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Multi Systems > Amputations > Flashcards

Amputations Flashcards

1
Q

Etiology

A
  1. Peripheral Artery Disease (M>F)
    Most common cause. Most common is DM II > leading to infections > amputation
  2. Trauma (M>F) - d/t high risk behavior. ** Generally more young
  3. Infection - osteomyelitis
  4. Congenital Deficiency
    Require an amputation to fit a prothesis or cosmetic/functional
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2
Q

Syme’s Amputation

A

Also known as Ankle Disarticulation

Amputation through the malleoli
- Take out the talus & calcaneous - heel pad gets wrap under the the tibia/fibula = weight bearing stump

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3
Q

Lisfranc’s Amputation

A

Disarticulation at the tarsometatarsal joint - leads to mm imbbalance - leads to equinus gait & inversion

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4
Q

Chopart Disarticulation

A

Disarticulation at the mid tarsal joints

Leads to mm imbalances - causes equinus gait & inversion

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5
Q

Transtibial Amputation

Advantages & disadvantages

A

Advantages
- Greater potential for ambulation - still have good control w/ a knee joint
- DEC energy expenditure with ambulation (compared to TF

Disadvantages:
- Not a weight bearing end (weight bearing on patellar tendon)
- Bony prominences are at increased risk for skin breakdown - a lot of points of contact that can lead to skin breakdown

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6
Q

Transfemoral Amputation

Advantages & Disadvantages

A

Advantages:
- Greater healing in vascular amputees compared to transtibial amputees
** Lower down the PVD is going to be worse - less blood flow = poor healing

Disadvantages:
- Not a weight bearing end
- Lower potential for ambulation
- INC energy expenditure with ambulation

The higher up you go = the greater the energy cost
External knee joint = harder to control

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7
Q

Rotationplasty

A

Also known as Ves Nes rotationplasty
- Used to treat bone tumors in children which occur around the knee, when the lower leg and ankle are still health
- Part of the limb (leg or thigh) is removed, while the health remaining lower portion of the limb (lower leg & ankle) is rotated and reattached
- This procedure allows the ankle joint to act as a knee joint in prosthesis

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8
Q

Goal of Post-Surgicial Dressings

(4)

A
  1. Control edema - external dressings
    - Edema can compromise healing and cause pain
  2. Prevent infection
  3. Protect limb from external trauma - especially more rigid dressings
  4. Shape residum in preparation for prosthesis
    - If you do this incorrectly or not do it at all = lose opportunity to wear a prothesis in future
    - Shape residuum for the prothesis - so when it is WB, it can accept the load & does not put to much pressure on a specific spot
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9
Q

Rigid Dressing

Types & Adv/Disadv

A

Non-removable
1. Immediate postoperative prosthesis (IPOP)
- Handmade from plaster
- Follows the general configuration of the prosthetic socket
- Put it on IMMEDIATELY - cut to take it off & as the limb chnages then casts are changed
- Removed at 10-14 days

Removable
1. Removable Rigid Dressing (RRDs)
- Handmade from plaster or refabricated plastic materials
- Comes in different sizes and adjustable as limb changes
- May be removed to inspect wound

Advantages:
- Excellent for edema control - BEST Dressing
- Excellent for pain control
- Excellent protection - harder
- Enhances healing
- May help prevent knee flexion contractures

Disadvantages:
- Can not inspect incision with IPOP
- More expensive than other dressings

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10
Q

Semi-rigid Dressing

Type & Adv/Disadv

A

Unna’s Paste
- Rolls of gauze soaked with a compound of zinc oxiden, gelatin, glycerin, and calamine

Advantages:
- Good edma control (better than soft dressing, not as good as rigid)
- Can remove and reapply easily to inspect incision
- Superior to soft dressing in enhancing healing

Disadvantages:
- May loosen easily
- Needs frequent changing (application is not easy)
- Takes time to dry

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11
Q

Soft Dressing

Types (2) & Advantage/Disadvantages

A

Elastic Wrap - oldest method of post-surgicial dressings
- Figure-8 compression (tensor) wrap is applied after a dressing is applied to the incision with some form of guaze pad

Advantages:
- Can remove and reapply easily to inspect incision (indicated in cases of local infection) Only real advantage
- Inexpensive

Disadvantages:
- Poor edema control
- Minimal protection
- Requires frequent rewrapping - does loosen up
- Movement of residuum will cause slippage & change in pressure & pressure distribution (may cause limb to not shape as well)

If not skilled in the application = might create a 1. TOURNIQUET Affect - put it on so tight that it could cut off blood flow to the more distal end. 2. May not come out evenly - may have applied pressure unevenly

Elastic Shrinkers - MAIN way residuum is shaped & prepared for prothesis
- Sock-like prefabricated garmets made of heavy rubber, reinforced cotton
- Not used until incision has healed & the sutures have been removed

Advantages:
- Easy to apply
- Inexpensive
- Good edema control (not as good as rigid or semi)
- Good stump shaping (not as good as rigid or semi)

