Lecture 20 - Lower Limb Amputation Flashcards Preview

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Flashcards in Lecture 20 - Lower Limb Amputation Deck (49):
1

causes of amputation by percent? and etiology?

•Men > women

•Amputation rates increase steeply with age

–dysvascular disease is #1 cause

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2

describe Dysvascular disease as cause of amputation

PVD = something affecting blood flow to limbs, easier to happen farther from heart

Must have good vasculature to have a nerve

Healthy adult cartilage is aneural

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3

describe Peripheral Vascular Disease + Peripheral neuropathy

Common complications of diabetes

–Not isolated to diabetes

Both are predisposing factors for LE amputation

–non-healing and/or infected neuropathic ulcers precede approximately 85% of non-traumatic LE amputations in individuals with diabetes

4

signs and symptoms of peripheral neuropathy

–deficits of sensation (vibratory & protective)

–loss of Achilles and patellar reflexes

–motor impairments (weakness and atrophy of the intrinsic muscles of the foot)

–autonomic dysfunction (inadequate or abnormal hemodynamic mechanism, trophic changes of the skin, and distal loss of hair)

5

 what are Common subjective complaints of people with peripheral neuropathy?

1) “numbness” &/or “cold feet”

•feet may be warm and well perfused

2) Pain

“stabbing,” “pins and needles,” “shooting,” “electric shock”, “lancinating”

often worse at rest, particularly at night

N.B distinguish from Intermittent claudication

–cramping or aching pain, 1o in the calves, with walking

–relieved with rest (except in advanced stages)

–Sx of PAD

3) Muscular complaints

“night cramps,” “spasms,” or “aching”

*Note parasthesia is not numbness – parasthesia is like when you sit on your foot and it goes “numb”

6

describe sensory neuropathy

loss of thermal, pain, and protective sensation

increased vulnerability of the foot to acute, high-pressure and repetitive, low-pressure trauma

may be unaware of minor trauma

--pressure from poorly fitting shoes (sides and tops of feet)

--pressure from thickening plantar callus

--“I didn't know anything was wrong until I saw a blood stain on my sock”

7

describe motor neuropathy

1) associated weakness and atrophy contribute to development of bony deformity of the foot

•bony prominences

•mal-alignment of joints

•altered weight-bearing pressure dynamics

2) may present with observable gait deviations

•peroneal neuropathy → weakness of ankle dorsiflexors (foot drop)

3) classic “intrinsic-minus” foot

•cocked-up toes (claw toes)

•prominent extensor tendons

•a high arch

•prominent metatarsal heads

4) associated with skin breakdown due to altered pressure distribution

•high plantar pressures (MT heads)

•dorsal surfaces of the proximal interphalangeal joint (rub against shoe's toe box)

•distal tips of the toes (increased weight-bearing forces)

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8

Describe the 2 types of Autonomic Dysfunction (sympathetic nerve damage)

Sudomotor dysfunction

•impairment in sweat gland function

•reduced hydration of the tissues

•skin of the foot becomes dry, less pliable, and much more prone to fissuring (enable entry of bacteria &  infection)

Vasomotor dysfunction

•dilation of the arterioles of the foot

•hyperemia (↑ blood flow) of soft tissues and bone

•factor in the development of Charcot's arthropathy

9

what is Charcot's arthropathy?

Presentation in patient with neuropathy

–sudden onset of localized swelling, warmth, and erythema (redness of skin) in the absence of an open wound or anything else that would cause inflammation

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10

what is the second leading cause of amputation and epidemiology/etiology?

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11

describe the naming system of amputations

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12

what are the 3 top levels of amputation?

1) toe, 2) transtibial, 3) transfemoral

13

what are the 2 foot level amputations?

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14

what is the ankle level amputation?

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15

what is the best location for transtibial level amputation?

-Surgeon tries to preserve as much of the limb as possible

-Long = better to fit prosthetic

-Greater lever arm = better (note quads and hamstrings still attached, gastrocs not)

-Larger area for prosthetic to attach to = better able to control it

-More likely to develop phantom limb pain with shorter

-Psychological impact

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16

describe the types of knee level amputation

-B and c together = better option- no point in preserving because losing the insertion point of quads anyways.

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17

describe the level of amputation - Transfemoral

-Shorter limb = preferable this time bc of where the prosthetic knee goes

-Transfemoral pref to knee disarticulaiton

-Bc of potential problem of skin breakdown

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18

describe knee disarticulation vs. Transfemoral

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19

describe the level of amputation effect on musculature

Preservation of musculature

Loss of distal insertion point requires surgical repair

•muscle-to-bone fixations (myodesis) - preferred

•muscle-to-muscle fixation (myoplasty)

•muscle-to-fascia fixation (myofascial)

Biomechanical effect

•altered line of pull of the muscles

•loss of force generating capacity (loss of muscle mass)

•altered / loss of distal connective tissue (tendon, etc.)

