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What are the goals of amputation?
- decrease pain
- remove disease, narcotic tissue
- improve pt condition and function
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Why should you leave the residual limb as long as possible?
lever arm is longer -> less energy to use prosthetic
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What is usually done first, before amputation?
revascularize the limb
level of amputation is determined by the healing potential/nature of injury
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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
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What is the #1 indication for amputation?
peripheral vascular disease
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What is the pattern 50% of all non traumas follow?
DM-> ulcer-> inflammation/infection-> gangrene-> amputation
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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
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What is tissue death with absent blood supply?
gangrene
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What is the thickening, hardending, and narrowing of arteriole walls?
- arteriole sclerosis obliterans (ASO)
- common cause of CVA, TIA, and cardiovascular disease
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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
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What are some signs/symptoms of vascular disease?
- trophic changes
- vascular lesions (breakdown)
- stasis hemosiderosis - rusty color on shins
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What are tropic changes in vascular deficiency?
- shiny skin with marked loss of hair
- poor condition of nail beds
- loss of sweat response
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What are some frequent causes of death associated with amputation?
- MI
- CVA
- uremia
- pneumonia
- sepsis
- pulmonary embolism
- gas gangrene
- diabetic acidosis
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What are some contributing factors to death in pts with an amputation?
- DM
- obesity
- underlying heart disease
- advanced age
- gangrene with sepsis
- chronic pulmonary disease
- osetosarcoma
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What is a guillotine amputation?
- 16th century
- all tissues removed at same level with one stroke
- bleeding vessels sealed with hot irons or oils
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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
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What is a closed amputation?
- final amputation, often days after an open amputation
- surgeon creates residual limb for prosthesis
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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)
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What are the types of myofascial closure muscles are stabilized with?
- mypoplasty- muscle to muscle
- myodesis- muscle to bone
- tenodesis- tendon to bone
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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
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What is the mourning process of amputation consist of?
- impact phase
- retreat phase
- acknowledgement
- reconstruction
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What mourning phase does the pt feel despair and discouragement-loss of limb?
impact phase
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What mourning phase for the pt display grief, sleep disorders, anger, guilt, withdrawl, and has the reality of the lost limb?
retreat phase
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With what mourning phase does the pt accept the loss of the limb and begins to display increased motivation with PT?
acknowledgement
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With what mourning phase does the pt feel they are ok, and can make it?
reconstruction
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What are some post-op factors that affect healing?
- #1 cause- ill fittin prosthetic
- infection
- contaminated wounds
- edema
- 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
- contractures
- pts age
- other medical problems
- smoking
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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
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What are some complicating medical conditions that may lead to phantom pain?
- DM
- renal disease
- cardiac disease
- UTI
- pneumonia
- MI
- UGI bleed
- CVA
- depression
- psychosis
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What are some causes of UE amputation?
- trauma
- congenital
- malignancies/tumors
- 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
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