Disadvantages:
- Requires changing of size as residuum shrinks (coorect size essential)
- Nnot used until incision has healed & the sutures have been removed - friction occurs during application

Need to wear it 24/7 - need more than one (requires frequent cleaning)

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12
Q

Postsurgicial Phase: Goals

(4)

A
  1. Healing of resdiuum
  2. Protecting unamputated limb (if circulation is compromised) - majority of amputations are d/t vascular complications & about 1/2 of these are d/t Type II DM
  3. INC independence in transfers and mobility
  4. Understanding and demonstrating proper positioning
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13
Q

Positioning: TT & TF

A

Main goal: PREVENT contractures

TT:
- Common contractures are Knee flexion & Hip flexion
- Encourage patient to spend time in PRONE - 15-20 min/day minimum
- Do not place a pillow under residual limb in supine or between legs
- Use a stump board when sitting in W/C - prevents hanging in knee FLEX for prolonged periods

TF:
- Common contractures: Hip flexion, abduction, and ER
- Encourage patient to spend some time in prone
- Do not place a pillow under residual limb in supine or between legs - could cause an ABD contracture
- Do not place rediaul limb in abduction and ER

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14
Q

Post-Surgicial Phase: Balance

A

Sitting balance may be a problem w/ patients with LE bilateral amputations

Standing balance on unamputated limb is beneficial for gait aid use & living an active life during preposthetic phase

**Want pt to move - teach them how to use crutches & to have good SLS (balance)

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15
Q

Post-Surgicial Phase: Transfer Training

A

In early postsurgicial period patient should transfer leading with unamputated limb in order to protect residual limb from possible injury against transfer surgace

T/F towards good side - more limits of stability on sound side & also it is better to fall on that side compared to the side with an incision/healing

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16
Q

Post-Surgicial Phase: Mobility Training

(3)

A
  • Fit patient with appropriate mobility aid - should occur prior to Sx = easier transition afterwards
  • Walker provides greater stability, while crutches provide greater mobility & help train balance in preparation for prosthetic use
    Advantage (crutches): Helpful for quick ADLs @ home (ex. going to the bathroom at night) & can use them on the stairs
  • Wear a shoe on the remaining limb to prevent slippage & protect remaining foot
17
Q

Post-Surgicial Phase: Residual Limb Care

(4) + 2

A
  • Teach patient and family how to properly wrap limb
  • Teach patient how to protect residual limb while moving in bed or transferring
    1. Do not drag residuum on bed - shearing forces on skin - lift residuum up
    2. To transfer from supine-sit, slightly raise residual limb while rolling to unamputated side & then move from side-lying to sit
  • Teach the patient gentle ROM exercises for residual limb w/in a pain-free range
  • Resisted exercises for the residual limb in contraindicated in this phase (still healing)
18
Q

Preprosthetic Phase: Goals

(4)

A
  1. Independent in residual limb care
  2. Independent in mobility, transfers, and functional actvities
  3. Understanding of home exercse program
  4. Remaining limb care (if circulation is compromised)
19
Q

Preprosthetic Phase: Physical Examination:
Residual Limb

(6)

A

Skin
- Incision: healing, adherent scar, draining
- Lesions: dermatological reasons
- Sensation: intact - want them to be aware of the sensation around the residual limb so they can be aware if there is skin breakdown

Shape
- Normal: Cylindrical (**ideal), Conical (fibula is shorter than the tibia - not ideal), Bulbous end (Not ideal for trans amputations - difficulty w/ fitting prothesis - bulbous end gets in BUT the rest of the limb is loose)
- Abnormal: “dog ears” (pointy ends), skin folds, edematous

Length:
- Bone length
- Soft tissue length (not excess tissue)

Circumduction:
- Edema - to much = longer time to the prothesis phase. Want the volume of the limb to stabilize

Pain
- may feel sharp, sticking, or pressure at end of stump
- Commonly “prosthogenic” - due to improper fitting of the prothesis

Joint Proprioception

20
Q

Preprosthetic Phase: Physical Examination: Strength

(2)

A
  1. Gross motor strength (functional activities) - pushing through arms, transfers = more functional things
  2. MMT of residuum must wait until most healing has occurred

TT - NEED good strength in hip EXT, ABD, ADD & knee FLEX, EXT in order to be ambulating well w/ the prothesis

21
Q

Preprosthetic Phase: Physical Examination: Phantom Limb

(2)

A

Phantom Limb Sensation
- Sensation in the area of the limb that is no longer there = Hypo: pain d/t involvement of the somatosensory cotext - mapping - the area that controlled that limb still has memories of that body part & mvmt - why they have the “feeling”
- May feel burning, tingling, itching, pressure, numbness, or wet
- Majority of amputee patients will experience phantom limb sensation (may last months or years)

TENS, IFC, massage, ultrasound

Phantom Limb Pain
- Noxious sensation in the area of the limb that is no longer there
- Not well understood - somatosensory cortex plays a role in this
- Type of pain varies - so painful that they cannot start fitting of prothesis