•shift in functional position on the length-tension curve

**note: Femur has muscle attachment pretty much the whole way, Attachment on bone (instead of muscle or soft tissue) is preferred

Picture:

Biggest muscle = most likely to not be preserved

-Gluteus max = greatest extensors, illiopsoas = flexion, glut min and med = greatest abdution

-*major abd, ext, flex and rotators of hip not as affected – adduction – MOST affected!!

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20

Physical Therapy for LE Amputation - patient and family education

check marks = primarily pt role

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21

what is the role of PT for lower limb amputation?

1) Post-op, pre-prosthetic rehabilitation

–mobility and preparation for prosthetic training

2) Patient readiness for prosthetic fitting

–Assist physician & prosthetist

–Assist with choice of prosthetic components

3) Prosthetic training program

–functional ambulation and prosthetic management

4) Monitor condition of the remaining extremity

–patients with PVD, neuropathy, or diabetes

5) Assist with return to pre-amputation activities

22

what is the prognosis and progression through rehab for amputees?

Prognosis

Projection of rehabilitation potential and prosthetic use after amputation is based on

•pre-morbid level of mobility

•ADL status

•level of amputation (Level of amputation more of a secondary factor to things like age/level of activity pre-injury)

 

**Sitting is hard bc of BOS and COM position

**Don and doff = taking prosthesis on and off

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23

what are areas for specific assessment for amputees?

1) Presence of phantom limb sensation or pain

2) Residual limb characteristics

–Residual limb length (bone length, soft tissue length)

–Residual limb girth (Circumference measures – multiple levels)

–Redundant tissue (“dog ears,” adductor roll)

–Residual limb shape (bulbous, cylindrical, conical)

–Assessment of type and severity of edema

–Effectiveness of edema control strategy being used (“shrinkers” are worn for the initial period following amputation, when not using prosthetic)

3) Prosthetic Requirements

–Potential for functional prosthetic use

–Readiness for prosthetic fitting/prescription

–Prosthetic design, components, suspension

–Residual limb characteristics

–Energy cost of ambulation

•older patients, deconditioning, co-morbid conditions

•level of amputation (loss of joints, long bone length, muscle insertion)

–Level of amputation

24

describe prostheric requirements considering the level of amputation for a transtibial amputation w/ intact anatomical knee joint vs a bilateral transfemoral amputation

transtibial amputation w/ intact anatomical knee joint

–more energy-efficient prosthetic gait pattern and postural responses

–more likely to ambulate without additional assistive devices (walkers, crutches, or canes)

–more likely to be full-time prosthetic wearers

Bilateral transfemoral amputation

–Increased energy consumption for prosthetic ambulation (can prevent long-distance ambulation)

–wheelchair mobility may be more energy-efficient and effective means of locomotion

–ambulation potential depends on cardiac function, strength, balance, and endurance

25

Rehabilitation – Pre-Prosthetic - pain management (including phantom limb sensation/pain)

Primarily pharmacological

Other

–acupressure/acupuncture

–modalities (varying degrees of success)

•T.E.N.S.

•ultrasound

•cold or ice

•massage

Phantom Limb Sensations / Pain

–Medical / pharmacological management is common

–Experimental therapies

•“exercise” for phantom limb (Mental imagery, Mirror box)

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26

Rehabilitation – Pre-Prosthetic - sensory status for hyper and hyposensitivity 

Hyposensitivity

–Risk for skin breakdown

–Must be monitored

Hypersensitivity

Commonly encountered (secondary nerve damage from amputation surgery itself ?)

Management (“bombard” residual limb with tactile stimuli)

–various textures and pressures

•gently tapping with the fingers

•massaging with lotion

•touching with a soft fabric (e.g., flannel, towel)

•rolling a small ball over the residual limb

•wear schedule - shrinker socks and rigid dressings

–intensity based on the patient's tolerance

–progressed in intensity, type of modality used, and duration of stimulus

27

describe the various types of Limb Volume, Shaping, and Post-Op Edema

slides 48-54

28

describe Edema Control of Residual Limb

WB activities in prosthetic socket

–decreases limb edema

–accelerates maturation of the residual limb

–contact within the socket

–pumping from muscle contractions

Accommodating for fluctuation of residual limb size over course of the day

–add/remove of layers socks

29

describe Soft Tissue Mobility of Residual Limb

Adhesions around incision scar & surrounding area

–affect prosthetic tolerance, comfort, and use

Deeper scarring/adhesions from surgical procedure

–Muscle-to-muscle fixation (myoplasty)

–muscle-to-fascia fixation (myofascial)

–muscle-to-bone fixations (myodesis)

Soft tissue must move independently of scar tissue or skeletal structures

–stress can lead to tissue breakdown and discomfort

30

describe pre-prothesis rehab wrt 1) Bed Mobility and Transfers 2) ROm and muscle functioning 3) ambulation and locomotion

