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Year 3: Prosthetics and Orthotics > Lecture 8: Intro to Amputation > Flashcards

Lecture 8: Intro to Amputation Flashcards

1
Q

Facts about limb loss

A

those with diabetes = 30x greater risk for amputation

55% of those with diabetes and LE amputation will undergo an amputation of the other limb within 2-3 years

by 2050, it is projected to be 3.6 million individuals living with limb loss in the US

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2
Q

non-traumatic causes of amputation

A

Dysvascular (i.e. PAD, PVD, diabetes)
- non-healing wounds from osteomyelitis or gangrene are 2ndary dysvascular

limb deficiencies/congenital

infections

tumors

disease

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3
Q

traumatic causes amputation

A

high energy trauma

burns

electrocution

motor vehicle accident

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4
Q

most frequent causes of adult amputations

A

PVD
burns
tumors
trauma

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5
Q

most frequent causes of amputation with children

A

congenital limb deformities

tumors

trauma

infection

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6
Q

what is a limb deficiency or congenital amputation, types, and causes

A

malformation of limb bud around 28 days in utero

can be transverse or longitudinal

causes:
- meds or toxins
- viral infections rubella
- diabetes
- abortion attempts
- unknown

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7
Q

what is a transverse limb deficiency

A

distal structures do not exist

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8
Q

what is a longitudinal limb deficiency and possible sx interventions

A

partial or total absence of a structure along the axis of a segment

possible sx interventions:
- limb lengthening
- amputation

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9
Q

tibial deficiency longitudinal limb deficiency possible sx interventions

A

knee disarticulation

brown procedure- centralization of the fibula

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10
Q

possible sx interventions for proximal femoral focal deficiency (type of longitudinal limb deficiency)

A

limb lengthening

foot amputation

rotationplasty

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11
Q

goals of PT for a limb lengthening sx

A

maintain ROM above and below fixator

strengthen the limb

encourage weight bearing

increase endurance

restore function

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12
Q

indications for amputations for primary tumor control

A

bone sarcomas (i.e. osteosarcoma)

soft tissue tumors

metabolic disease

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13
Q

risk factors for amputation with diabetes

A

males
smoking
poor glycemic control
depression

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14
Q

risk factors for re-amputation, re-ulceration, and mortality with diabetes

A

previous amputation

level of amputation

comorbidities

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15
Q

osteomyelitis can be a complication or consequences of what conditions

A

PVD
diabetes
RA
corticosteroid therapy
poor nutritional status
post-prosthetic implantation (i.e. TKA)
trauma
fracture

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16
Q

infection types that may warrant an amputation

A

osteomyelitis and sepsis

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17
Q

type of burn injuries

A

electrical: due to contact with high voltage electrical current

chemical

thermal: extreme heat or frostbite

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18
Q

common types of trauma that can lead to amputations and common demographic for these type injuries

A

MVA/MCA

non-union fractures

military conflicts

work accidents

tend to be young adults, frequently males

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19
Q

reasons that recent wars in Iraq and Afghanistan have lowest fatality rates in American history

A

improvement in body armor

tourniquet use

in-theater trauma system; surgeons deployed

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20
Q

what are the 3 amputation rehab centers for the US military

A

MATC and Walter Reed National Military Medical Center

C5 at Naval Medical Center in San Diego

CFI at Brooke Army Medical Center

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21
Q

disarticulation vs trans- type amputations

A

disarticulation = through the joint/joint separation

trans- = through the bone

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22
Q

level of amputation is dependent on

A

vascular status of the limb

neuropathy

infection

necrosis

malignancy

bone and joint condition

age

function and rehab potential

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23
Q

general priciples of amputation in children

A

preserve proximal joints

preserve length growth plates

amputate through the joint if distal bone cannot be salvaged

proximal osteotomies or external fixator techniques (i.e. limb lengthening) may be needed to accomodate growth

