Midterm Review: Amputations PDF

Amputations LOWER EXTREMITY Primary causes of amputations - Vascular disease - most common - diabetes, atherosclerosis, smoking - Burns - Trauma-most common cause of UL amps - Frostbite - Cancer - Congenital - infection Buerger's Disease: thromboangiitis obliterans - Interm...

Amputations LOWER EXTREMITY Primary causes of amputations - Vascular disease - most common - diabetes, atherosclerosis, smoking - Burns - Trauma-most common cause of UL amps - Frostbite - Cancer - Congenital - infection Buerger's Disease: thromboangiitis obliterans - Intermittent vascular inflammation - Onset typically in 3rd to 5th decade - Starts distally in UE or LE - Smoking cessation halts disease progression Diabetes Mellitus: often develop foot disease - Diabetic peripheral neuropathy - Atherosclerotic peripheral artery disease - Cellulitis - Osteomyelitis - infection at the bone **contributes to 70% of non traumatic amps - Foot ulceration - a ects 15-25% of people w diabetes in their lifetime - One third of amps in 2011-12 were performed on ppl reporting a diabetic foot wound Diabetic foot ulcers - impaired sensation, structural abnormalities, poor blood flow to injured area Rays Resection and Partial foot: limits high performance activity - Impacts→ endurance, righting reactions - Pressure redist to other areas of remaining foot - Syme’s [Ankle Disarticulation] - Post Sx - NWB , pivot transfer on the other leg - Prosthesis for walking longer distances - Once healed: able to use Syme’s leg for WB to initiate swing phase or crutches for household distances  - Below knee amputation: - Post Sx - Non wb - Walking aid for ambulation - May req assistance w BADLs or adapted devices - May have to suspend work for 3-6 months - Limit to change active leisure activities  - Req a manual wheelchair - Most common LE amputation - May or may not need a walking aid long term - Limited long term impact on BADLs Edema management: post Sx- Ossur Rigid Dressing [ORD] - Residual limb wrapping - BKA - - Tensor bandage - BKA Figure of 8 - pressure over bony prominences  Proximal constriction *Elastic tubular bandage Below knee prosthesis Bilateral below knee amputations - Goal: independence w/o prosthesis - Transfers are primary focus - Start w either a slide board or front on transfer - Prosthesis can give them the ability to ambulate but it takes more energy and is not appropriate for all pts depending on PMH Post Op Therapy Program - Promote wound healing - Control incisional and phantom pain - Maintain joint ROM  - Aid w body image and adjustment - Education on residual limb edema management Pre prosthetic Therapy program - Residual limb shrinkage and shaping - Residual limb desensitization - Maintenance of joint ROM - Education on limb hygiene - Maximizing fxnal independence Prosthetic Therapy Program - Residual limb inspection - Gait retraining - Sock selection - Balance training - Functional transfers - Incorporate functional tasks Through/above knee - Post Sx- req a walking aid for ambulation - May req assistance w BADLs or adaptive devices - Long terms need walking aid - May have to suspend work for 3-6 mo - Limit or change leisure activities - Req a manual w/c Tensor wrapping above knee - May also use shrinker socks Above knee prosthesis Single axis- locked knee - Locks in extension  - Provides max stability - User can release knee manually - Used w weak unstable or bilateral amps - Single axis - free knee - No automatic lock in extension - Lightest and most durable above knee prosthesis - Polycentric knee - Multiple axis of rotation - Overall length shortens when in swing phase, reducing risk of stumbling - More stable in stance phase and w heel strike - Hydraulic Knee - Allows for variable gait speeds - Very stable in stance phase - Heavy, costly, req freq maintenance - Good for very active ppl - Microprocessor knee - On board sensors detect movt and control the knee accordingly - Goal is more natural gait pattern and improved fxn w non walking tasks - Osseointegration Manual w/c considerations for BKA/AKA - Consider: - Hanger angle - 70 degrees or 60 degrees - As angle incr so does the total length of the w/c - Consider comfort of the pt in their socket while seated in w/c - Seat to floor high - too low or high is problematic - Arm rests - flip back or mounted - Hand rim type - Break extension level - Rear wheel axle pos - Anti tipper rollers Amputee board/pad: sits under w/c cushion - Slides out 1 to 5 inches and supports limb - Req equip for all BK amputees - aids in preventing flexion contractures, limits swelling of amputated limb Van Ness [rotationplasty] - Age 5-12 w osteosarcoma or congenital LL di erences - Part of leg including knee is removed - Proximal leg and the rotated distal joints are joined - N and blood vessels remain intact Hip disarticulations/hemipelvectomy: seating an issue post Sx - Commonly not fit w a prosthesis - Optimal to be independent w/o prosthesis for ADL’s - Impact on sexual function and body image is esp important here  - Care of remaining limb - Often medical issues w remaining limb - Comprehensive assessment of limb may be indicated including - footwear/insoles, sensory, visual assessment of skin and nails, vascular assessment General impact on function [all levels of amputation - Return to driving- req by law to inform alberta transportation driver fitness and monitoring Left BKAs /AKAs do not require vehicle mods unless they drive standard Right BKAs can use a left foot accelerator, drive w left foot, or drive w below knee prosthesis ○ Same w right AKAs except cannot use prosthesis to drive - IADLs - Body image - Sex - Productivity - Leisure - Travel UE Amputations Partial Hand and digital amputations - Primary causes - trauma, congenital - Freq injuries occur at work - Can result in significant pain [incld phantom