Amputation PDF

1. AMPUTATION PATHOPHYSIOLOGY (Sullivan pp. 1002-1004) DEFINITION - SURGICAL PROCESS - Amputation refers to the surgical cutting of a limb and...

1. AMPUTATION PATHOPHYSIOLOGY (Sullivan pp. 1002-1004) DEFINITION - SURGICAL PROCESS - Amputation refers to the surgical cutting of a limb and is performed to - The specific type of surgery is determined by the surgeon remove limbs that are no longer functional because of injury or disease. - Whose decision depends on the status of the extremity at the time of amputation; must allow for - TWO MAJOR CATEGORIES OF AMPUTATION: primary or secondary wound healing; and construct Acquired Amputation a residual limb optimal for prosthetic fitting and - loss of part or all of an extremity as the direct result of trauma function or by surgery. It is also done to revise a congenital limb - Muscle stabilization amputation or alter a deformity secondary to burns or trauma. - Allows for maximum retention of function. Muscle Congenital Amputation stabilization maybe achieved by - loss of a limb in the uterus and are believed to result from - Myofascial closure - muscle to fascia such stimuli as drug toxicity. There is failure of formation or - Myoplasty - muscle to muscle strangulation of limb buds by the umbilical cord. - Myodesis - muscle to bone - Tenodesis - tendon to bone EPIDEMIOLOGY - Principle: whatever the technique, muscle - Prevalence greater in LE > UE with a 5:1 ratio stabilization under some tension is desirable at all - Male > Female levels where muscles must be transected - Peripheral Vascular Disease: MC cause of LE amputation - Neuromas - Trauma: MC cause of UE amputation - Severed peripheral nerves from neuromas (a collection of nerve cell ends) in the residual limb. ETIOLOGY The neuroma must be well surrounded by soft tissue a. Congenital Anomaly so as not to cause pain and interfere with prosthetic - Absence or abnormality of a limb evident at birth wear b. Peripheral Vascular Disease - Hemostasis - Embolus or thrombus obstructing blood supply resulting in - Achieved by ligating major veins and arteries ischemia, necrosis, gangrene, and ulceration - Cauterization c. Trauma - Used only for small bleeders - When trauma is so severe that function is impeded without - Beveled surgical amputation - Sharp bone ends are smoothed and rounded to d. Infection reduce pressure between the end of the bone and - Amputation is done primarily to prevent the spread of the prosthetic socket infection and when that infection can’t be controlled by other medical means - HEALING PROCESS e. Tumor - (review phase of wound healing) - Amputation is indicated for primary malignant tumors that are - Inflammatory Stage not possible to resect or radiate without risk of recurrences - Proliferative STage f. Thermal, Chemical, and Electrical injuries - Maturation or Remodelling Phase - Amputation done after an injury produces severe tissue damage CLINICAL MANIFESTATION - Pain  - Edema - MOI: - Decreased Function - Amelia - Complete absence of at least 1 Hand Percentage limb - Meromelia Thumb 40 - Partial absence of at least 1 limb Index 20 - Phocomelia - No proximal bone Middle 20 - Hemimelia - Short bone Ring 10 - Adactyly - No fingers Little 10 MED/SURG MANAGEMENT - Increased Energy Expenditure - Medical - Analgesics - oral opiates Single BKA 40 - Anti-depressants - Anti-inflammatory Double BKA 41 - Goal: non-tender and healthy residual limb for prosthetic use. Single AKA 65 - Promote Healing: - Careful handling Double AKA 110 - Controlling edema 1 AKA + 1 BKA 75 - Preventing infections - Types of Dressing With prosthesis 60 - Closed rigid dressing - Removable rigid dressing Without prosthesis 70 - Soft dressing - Surgical Wheelchair 9 - Basic Surgical Procedures of Amputation - Psychological Outcome: Depression - General Procedure: - Surgeon removes part or the entire limb DIFFERENTIAL DIAGNOSIS/COMPLICATIONS - Type of amputation is at the discretion of - Surgical the surgeon and the state of the extremiry - Not present at birth at the time of the amputation - MOI: - Allow for 1 or 2 wound healing - Trauma - Contruct a resident limb for optimum - PVD prosthetic fitting and function - Infection - Types of Surgical Amputation - Tumor - Open Amputation (Guillotine Amputation) - Congenital - Often indicated for infection - Present at birth - Close Amputation (Flap Amputation)  - Amputation in which the stump is closed or covered by a flap skin sutured over the DEFINITION bone end of the stump. This type of - A form of facial paralysis of acute onset with an unknown etiology. It is amputation is preferred when there is no presumed to be due to a non-suppurative inflammation of the facial evidence of infection and consequently no nerve inside its canal above the stylomastoid foramen. It was named need for extensive open drainage. after Sir Charles Bell who stated that the facial nerve is the mother of - Minor Amputation the face. - Done through or distal to the metacarpus - It occurs when a nerve transmits faulty signals to muscles in the face. It or the metatarsus happens with little or no warning symptoms may even suggest a stroke. - Major Amputation - The functional components of the facial and intermediate nerve include: - Done proximal to the metatarsal or 1. Special visceral efferent (SVE, branchiomotor) metacarpal bones and they are designed fibers, to produce a stump suitable for an artificial 2. General visceral efferent (GVE, parasympathetic) limb fibers, - Joint Amputation 3. Special visceral efferent (SVE, taste) and - Done at the joint 4. A few general somatic efferent (GSA, sensory) fibers. Special visceral efferent fibers of the motor PT ASSESSMENT component innervate the muscles of facial - Subjective: expression, the platysma, the buccinator and the - CHLORIDEPP stapedius muscles. Synapses with the - HPI postganglionic neurons occur in the pterygopalatine - Home Situation and submandibular ganglia. Postganglionic fibers - Goals from the pterygopalatine ganglion give rise to - Objective: secretory and vasomotor fibers that innervate the - MS lacrimal gland and the mucous membrane of the - MMT nose and mouth. - ROM - - LGM EPIDEMIOLOGY - LLD - Lifetime prevalence: 6.4 per 100 - Neurologic - Incidence: Increase with age - Integumentary - Season: occurs at all times of the year - Vascular - Males = Females - Lesions - 7% recurrence - Gait - 63% R side affected - Posture - Balance and Coordination ETIOLOGY - FIM - Unknown, maybe after: - Trauma to CN7 PT MANAGEMENT (Separate Notes!) - Pressure d/t tumor - Exposure to cold 2. BELL’S PALSY - Maybe associated with:  - Viral meningitis - Acute pain within & behind the ear - Flu-like illness - Ramsey-hunt syndrome associated c herpes infection of the - Chronic middle ear infection geniculate ganglion - High blood pressure and diabetes - Lesion 5: internal auditory meatus - Temporal bone fractures - All signs of lesions 1-4 are present - Hemorrhages - Deafness from CN 8 - Infectious diseases - Lesion 6: facial nerve from the pons & c possible involvement of other - Three Categories: cranial nerve nuclei - Hereditary - All s/sx of Bell’s palsy - d/t the diameter of the axons - Vascular ischemic theory DIFFERENTIAL DIAGNOSIS/COMPLICATIONS - Exposure to cold Complications - Inability to close the eyelids - ABERRANT REGENERATION - Crocodile tears - Viral theory - Movement synkinesis - Herpes simplex → antibodies → inflammation - Facial spasms PATHOPHYSIOLOGY - Develops & persists indefinitely & initiated by facial Acute non-suppurative inflammation → edema & hyperemia → compression of movements axons in the facial canal →onset of s/sx - Usually begins in the orbicularis oculi mm & gradually spreads to another mm on that side of the face CLINICAL MANIFESTATION - Associated movement synkinesis - Lesion 1: at the level of the stylomastoid foramen - Attempts to move one group of facial mm results in - I/L weakness: contraction of all of them - (+) bell’s phenomenon - (+) Marcus-gunn (jaw winking) - (-) corneal reflex - (+) Marin-amat sign - Widening of palpebral fissure = weak orbicularis palpebrum - Nasal obstruction - Obliterated nasolabial fold, wrinkled brow, mouth sags & expressionless affected side DDX - Mouth actively drawn to N° side RULE IN RULE OUT - Automatic abns: rolling of tears (lacrimal) down the cheek & dribbling of saliva (salivary) from the mouth Facial Paralysis Lower ¼ of the face ½ of face - Lesion 2: at the level of the facial canal → chorda tympani C/l affectation I/L - All signs of lesion 1 are present Spastic Flaccid - Loss of taste in the anterior ⅔ Central Peripheral - Reduced salivation on the affected side - Lesion 3: stapedius muscle Myasthenia Gravis Weak ocular, orofacial, limb, I/L ½ - All signs of lesions 1&2 are present respiratory mm Localized to face - Hyperacusis: painful sensitivity to loud sound Marked asymmetric Fatigue, dysphagia, ptosis - Lesion 4: geniculate ganglion - All signs of lesions 1-3 are present  DEFINITION Muscular Muscle tone Localized to face - Burn is a type of tissue injury, protein denaturation, edema, & loss of Dystrophy Coordination May get better Mental function intravascular fluid caused by heat, cold, electricity, chemicals, light, radiation, or fraction. MED/SURG MANAGEMENT EPIDEMIOLOGY - Medical Management - M>F - Eye patch/sunglasses - 20-40 y.o. - Artificial tears - MC: 60% fire, 10% scald aldut, 30% scald (1-5 y.o.) - Moisture chamber - Mortality: young, old > adult; f > m, inhalation - Bland ointment - According to classification/cause: - Consultation c ophthalmologist - Thermal: 95% of all - Pharmacologist Management - Chemical: lab - Oral steroids - Electrical: ⅓ electrician, ⅓ construction, ⅓ home - Analgesics - Radiation: rare, UVR exposure, sunburn - Antiviral agents - Prednisone ETIOLOGY - Surgical Mx: (Stitched lids) - Thermal: cold burn, hot liquid/gas, flame, contact - Malignancy - Chemical: strong acid/base, hydroflauric/gas - Slow progression - Radiation: UVA (dermis), UVB (epidermis) - No recovery p 6 mos - Tanning booth (UVA), x-rays (EM radiation) sunlamp (UVB) - Mass in the parotid/bet. the mandible & mastoid - Electrical: passage of electric current - Progressions of other cranial deficits - IC (entrance) = charred, depressed, small, yellow - Branches of the facial nerve is spared - Grand (exit) = dry, big, necrotic & gangerous - Trauma c sup for a traumatic resectuon - Arteriospasm = (+) necrosis of arterial wall PT ASSESSMENT - Low 1000 - House-Brackmann scale - Mechanical: friction PATHOPHYSIOLOGY PT MANAGEMENT Burn→ Release Histamine → Vasoconstriction → Plasma Loss → Abn - Facial massage (effleurage and/or raindrops tech) Aggregation → Thrombosis → Vascular Destruction → ↑ Area of Ischemia → - Use of eyepatch, goggles/sunglasses Impaired Recurrent Trans. → More Damage - Infrared radiation and/or HMP - ES application - monopolar, direct current along the facial motor points CLINICAL MANIFESTATION for mm re-ed - Cannot regulate H2O loss → ↓ body fluid - US over the nerve trunk, in front of the tragus of the ear - Susceptible to infection → sepsis 2° bacterial contamination - Facial PNF exercises for mm re-ed - Zones of burn injuries: - ROM exercises using different facial movements 1. Coagulation - Patients/family/caregiver education 2. Stasis 3. Hyperemia 3. BURNS - Classification of Burns:  1st Degree Burn Contact Dermatitis MOI: exposure to irritating MOI: heat/cold, (Epidermis) substances acid/base Itchy (+) eschar (-) blisters skin if rubified c Healed in 3-10 days Hive-like rash (+) bleeding (+) inflamm. Open wound 2nd Degree Superficial Burn Shingles Viral infection Sepsis 2° bacterial (Epidermis & Dermis (Papillary Layer)) Painful rash/blister infection Chills, fever, headache, (+) open wound upset tummy (+) eschar (+) BEEP Healed in 1-3 weeks 2nd Degree Deep Burn Complications (Epidermis & Dermis (Papillary & Reticular Layer)) 1. Infection (pseudomonas aeruginosa & staphylococcus aureus) 2. Pulmonary (+) broken blisters Healed in 3-5 weeks 3. Metabolic (+) hypoesthesia Burnt area is red/white 4. CV 3rd Degree Burn - Full-Thickness Burn Deformity (Epidermis, Dermis, & Subcuntaneous Tissue) - Neck - SH Adduction-IR (-) pain Skin graft is needed - Elbow (Prone) (+) eschar, shock - Hip Flexion-Adduction-IR Burnt area is white/brown - Knee d/t blood clot - Foot PF - Hard intrinsic (+) claw 4th Degree Burn - Subcutaneous Burn (Epidermis, Dermis, Subcuntaneous & Adipose Tissue, Muscles, Tendons, Bones) MED/SURG MANAGEMENT Medical: Caused by electrical, hot Amputation & extensive - Silver sulfadiazane = MC fluid, flame burn for a long skin graft is needed - Mafenide Acetate = gram (+) & (-), eschar time Skin is barren & dry PT ASSESSMENT - Subjectibe & Objective DIFFERENTIAL DIAGNOSIS/COMPLICATIONS PT MANAGEMENT DDX - Positioning - Exercise Therapy RULE IN RULE OUT - Manual Therapy - Therapeutic Massage Pressure Sore (+) prolonged immob Etiology (+) pressure on the bony May form blister - Joint Mobilization prominence - Physical Agent Modalites - Microwave Diathermy Therapy  - Infrared Therapy - Abnormal: - Whirlpool Bath Therapy - Tone - Warm Bath Therapy - Posture - Movement 4. CEREBRAL PALSY - Reflexes - Classification: DEFINITION - Dyskinetic CP - A static, non-progressive, neurological disability characterized by - Athetoid abnormal movement, tone & posture resulting from lesion on an - Choreiform immature brain. Formerly “little dse” c hallmark signs of delayed - Dystonic developmental milestones. - Ataxic - Spastic CP EPIDEMIOLOGY - Monoplegia - 2-3 in every 1K - Diplegia (MC) - M>F - Hemiplegia - MC: childhood disability - Triplegia (2LE:1UE) - Quadriplegia ETIOLOGY - Hypotonic CP A. Prenatal - Mixed - Premature F but changes c age - Blacks > whites Surgical - Smokers > non- smokers - Surgery for sitting - ↑ incidence c uncontrolled risk factors - Hip flexior lengthening - Hip adductor lengthening/release ETIOLOGY - Hip fusion, artificial jt replacement, resection of femoral head 1. Ischemic: general narrowing of blood vessel - Hamstring lengthening a. Atherosclerosis - plaque formation in lumen - Molded thoracic lumbar orthosis for early tx for scolio b. Thrombotic - clot formation (locally) - Knee flexion contracture release c. Embolic - clot from distal areas - Anterior branch obturator neurectomy d. Lacunar - clot of small blood vessels - Chronic cerebellar stimulation - implanted electrodes for 2. Hemmorhge: leakage of blood into/around brain