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24
Q

common traumatic amputation complications for adults

A

infection

slow wound healing

DVT

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25
traumatic amputation complications for children
phantom limb pain residual limb pain terminal overgrowth (common in humerus and fibula)
26
general surgical principles for amputation
maintain adequate length of residual limb protect neuromuscular structure stabilize mm non-tender/non-adherent scar/skin functional shape of residual limb
27
surgical procedure for amputation
major nn are cut high and retract into soft tissue to prevent neuromas ligation (tied/closed off) of major arteries and veins; cauterize smaller vessels distal bone is beveled to help prosthetic fit
28
surgical techniques for mm stabilization
myofascial closure = mm to skin myoplasty = mm to mm myodesis = mm to bone tendodesis = tendon to bone posterior skin flap (posterior skin generally has better blood supply than anterior); scar on anterior
29
residual limb shapes
bulbous = common post op due to swelling conical = common in congenital amputations dog ears = typically due to poor sx technique complicated = common in traumatic amputations cylindrical = IDEAL; durable; well vascularized; tolerates pressure and friction
30
things to examine for residual limb
length and circumference integ and vascular status sensation pain ROM strength
31
purpose of soft post op dressings and examples
use if pt is at high risk for infection to allow wound infection worn all day except bathing reapplied every 4-6 hours can teach pt or caregiver how to apply common! i.e. shrinker or elastic wrap
32
purpose of semirigid post op dressings
better edema control than soft but not as good as rigid impregnated bandage with a paste compound of zinc oxide, gelatin, glycerin, and calamine typically 4 in wide not common
33
purpose of rigid post op dressing, complications, and example
can be removable or non removable can have a pylon and foot component common complications = infection, damage to wound, pressure or traction from poisoning i.e. = plaster of Paris cast; typically left on 1-3 weeks
34
key domains of care for amputees
post op pain physical health function psychosocial support and well being pt satisfaction community reintegration healthcare utilization
35
amputation CPG highlights
promote pt centered transdisciplinary team address key aspects of rehab focused on maximizing pt functional independence and QOL - prosthetic selection/fitting - ADLs - IADLs w/ and w/o prosthesis - promote physical conditioning - optimize pain/medical management develop recommendations that are consistent with evidence based rehab methods provide rehab providers with algorithm of appropriate rehab interventions to improve pt outcomes and reduce practice variation provide PCPs with algorithm to assist with referral process establish priorities for future research that will generate evidence for practice improvement
36
goals of rehab for pts with amputation
manage pain prevent injuries improve/maintain physical health become independent and safe in walking and ADLs participate in community, return to work, and leisurely activities maintain QOL foster healthy body image and self esteem find satisfaction with independence, prosthesis and rehab team improve functional independence with and without a prosthesis
37
phases of rehab
pre surgical acute post sx (1-2 weeks) pre-prosthetic training (2-8 weeks) prosthetic training (8 weeks -18 months) lifelong care (throughout lifespan)
38
factors impacting rehab potential
level of amputation comorbidities (i.e. DM, CVD, renal disease) emotional/social support cognitive impairment physical conditioning smoking visual impairment psychological factors pt compliance
39
important component throughout all stages of amputation rehab to help develop individualized treatment plans
consider pts birth sex and self identified gender identity in developing individualized treatment plans
40
suggested things to do with amputees throughout all phases of rehab process
provide edu measure intensity of pain and interference with functioning for each type of pain and location using standardized tools offer multimodal transdisciplinary approach to pain management including transition to non-narcotics; consider physical, psychological, and mechanical modalities offer peer support interventions as early as feasible and throughout rehab process
41
good outcome measure to measure pain intensity
pain interference from PROMIS pt reported outcome measurement information system
42
types of pain
immediate post sx residual limb pain phantom limb pain/sensations secondary MSK pain
43
causes of residual limb pain
expected from sx trauma poor prosthetic fit brushing/chafing poor perfusion/ischemia heterotypic ossification neuroma
44
treatment for residual limb pain
oral meds = antidepressants, tricyclics, antiepileptics, opioids intravenous = ketamine, opioids nerve block PT = exercise, massage, TENS, desensitization exercises prosthetic mods
45
what is phantom limb pain
occurs in 80% pts with amputatuions and can last decades typically episodic lasts seconds to days; can be continuous unclear mechanisms: - abnormal regeneration of primary afferent neurons - central sensitization - chronic pre amputation pain
46
treatment for phantom limb pain
massage US ice TENS non-narcotic analgesics biofeedback guided imagery nn block mirror therapy
47
implications of secondary MSK pain for pts
traumatic LE amputations: - many develop overuse injury w/I first year - unilateral amputees more likely to develop UE/LE MSK injury - bilateral amputees were more likely to develop L/S injury and UE injury traumatic UE amputations: - many develop overuse injury in first year
48
recommendations (Grade A) for preoperative phase of amputations from CPG
include both open and closed chain exercises with progressive resistance to improve gait, mobility, strength, CV fitness, and ADL performance to maximize function
49
suggestions for preoperative phase from CPG
rehab goals and outcomes should be included in shared decision making rigid or semi-rigid dressings to promote healing and early prosthetic use (rigid preferred if limb protection is priority) cognitive screening for to prior to setting goals to help determine type of prosthesis physical rehab and appropriate DME acute inpatient rehab over a SNF initiate mobility training ASAP; may include ipsilateral WBing ambulation with pylon to improve function and gait parameters
50
expert opinion suggestions for perioperative phase
decision to amputate based upon medical standards of care communication between surgical and non-surgical team ensure pt is optimized for rehab tp enhance functional outcome care team should ensure pt achieves their highest level of functional independence WITHOUT PROSTHESIS
51
CPG for perioperative phase post amputation has insufficient evidence for or against what
one surgical procedure over the other procedure should be determined after conversation with surgeon and pt, involving rehab team, to better ak=lign expected sx outcomes with rehab outcomes
52
post op timeline for lower limb amputation
days 1-2 = ROM, bed mobility, transfers, sound limb exercises, post op dressing days 3-14 = pre-prosthetic ambulation with crutches, post op dressing weeks 2-3 = staples removed, shrinker or wrap, dynamic resistive exercises, ROM, and ambulation weeks 4-6 - shrinker, monitor healing, prevention of complications, casting for prosthesis socket fi incision healed
53
ROM considerations for PT exam
check for contractures liner/socket limited ROM *think about reference for moving arm (i.e. does pt still have fulcrum landmark)
54
common contractures with transfemoral
hip flexion hip abduction
55
common contractures with transtibial
knee flexion hip flexion
56
causes of contractures
poor positioning prolonged sitting position/WC use
57
management of contractures
appropriate positioning ambulation prosthetic modification casts sx
58
consequences of contractures
functional leg length discrepancy poor prosthetic alignment
59
proper positioning for contracture prevention
neutral hip RT knee extension hip and knee ext when prone knee ext in sitting for TFA, avoid hip ABD
60

Year 3: Prosthetics and Orthotics (10 decks)

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