What are the goals of amputation?
- decrease pain
- remove disease, narcotic tissue
- improve pt condition and function
Why should you leave the residual limb as long as possible?
lever arm is longer -> less energy to use prosthetic
What is usually done first, before amputation?
revascularize the limb
level of amputation is determined by the healing potential/nature of injury
What are some major indications of amputation?
- 3% congenital (correct a defect)
- 4% tumor (osteogenic sarcoma)
- 22% trauma (2nd most common cause)
- #1 cause is PVD
What is the #1 indication for amputation?
peripheral vascular disease
What is the pattern 50% of all non traumas follow?
DM-> ulcer-> inflammation/infection-> gangrene-> amputation
What is intermittent claudication?
- severe LE pain that increases with activity and decreases with rest
- due to inadequate blood supply to exercising mm
- most common in those 61-70yrs old
What is tissue death with absent blood supply?
What is the thickening, hardending, and narrowing of arteriole walls?
- arteriole sclerosis obliterans (ASO)
- common cause of CVA, TIA, and cardiovascular disease
What is buergers diease?
- thromboangitis obliterans (TAO)
- parasthesia of foot or pain confined to one toe, easiliy fatigues, cramps in legs, legs give out, ulcerations and moist gangrene may set in
- 2nd most common chronic occulsive arterial disease
- nicotine is a vasoconstrictor
What are some signs/symptoms of vascular disease?
- trophic changes
- vascular lesions (breakdown)
- stasis hemosiderosis - rusty color on shins
What are tropic changes in vascular deficiency?
- shiny skin with marked loss of hair
- poor condition of nail beds
- loss of sweat response
What are some frequent causes of death associated with amputation?
- pulmonary embolism
- gas gangrene
- diabetic acidosis
What are some contributing factors to death in pts with an amputation?
- underlying heart disease
- advanced age
- gangrene with sepsis
- chronic pulmonary disease
What is a guillotine amputation?
- 16th century
- all tissues removed at same level with one stroke
- bleeding vessels sealed with hot irons or oils
What is an open amputation?
- no sutures used
- used with spreading infection-decreased septicemia
- general toxicity-increased overall health
- also used with dirty traumas where debris needs to be identified and removed
skin traction: 6-8lbs for transfemoral, 4-6lbs for transtibial
What is a closed amputation?
- final amputation, often days after an open amputation
- surgeon creates residual limb for prosthesis
What are the shapes of the skin flaps?
- equal length (ant and post with scar at distal end)
- long posterior flap (scar over ant distal end of tibia-used for devascular limbs)
What are the types of myofascial closure muscles are stabilized with?
- mypoplasty- muscle to muscle
- myodesis- muscle to bone
- tenodesis- tendon to bone
Why are bones sectioned to a length?
- to allow wound closure
- avoid excessive redundant tissue
- without placing too much tension on the scar
- sharp bone ends are smoothes and rounded
vessels and nerves are neatly cut
What is the mourning process of amputation consist of?
- impact phase
- retreat phase
What mourning phase does the pt feel despair and discouragement-loss of limb?
What mourning phase for the pt display grief, sleep disorders, anger, guilt, withdrawl, and has the reality of the lost limb?
With what mourning phase does the pt accept the loss of the limb and begins to display increased motivation with PT?
With what mourning phase does the pt feel they are ok, and can make it?
What are some post-op factors that affect healing?
- #1 cause- ill fittin prosthetic
- contaminated wounds
- ulcer-> skin breakdown
- failed attempts at revascularization
- severity of the vascular problems
- neuroma (ends of nerve is cut and continues to grow out of soft tissue, if caught in scar tissue or subject to pressure or tension-pain results)
- phantom sensation (awarness of limb being complete-painless sensation)
- phantom pain (pain in area of removed extremity; 50% of ppl complain of this)
- dog ears
- skin folds or creases
- pts age
- other medical problems
What are the theories of phantom pain?
gate control theory: sensory input into dorsal horn and interpreted as pain
peripheral theory: sensation from nerve ending in stump is still carrying input into the brain
psychological theory: pt is in mourning and cannot accept, therefore bringing the pain on themseleves
What are some complicating medical conditions that may lead to phantom pain?
- renal disease
- cardiac disease
- UGI bleed
What are some causes of UE amputation?
- prosthetic use is most likely with a transradial
- most important digit to save is the thumb
- may occur at any level; less frequent than LE loss