Lecture 20 - Lower Limb Amputation Flashcards
(49 cards)
causes of amputation by percent? and etiology?
- Men > women
- Amputation rates increase steeply with age
–dysvascular disease is #1 cause
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
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
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)
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”
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”
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)
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
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
what is the second leading cause of amputation and epidemiology/etiology?
describe the naming system of amputations
what are the 3 top levels of amputation?
1) toe, 2) transtibial, 3) transfemoral
what are the 2 foot level amputations?
what is the ankle level amputation?
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
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.
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
describe knee disarticulation vs. Transfemoral
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!!
Physical Therapy for LE Amputation - patient and family education
check marks = primarily pt role
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
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
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
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