causing ↑ ICP spasticity a. Intracranial - bleeding into brain - Surgery for Standing b. SAH - bleeding in subarachnoid space; “worst headache of - Hamstring lengthening my life!” - Achilles tendon lengthening c. Arteriovenous malformation - congenital; tortuous tangle of arteries & veins PT ASSESSMENT - Moevement: hemiparesis, diplegia, athetosis, dyskinetic movements PATHOPHYSIOLOGY - Postural Control: posture, postural tone & abnormalities Sudden cessation of oxygen & glucose supply → pathological events → neurons - Musculoskeletal Assessment die → ischemic cascade → damaging cellular events - Gait Assessment CLINICAL MANIFESTATION PT MANAGEMENT - Impaired: sensation & motor - Strengthening & stretching - Deficits: motor progam & perception - NDT - Cognitive & behavioral changes - Therapeutic Handling - Communication d/o - Sensory Integration & Processing - Bowel & bladder dysfunction - Modified Constraint-Induce Movement Therapy - Spasticity c/l affected side - ES - Gait Training DIFFERENTIAL DIAGNOSIS/COMPLICATIONS MED/SURG MANAGEMENT Complications Medical: A. Muscukoskeletal 1. Anticoagulant 1. Contracture 2. Antiplatelets 2. HO (SH & HIP) 3. Antispasticity 3. FS 4. Antihypertension B. Neurological 5. Anticonvulsants 1. Intellectual regression 6. Anticholesterol C. Cardio-Pulmo 7. Thrombolytics 1. Pneuomonia 2. Pulmonary Embolism Surgical: 3. Deconditioning 1. Endarterectomy 4. DVT 2. Embolectomy D. Integumentary 3. CABG 1. Pressure sores 4. Clot removal - cerebellar CVA E. Psychological 1. Depression PT ASSESSMENT F. Metabolic - All that you know! 1. Bowel dysfunction 2. Bladder incontinence PT MANAGEMENT 3. Urinary sepsis - NDT: brunnstrom, roods, bobath, PNF, motor relearning strat - Sensory reeducation & stimulatiom DDX - Flexibility exercises & jt integrity exercises: ROM, stretching, positioning strat & stab exercises RULE IN RULE OUT - Strength training - Wt bearing & jt approximation TBI Trauma Vascular complication s Vomiting & LOC trauma Post-traumatic amnesia CN affectation 6. FROZEN SHOULDER/ADHESIVE CAPSULITIS Unilateral/Bilateral manifestation DEFINITION - A condition characterized by restriction in shoulder motion as a result of SCI MOI: flexion, compression, MOI: inflammation & fibrosis of SH capsule d/t disease or repetitive trauma. hyperflexion of VC ischemic/hemorrhage (+) areflexia (+) aphasia Manifestation is reliant on (+) cognitive & EPIDEMIOLOGY neurological level behavioral defiency - Insidious - 40-60 y.o. PD Rigidity Spasticity - F>M slowed/slurred speech (+) aphasia - Non-dominant arm Shuffling gait c freezing Possible circumduction - 5th - 6th decade phenomenon d/t mm imbalnces ETIOLOGY  A. Idiopathic - no unknown cause (primary) - Persistent & ↑ intensity @ rest B. Intrinsic d/o - Limited in all - Tendinitis 3. Frozen - Partial RCT - Only c movement - Joint strain - Significant adhesionms - Immobilization - Substitute motions of scapula C. Extrinsic d/o - Atrophy of deltoids, RC, biceps, & triceps - Visceral referral pain 4. Thawing - Cervical spondylosis - No synovitis (15-24) - CVA - Capsular restriction - Mm spasm - Gradually improve - May never regain N° ROM PATHOPHYSIOLOGY Adhesion of synovium → inflammation → secretion of exudate → attach to adj. DIFFERENTIAL DIAGNOSIS/COMPLICATIONS Synovial layers → sympathetic reaction (vasospasm & mast to fibroblast) → Complications ↑LOM → capsular pain - Disuse mm atrophy - OA CLINICAL MANIFESTATION - Faulty posture A. Acute - Poor arm swing - Diffuse, aching pain @ rest - Guarded SH motion - Guarding - Impingement - ER & ABD restriction - Edema - Radiating pain below the elbow - tenderness DDX B. Subacute RULE IN RULE OUT - Capsular tightness - ER > AB > IR SH FX LOM 4 stages - Pain @ end-range Pain MOI: disuse & immob - Limited joint play MOI: trauma - Contracture C. Chronic RCT (+) empty can test MOI: immob & disuse - Restriction of the GH joint MOI: trauma, tears (+) coracoid pain test - ↓ joint play Pain in motion Pain @ rest esp @ - Inability to reach overhead, outward, & behind night - Localized to deltoid region Impingement (+) neer’s test, no specific Localized pain Stages!! nerve ↓ arm swing during gait 1. Pre-Freezing Tingling & paresthesia - Gradual ↑ c movement & pain @ night - Loss of ER - Intact RCT MED/SURG MANAGEMENT 2. Freezing Medical: - Phenylbutazone  - Procaine: severe pain & localized tenderness - Falls (16%) - Prednisone - Recreation (16%) - Sympathetic block - Violence (14%) - Other trauma Surgical: B. Non-Traumatic (30%) - Removal of intra-articular biceps - Vascular malfunction - Excision of acromion & bursae - Vertebral subluxation - Arthrotomy - Infection - Replacement of humeral head - Neoplasm - MS PT ASSESSMENT - Special Test/s: PATHOPHYSIOLOGY - Apley’s Scratch Test Destruction of neuron @ level of injury → vascontriction of vessels & ischemia → - Yergasson’s Test/Speed Test desruption leads to ion imbalance → ↑ osmotic pressure & edema → trauma to - Resisted Isomes oligondendrites → ↓ rate of firing → inflammation → scarring - Sensory Testing CLINICAL MANIFESTATION - ROM 1. Spinal shock PT MANAGEMENT 2. Motor & sensory impairments - Codman’s Exercises 3. Postural hypotension - ROM Exercises 4. Impaired temperature control - Moderate Stretching 5. Respiratory impairment - Modalities 6. Spasticity - Massage 7. Bowel & bladder dysfunction 8. Sexual Dysfunction 7. SPINAL CORD INJURY Classification: A. Topographical DEFINITION - tetra/quadriplegia - An insult to the spinal cord from trauma or non-traumatic cause thereby - Paraplegia causing alterations of motor, sensory, and traumatic functions - Diplegia - Protoplegia (high tetra) EPIDEMIOLOGY B. Extent - M > F (4:1) - Complete - >50% in 25 to 44 y.o. C median of 26 y.o. - Incomplete - Cervical: C5-C7; Lumbar: L1-L2 - Tetraplegia > Paraplegia MOI: - Incomplete > Complete A. Flexion B. Compression ETIOLOGY C. Hyperextension A. Traumatic (70%) D. Flexion-rotation - MVA (45%) Syndromes: 1. Spinal decompression A. Anterior: flexion (worst prognosis) 2. Spinal fusion B. Posterior: contusion & syphilis (rare) 3. Myotomy, neurectomy, tenotomy C. Central-Cord: hyperextension (walking) D. Brown-sequard: stab/GSW S/P E. Cauda Equina: LMNL 1. Fx stab F. Conus Medullaris: pelvic mm, erection & ejaculation, (-) KJR 2. Orthosis: a. Knight-taylor DIFFERENTIAL DIAGNOSIS/COMPLICATIONS b. Jewett Complication c. Halo - Integumentary: pressure sore 3. Traction - ANS: autonomic dysreflexia 4. Turning frames & beds - Cardiovascular: orthostatic, hypotension, DVT, deconditioning - Pulmonary: pneumonia, pulmonary embolism PT ASSESSMENT - Musculoskeletal: HO, contractures, osteoporosis PT MANAGEMENT American Spinal Injury Association (ASIA) Impairment Scale (AIS) DDX All that you know! RULE IN RULE OUT TBI Vomiting & LOC Spinal shock Post-traumatic amnesia Possible affectation of reflexogenic erection Cauda Equina Flaccid Spastic Syndrome Areflexia Hyperreflexive Gradual & unilateral Usually bilat MS Optical neuritis (-) cognitive dysfunction Periods of relapsing & (-) intention tremor remitting Progressive MED/SURG MANAGEMENT Medical 1. Baclofen: 2. Diazepam: CNS 3. Dantrolene NA: skeletal mm 2° intrafusal fibers 4. Catheterization 5. Timed voiding 6. Pressure sore managament Surgical