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Flashcards in Amputation Deck (85):

how many americans will undergo amputation

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


What is the estimated cost of amputation?

over $8.3 billion dollars


over 80% of lower extremity amputations are due to...

vascular disease and/or neuropathy


over 70% of upper extremity amputations are due to...



what are some other causes of amputation

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


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

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

associated with diabetes and/or smoking


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

obesity, HTN, HLP, nephropathy


What does diabetes increase risk for?

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


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

foot ulceration


55% of those whose PVD result in amputation....

will eventually undergo bilateral amputations


what is the 30 day mortality following a major leg amputation

it is as high as 40%


what is 5 year mortality?

as high as 70%


Causes of traumatic amputation? who most likely has them?

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

more common among younger men


When does reimplantation have to occur?

must occur within 12 hour window


What is also associated with traumatic amputation?

psychological trauma and an extended period of adjustment


What are advantages and disadvantages of amputation vs. salvage

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


When is malignancy involved with amputation?

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


What are causes for pediatric amputation?

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


What must be considered with pediatric amputation?

Disarticulation minimizes growth plate disruption
Must consider longitudinal and circumferential growth


What make pediatric amputations different than adult?

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


What are surgical principles that must be considered?

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


What are surgical considerations with dysvascular patients

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


What are surgical considerations for traumatic injuries?

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


What are surgical considerations for cancer related amputation?

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


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


Why must there be muscle stabilization techniques?

muscle length must be preserved to prevent contracture and atrophy


What is myodesis

transected muscles are re-attached by suturing through drill holes at distal end of the bone


tenodesis technique

intact tendons reattached to bone


myofascial technique

fascial envelope is sutured over transected muscles


myoplasty technique

suturing of one muscle group to its antagonist


open (guillotine), provisional, or delayed closure technique

indicated if severe infection or toxicity are present


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


Why is it important to stabilize distal tibia and fibula?

prevents chopsticking of distal bone ends
improves weight bearing on residual limb


What are post-operative complications

contracture, edema, phantom limb sensation or pain, personal grief and depression
surgical complications: pain, infection, respiratory compromise, DVT, etc


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)


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


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


What can you educate the patient on?

post-op goals and expectations
pain relief
residual limb care, inspection, and handling
protection of contralateral leg
prosthetic information and time frame
stop smoking


What is important in post surgical phase?

compression, ROM, positioning, endurance


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


What is a IPOP?

immediate post op prosthetic
plaster socket with removable pylon and foot


What are advantages of IPOP?

Limits edema, reduces pain, prevents contracture, protects limb, allows early weight bearing and gait, easier move to definitive prosthesis


What are disadvantages of IPOP?

Difficult to apply, requires very close supervision, cannot visualize wound or residual limb


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


What are advantages and disadvantages of RRD?

Advantages: allows skin inspection, provides consistent pressure, easily donned, protects residual limb
Disadvantages: may require frequent refitting


What is semi rigid dressing?

zinc-oxide, gelatin, glycerin, and calamine compound
applied in OR or PACU


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


What is a soft dressing?

incision dressed with 4x4's and Kerlix
compression provided with ACE bandages or elastic shrinker


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


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


What are limb shrinkers?

Elastic socks that help decrease edema and assist in shaping the residual limb
Have distal to proximal pressure gradient


When are limb shrinkers used?

used prior to prosthetic fitting and prosthetic wearing
worn 24 hours/day


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


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


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


What is phantom limb sensation?

painless awareness of the amputated body part
incomplete sensation, often mild tingling


Is phantom limb sensation normal?

YES. Occurs in over 90% of traumatic and surgical amputees. Usually persists throughout life


What is phantom limb pain?

Painful sensation of amputated body part.


How is phantom limb pain described?

Constant or intermittent, with varying intensity
Often described as cramping, squeezing, burning, or shooting pain


In what populations is phantom limb pain common?

More common after crush injury or amputation in later life
Uncommon in individuals with congenital amputation


How common in phantom limb pain?

incidence is unclear- anywhere from 30-75%


What are interventions for phantom pain?

desensitization and massage
limb handling and use
modalities: TENS, US, ice
psychological counseling


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


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


When should massage be used?

Should be used as an adjunct to daily skin inspection and care routine


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


When should you start ROM?

Initiate ROM as soon as surgeon allows (usually immediately post-op)


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


When should you start wrapping?

Initiate wrapping or shrinker as soon as surgeon allows; monitor application

Monitor edema and limb volume fluctuation


What ther ex should be done with amputation?

maintain full ROM and strengthen hip extensors, hip adductors, and knee extensors
closed chain functional exercises


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%


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


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


What is involved with prosthetic potential?

level of amputation and pre-surgical function are the best predictors of prosthetic potential


Who is more likely to be functionally independent after amputation?

any unilateral BKA
younger bilateral BKA


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


What are the contraindications for prosthetic use?

advanced cardiopulmonary or neurologic disease
bilateral transfemoral amputations with inability to transfer or stand
unacceptable energy expenditure for ambulation


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


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


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


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


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


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
Lifting and carrying objects


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


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