pain], hypersensitivity, and greatly impact function - Loss of thumb, index and pinky are esp significant - Functional impact depends on fingers amp and what level - middle finger has the lowest fxnal impact, thumb has the highest - Prosthetic options are limited- decide between fxnal or cosmetic - Desensitization is critical post Sx - high hypersensitivity in the hand bc more nn here Desensitization Techniques - Tapping - Vibration - Submerging - Rubbing - Exercise - Massage Edema management  - Trying to move away from tensor Tx in practice now Adaptive Devices Partial Hand Prosthesis - Functional - Depends on the # of digits and level, if the thumb is amp, amount of trauma to hand - Cosmetic [no fxnal use] Wrist Hinged Prosthesis - For transMC level only - Allows for cylindrical grasp to hold and support - No wrist deviation and limits wrist flexion - Transradial [below elbow] - Ideal length for prosthetic fxn is half of the forearm* - Can use the residual limb for holding, support and bi-manual tasks - Important to maintain fxnal AROM at elbow - - Rehab priority- one handed techniques - Fxn significantly impaired if dominant side - Residual limb care- edema, wound and skin integrity - Strengthening of the shoulder complex is critical to prosthetic success - 2 options for prosthetic= body/cable powered, myoelectric -  - - - Hook: voluntary opening devices - Most popular option due to simple design and fxnal use - Lightweight - Aluminium or stainless steel - Work Hook: incl a knife holder, wider opening, serrated tines, nail holder, screwdriver holding device located in the guards - Range in weight from 120g-300g - Wrist flexion units may be incl and utilize an adjustable friction setting for rotation and locking positions for flexion at 0, 30, 50 deg - Prehensor: voluntary closing device - Works well for cylindrical objects - Has potential for wider opening than a hook - Less surface area contact to pick up small objects - Gripping force can exceed 100 lbs - Locking pin option to hold item in terminal device - Hand: cosmetic - Passive or active - Challenging to grasp - Heaviest - Poor opening width - D5 and D4 remain static even w an active device and can get in the way ** can also attach tools as terminal devices like shovel, hairbrush, cooking utensils Transhumeral [above elbow] - Priority is 1 handed techniques - Shoulder complex strengthening - Limb care- edema control - Also have the 2 prosthetic options [body/cable powered, myoelectric] - Prosthesis has multi joint fxn - Length in residual limb improves prosthetic success - All prn/sup gone - Ideal length is half the humerus - Freq a secondary diagnosis of shoulder dysfunction - Limited use of residual limb w/o prosthesis - Transhumeral prosthesis Locking elbow as well as cable powered terminal device Can have a free swing fxn or elbow lock in 5 di angles Length of the residual limb will sig improve prosthetic success  Shoulder disarticulation - Prosthetic fxn is limited to one movt at a time - Limited shoulder flexion w body powered prosthesis - Mostly use prosthesis in an elbow flexed position [approx 90] - Fxnal usage of prosthesis is for holding, lifting, stabilization UE prosthetic training - Prosthesis for transradial and above usually incl a harness and some form of terminal device - Training includes - Orientation of objects in terminal device for pickup and drop * planning v important bc no active wrist flexion/extension or deviation - Body mechanics Teach pt to- plan for tasks, choose appropriate terminal device position for task, limit trunk deviation, use the prosthesis for common bimanual tasks which they  may have learned to do one handed, use items in surroundings to change the position of the object once it has been picked up to decr compensatory movt - Grading the resistance of the terminal device Adding additional elastic bands will provide more resistance to opening the terminal device - Positioning of the terminal device for di tasks Positioning of terminal device for di tasks - can rotate upward to 90 degrees depending on the tightness of the cable and type of terminal device Flexion release button can also assist w positioning and limit energy req for a task - Education on skin inspection Early stages - check 1x per hour, look for any redness and pressure areas, limb will change size throughout the day, alpha liners are commonly used for transradial prosthesis - Training on don/do strategies Pain Management - Medications - Positioning - Desensitization - Mirror therapy For phantom limb pain [occurs in 90% of amputees] Visual feedback to replace some of the sensory input dedicated to the amputated area V helpful to release tension in amputated hand Pt has to be able to focus on task and relax Arm is fully covered so the eyes see a functional arm/hand Encourage slow and small movts - Visualization - Fitting w prosthesis - Edema control - Relaxation techniques Limitations on body powered prosthesis - Impact on contralateral shoulder - No active wrist mvmt - Not equal function in di arm positions - Large or heavy objects challenging - Lim grip strength - Terminal devices often do not resemble a human hand - Socket limits forearm rotation - 1 degree of freedom gained Degrees of freedom: number of axis which a joint can move Myoelectric prosthesis - Utilizes electrical activity of mm contractions - myoelectric signals - Cutaneous electrodes receive myoelectric signals to control a programmable motorized device - - Multifunctional hands - Programmable grip patterns - $$$ Limitations of myoelectric control - No controlled digital abb/add - Inadvertent signal can prod unwanted movt - Muscular fatigue limits fxn - Cost - Access - Compliance - Weight dist of the prosthesis - Inability to execute 2 or more fxns - Charge battery daily - No active wrist flexion or ext, ulnar or radial deviation - No tactile feedback