable Dressing after suture/staple removal a polypropylene or cast is fit from an impression of the residual limb RRD is worn over the wound dressing or compression socks
45
What are advantages and disadvantages of RRD?
Advantages: allows skin inspection, provides consistent pressure, easily donned, protects residual limb Disadvantages: may require frequent refitting
46
What is semi rigid dressing?
zinc-oxide, gelatin, glycerin, and calamine compound | applied in OR or PACU
47
What are advantages and disadvantages of semi rigid dressing?
advantages: controls edema, adheres to skin, allows some ROM, breathable, inexpensive, easy to contour disadvantages: loses effectiveness as edema resolves, not as protective, may permit contracture formation
48
What is a soft dressing?
incision dressed with 4x4's and Kerlix | compression provided with ACE bandages or elastic shrinker
49
What are advantages and disadvantages of soft dressing?
Advantages: inexpensive, lightweight, readily available Disadvantages: inconsistent weak compression, requires frequent re-wrapping and replacement, does not prevent contracture, difficult for patient to self-apply
50
How should you wrap and ACE bandage?
rewrapped every 4-6 hours distal to proximal pressure gradient below knee: pull in medial to lateral, posterior to anterior direction above knee: include adductor tissue (prevent adductor roll), pull into extension and adduction figure 8 pattern to prevent tourniquet effect
51
What are limb shrinkers?
Elastic socks that help decrease edema and assist in shaping the residual limb Have distal to proximal pressure gradient
52
When are limb shrinkers used?
used prior to prosthetic fitting and prosthetic wearing | worn 24 hours/day
53
How are limb shrinkers sized? What other requirements are needed?
Sizing determined by circumferential measurements and length AKA socks require waist belt MUST continue skin inspection
54
What are limb socks?
Cotton, wool or blended fabric that are used between residual limb and prosthetic socket for protection, friction, absorption, and to fill socket volume
55
Why are limb socks useful?
They absorb perspiration Allows optimal socket fit and contact 1, 3, and 5 ply socks can be layered up to 15 ply
56
What is phantom limb sensation?
painless awareness of the amputated body part | incomplete sensation, often mild tingling
57
Is phantom limb sensation normal?
YES. Occurs in over 90% of traumatic and surgical amputees. Usually persists throughout life
58
What is phantom limb pain?
Painful sensation of amputated body part.
59
How is phantom limb pain described?
Constant or intermittent, with varying intensity | Often described as cramping, squeezing, burning, or shooting pain
60
In what populations is phantom limb pain common?
More common after crush injury or amputation in later life | Uncommon in individuals with congenital amputation
61
How common in phantom limb pain?
incidence is unclear- anywhere from 30-75%
62
What are interventions for phantom pain?
``` desensitization and massage compression exercise limb handling and use modalities: TENS, US, ice psychological counseling ```
63
What is mirror therapy?
intervention for phantom pain patient performs a movement with the unaffected limb movement is viewed in mirror positioned in front of patient simultaneously, patient attempts to perform the movement with their residual or phantom limb
64
When should you start desensitization?
initiate gentle touch and textural stimulation after wound is closed initiate scar and deep friction massage after the incision is fully healed
65
When should massage be used?
Should be used as an adjunct to daily skin inspection and care routine
66
When does skin heal and does it return to normal?
Scar maturation continues for up to 1 year | Skin integrity and pressure tolerance only 40% of normal
67
When should you start ROM?
Initiate ROM as soon as surgeon allows (usually immediately post-op)
68
When should you start positioning?
Initiate positioning immediately; prone positioning as soon as medically feasible (if tolerated) Optimize positioning both in and out of bed
69
When should you start wrapping?
Initiate wrapping or shrinker as soon as surgeon allows; monitor application Monitor edema and limb volume fluctuation
70
What ther ex should be done with amputation?
maintain full ROM and strengthen hip extensors, hip adductors, and knee extensors closed chain functional exercises
71
What happens to cardiovascular endurance with amputation?
``` unilateral BKA increases energy cost of ambulation by 20% unilateral AKA by 49-65% bilateral BKA less than unilateral AKA hip disarticulation by 200% bilateral AKA by 280% ```
72
When should transfer training start and what assistive equipment should be used?
Start POD 1 if medically stable if able, stand pivot with RW, have RW positioned so patient's elbows are in full extension Use sliding board if unable to stand transfer prosthesis may be useful for non-ambulatory patients
73
What are considerations for wheelchair use?
provide w/c and cushion for those at high risk fro skin compromise or socket intolerance decision to use w/c is largely based on energy cost of ambulation consider offset rear axis, power system, and anti-tip system consider specialized cushions for long-term use
74
What is involved with prosthetic potential?
level of amputation and pre-surgical function are the best predictors of prosthetic potential
75
Who is more likely to be functionally independent after amputation?
any unilateral BKA | younger bilateral BKA
76
Who is more likely to not be functional after amputation?
older unilateral AKA amputees will have difficulty regaining upright tolerance most bilateral AKA amputees are not prosthetic users
77
What are the contraindications for prosthetic use?
dementia institutionalization advanced cardiopulmonary or neurologic disease bilateral transfemoral amputations with inability to transfer or stand unacceptable energy expenditure for ambulation
78
What are residual limb requirements before getting a prosthetic?
``` fully healed incision no signs/symptoms of infection no drainage from incision site ability to tolerate weight bearing frequent skin inspection ```
79
Whose input must be considered for prosthetic decisions?
based on input from patient, prosthetist, PT, and MD; as well as patient's performance with temporary prosthesis
80
How are components chosen for prosthetic?
selected based on patient's age, activity level and vocational demands, funding sources, and compliance patient and PT must have understanding of selected components and their functional implications
81
What is the point of a temporary prosthesis?
Shapes residual limb Allows early gait training and independence Evaluation of potential for prosthetic use Allows endurance training Discourages contracture development NOT intended for full time wear Definitive socket provided when volume stabilized
82
What should be done with gait training?
sit to stand transitions, single leg stance, weight shifting with prosthesis in parallel bars Progress to stand to stand transitions and hopping or stepping with RW or SW Integrate functional tasks: standing, reaching, bending, turning, etc Emphasize stance and stability on the prosthesis
83
What are examples of advanced gait training?
``` Step up/downs onto prosthetic leg Resisted ambulation Running and jumping Transfers to and from the floor Uneven terrain, congested community ambulation Curb and stair training Reaching Lifting and carrying objects ```
84
What must be considered when working with prosthetist?
Refer if weight gain, volume changes, ROM or functional changes or demands significantly or consistently affect prosthetic fit DO NOT make significant adjustments to prosthesis without input from prosthetist
85
Are there UE prosthetics?
Typically utilize harness and body powered cable control systems Myoelectric control systems are increasingly prevalent Acceptance is issue- especially in kids

PTRS 746 (15 decks)

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