Mirror Therapy - retraining the brain
Virtual Reality

22
Q

Preprosthetic Phase: Intervention
Skin Care

(3)

A
  1. Education on proper hygience & skin care
  2. Inspect Residuum
    Inspect with a mirror daily
    Look for sores, cuts, or other problems and report to doctor if found
  3. Friction Massage
    Gently peform friction massage over the incision to prevent or mobilize adherent scar tissue - want to prevent adherence = INC risk of skin breakdown (shearing forces)
    Incision must be healed and should be clear of infection
    Desensitizes residuum to touch & pressure
    ** Rub, slap, vibrations - getting used to a variety of sensations to INC tolerance so it is not a problem later on
23
Q

Key muscles for ambulation with prosthetic?

TT & TF

A

TF:
- hip extensor, abductors, adductors

TT:
- Hip extensors, abductors, adductors, Knee extensors & flexors

24
Q

Preprosthetic Phase: Intervention:
ROM

Key Detail

A

ROM helps with MILD contractures
Not effective at improving MOD-SEVERE

Techniques:
1. Positioning
2. Manual mobilization
3. Active exercises
4. Stretching
5. PNF - more effective at preventing contractures than stretching

25
Q

Prosthetic Training: Goals

(4)

A
  1. Smooth, energy-efficient gait in order to perform ADLs, employment, and recreational activities
  2. Do as much training as possible w/o ambulatory aids
  3. Cane may be used if necessary
  4. Never use a walker as part of prothetic training (unless patient was using walker before amutation)
    ** want to optimize function
    Train more stability -> less stability
26
Q

Pressure Sensitive & Tolerant Areas

Definition & Sensitive & Insensitive

A

In order to maximize prostetic comfort, pressure is relieved from pressure sensitive areas & increased over pressure intolerant areas

Presure sensitive structurers:
- End of bone cut during amputation
- Bony prominences
- Nerves or neuromas exposed to pressure
- Cord-like tendons (adductor longus, hamstrings, etc)
- Non-weight bearing bone surfaces (pubic ramus)

Pressure tolerant structures:
- Flat bone surface
- Flat tendons (patellar tendon) - pressure bearing surface
- Normal wt-bearing surfaces (ischial tuberosity, joint surfaces)
- Muscle
- Fat

27
Q

Pressure Sensitive Areas:
Transtibial Stump

(10)

A
  1. Patella
  2. Lateral tibia condyle
  3. Tibial tuberosity
  4. Tibial Crest
  5. Anterior-distal end of tibia
  6. Fibular head
  7. Distal end of fibula
  8. Distal end of stump with surgical suture
  9. Medial femoral condyle
  10. Lateral femoral condyle
28
Q

Pressure Tolerant Areas:
Transtibial

(8)

A
  1. Supracondular areas
  2. Suprapatellar areas
  3. Patellar Tendon
  4. Medial flare of tibia
  5. Latreal flare of tibia
  6. Lateral flare of fibula
  7. Posterior area of the stump
  8. Popliteal area (gently)
  9. Distal end of the stump for total contact socket
    (No pressure, contact only
29
Q

Pressure Sensitive Areas:
Transfemoral

(8)

A
  1. Greater trochanter
  2. Ramus
  3. Anterior Superior Iliac crest
  4. Adductor tendon
  5. Distal end of the femur
  6. Inguinal fossa
  7. Pubic tubercle
  8. Surgicial suture
30
Q

Pressure Tolerant Areas:
Transfemoral

(6)

A
  1. Ischial Tuberosity
  2. Lateral flare of stump
  3. Medial flare of stump
  4. Anterior flare of stump
  5. Posterior flare of stump
  6. Distal end of stump for total contect socket
    (No pressure, contact only)
31
Q

Prosthetic Training: Critical Elements

(9)

A
  1. Stability - both legs - w/o holding onto anything
    Weight shift - want to encourage them to shift wt onto the prothesis
  2. Knee control (TF) - have a prothetic knee to control - ** feel of knee w/ different socket pressures
  3. Stability on prosthesis - SLS - stepping up/down on stool OR kick a ball
  4. Prosthetic control - kick a ball w/ prothetic leg
  5. Proprioception - standing on “clock & shift body to a specific time
  6. Pevlic control - walking - PT resists pelvis from tanslating foward & tihs encourages pt to ranslate wt smoother
  7. Stepping with prothesis (forward & backwards)
  8. Stepping with sound leg
  9. Side stepping/backward stepping - more advance skills
32
Q

Prothetic: More Advanced Training

(6)

A
  1. Going up & down stairs and ramps
    Good goes to Heaven, bad goes to Hell
    Walking sideways to get stability
  2. Sitting on the floor - flex knee (TF)
  3. Getting up from the floor
    Many ways: Most common is kicking prothetic leg out to the side & into EXT - SL squat on sound leg & push w/ arms
  4. Kneeling
  5. Picking up an object from the floor
  6. Clearing obstables

Multi Systems (14 decks)

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