1) Independence should be early goal

–need for training may depend on pre-amputation functional status

–approach / techniques will not differ dramatically from pre-amputation state

–must account for new limitations

2) General strengthening, ROM & Flexibility

–trunk, upper extremities and shoulder girdle

•transfers

•gait (upper limbs – use of assistive devices, trunk - energy transfer & stability)

3) Ambulation and Locomotion

•Wheelchair training

•Encourage ambulation for individuals able to stand / use an assistive device (parallel bars, crutches (ideally), stairs, uneven surfaces)

•N.B. functional single limb ambulation is not a prerequisite for prosthetic fitting

31

Rehabilitation – Transtibial - describe potential pre-prosthetic problems

high risk of knee flexion contracture

•negative impact on future prosthetic use

prolonged dependence of residual limb in knee flexion when sitting causes distal edema

•can delay readiness for prosthetic fitting

•wheelchair with elevating leg rests

•posterior trough splint

32

describe Rehabilitation – Transtibial positioning supine

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33

describe Rehabilitation – Transtibial positioning prone

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34

describe Prosthetic Consequences of Limitations in ROM (transtibial amputations)

1) ↓’d hip extension

–Inability to achieve upright posture in stance

–Compensatory knee flexion causes instability in gait

–LBP due to compensatory anterior pelvic tilt

–Decreased stride length of contralateral limb in gait

2) ↓’d hip adduction

–Abducted stance in gait

–Abductor lurch on ipsilateral side in gait

3) ↓’d internal rotation

–Toe-out stance and gait

–Knee joint pain or pathology due to lack of anterior/posterior orientation of knee joint

4)↓’d knee extension

–Limb functionally shorter w/ associated gait deviations

–Decreased mid-stance stability in gait

–Prosthetic alignment adjustments to compensate

5)↓’d knee flexion

–Inability to place foot flat on the floor when sitting

–Inability to bear weight through prosthesis during sit-to-stand transfers

–Difficulty managing steps and curbs

35

describe muscle functioning after transtibial amputation 

–attachments of the quadriceps and hamstrings are typically intact

–pre-prosthetic strengthening exercises emphasize

•control of the knee

•hip strength for stability in stance

36

describe Muscle Function Exercises for transtibial rehab

Hip extensors

–Manual resistance +/- gravity

–Prone leg lifts +/- weights

–Bridging - residual limb over ball, padded stool, etc.

–Standing (parallel bars) vs. pulley, elastic bands, etc.

Hip abductors

–Manual resistance +/- gravity

–Side lying abduction – residual limb on top

•+/- manual resistance or weights

–Side-lying bridges – residual limb on bottom

•small ball or padded stool under knee of residual limb

–Standing hip abduction with pulleys or elastic bands

Hip flexors

–Supine SLR +/- manual resistance or weights

–Standing hip flexion with pulleys or elastic bands

Hip ER/IR

–Seated hip ER and IR

•+/- manual resistance or elastic bands

•caution re: knee ligaments

Knee extensors

–Seated knee extension

•CKC or OKC

•+/- manual resistance or weights

Knee flexors

–Seated knee flexion

•manual resistance, pulleys, elastic bands

–Prone knee flexion

•manual resistance or weights

–Bridging - residual limb over ball, padded stool, etc.

37

describe Transfemoral Rehabilitation for pre-prosthetic ROM

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38

what are the transfemoral amputation altered and intact distal muscle attachments and consequences?

Altered distal muscle attachments

•hamstrings

•rectus femoris

•sartorius

•tensor fasciae latae/iliotibial band

•+/- adductor longus

•+/- adductor magnus

Consequence

•altered line of pull

•loss of muscle mass

•change in length-tension profile relative to joint ROM

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39

what are the pre-prosthetic strengthening targets for transfemoral amputation?

1) hip extension - needed to control the prosthetic knee unit

2) hip abduction - needed to keep the pelvis level during stance

3) hip adduction - needed to adjust to new muscle mechanics

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40

describe prosthetic training (lecture)

- slides 79-85

41

reading - describe the socket (hard vs flexible)

p1

42

describe pressure tolerant vs pressure intolerant areas for transtibial sockets

p 1-2

43

describe transfemoral sockets

p 2-3

44

describe types of socket liners

p 3-4

1) prosthetic socks

2) roll-on liners

3) soft liner

45

describe transfemoral suspension types

p 4-5

1) Silesian belt suspension

2) total elastic suspension belt

3) pelvic belt with a hip joint

46

describe transtibial suspension types

p 5

1) waist belt with an anterior elastic strap

2) supracondylar cuff strap suspension

47

what are Suspension systems for both Transfemoral and Transtibial prostheses

p 6

silicone roll-on liners with a shuttle-lock system (pin & lock) suspension.

48

describe Knee Unit Transfemoral Prostheses - and the TKA line!

p 6-8

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49

what are the 4 designs for prosthetic feet?

p 8-10

1) Non-articulating feet

2) Articulating designs

3) Prosthetic feet with elastic keels

4) Dynamic-response or energy-storing designs