What are the major causes of lower extremity amputation? (4)
PVD
Trauma
Cancer
Congenital defects
Risk factors for _ _ _ include: diabetes, poorly managed HTN, high cholesterol, and smoking.
PVD
_______ _______: significant cramping pain, usually in the calf that is induced by walking or other prolonged muscle contraction and relieved by a short period of rest. (ischemic response)
intermittent claudication (indication of vascular insufficiency also includes vascular pain, and loss of one or more of lower extremity pulses)
Protective sensation:
- must be able to perceive _._ _ semmes-weinstein monofilament.
5.07
What should be the primary goal be with PVD/DM in regards to feet?
prevention
What are the 5 levels/classifications of amputations?
transtibial
transfemoral
syme/foot
hip disarticulation
upper extremity
The higher the amputation, the (more or less) difficult the rehab. The (older/younger) the more difficult the treatment.
more
older
When should mmt and ROM be assessed after amputation?
-can be done post-operatively immediately but is non-resisted
-once the incision is healed, full grade of motion and strength can be determined
-i'm a trickster
How can a PT record measurements of residual limbs?
measurements are taken from an easily ID'd bony landmark to the palpated end of the long bone, to the incision line, or to the end of the soft tissue
Once primary healing has established, teach pt. scar massage where?
Once wound is well closed, and no steri strips, can begin to?
above and below (not across)
mobilize scar itself (reduces skin breakdown)
_____ _____ _____: (70%) experience numbness, tingling, pressure, itching, and mild cramping in non-existent limb.
_____ ____ ____: shooting limb pain, severe cramping, severe burning in amputated foot/limb. More common in dysvascular limb pt.s
phantom limb sensation
phantom limb pain
How would you explain phantom limb pain to a pt?
all nerves that once had branches to LE are still present, but end at a new place. it takes time for the brain to learn this fact. also, these nerves may be very sensitive from the amputation surgery as they are pulled and then severed and allowed to retract.
Why is compression bandaging important for all amputees? (5)
reduce edema
control pain
enhance wound healing
protect incision
pacilitate prep for prosthetic limb
What are the most common contractures?
transtibial (2)
transfemoral (3)
transtibial: hip flexion, knee flexion
transfemoral: hip flexion, hip abduction, hip lateral rotation
The shorter the residual limb, the more you need to build in _____ in the design of the prosthetic componets.
stability
Care for residual limb post op:
-wash nightly with mild, ___-___ soap.
-small amnt of ____ to make skin soft and pliable and more tolerant of the posthetic.
-do not use _____ to clean.
non-drying
lotion
alcohol
Target clinical pathway:
Day _: amputation surgery
Day _-_: acute hospital, pre-prosthetic PT
Day _-_: sub-acute rehab hospital or home for wound healing and continued pre-prosthetic PT
Day _-_: suture/staple removal followed by casting for temporary prosthesis.
day 0
day 1-4
day 5-21
day 21-28
How would you teach a pt to don his prosthesis?
-sit in firm chair with arms
- identify and check prosthesis
-inspect condition of residual and remaining limb
-place sheath, socks, or gel liner over residual limb (no wrinkles)
-insert residual limb
-step into prosthesis while sitting
-attach suspension
-reverse to doff
Skin-check every __ minutes in inital prosthetic wear. look for texture, appearance, color and condition. Reddened areas should disappear in __ minutes
15
15
Problem solving abnormal pressure patterns:
-Pressure on inferior pole of patella? going (too far or too short in) socket. Solution?
-Pressure on tibial tuberosity? going (too far or too short in) socket. Solution?
too far. add socks
too short. decrease socks
_______: movement between skin and the socket, excessive drop of socket away from reisdual limb in swing (problem with suspension).
pistoning
_____ _____: in order to initiate the progression towards normal gait, the primary goal is to get the pt to stand in parallel bars with an ____ hand, feet 4 inches apart and to move side to side, front to back, and diagnolly. Progress to one hand, and no hands
weight shift
open hand
What info should be included in a HEP for a prosthesis? (5)
-don/doff
-wear schedule
-care for prosthesis
-care of sound limb
-changes in weather and weight
When will PT discharge/discontinue pt?
-when pt can do all functional skills without pain, huge energy cost or abnormal gait
-when pt has reached maximal potential (no more progress)
Before discharge or discontinuation of care
-Transtibial amputee should be able to wear prosthesis __-__ hours a day, with good knowledge of skin and prosthetic management, and proficient with prosthetic skills.
-Transfemoral amputee may only wear prosthesis for __-__ minutes.
3-4
30-60
______: ending PT secondary to pt. reached anticipated goals/outcomes.
_____: ending PT secondary to: patient request, unable to continue secondary to insurance, finances, transportationl or medical complications, and or Pt. no longer benefits
discharge
discontinuation
Most new wearers need a major socket revision/new socket within (how long?) to accomodate shrinkage.
1 year
-Transmetatarsal: %functional recovery? increased energy requirement?
-Transtibial: %functional recovery? increased energy requirement?
-transfemoral: %functional recovery? increased energy requirement?
- 95%/0%
-70-75%/20-40%
-20-40%/50-80%
Level _: pt. is non ambulatory;medicare wont pay for prosthesis.
Level _: transfers or limited household ambulator; single axis foot/manual knee lock
Level_: limited community ambulator; multi-axis foot/polycentric knee
Level_: unlimited community ambulator
Level_: high energy activities; energy storing feet and hydraulic/microprocessor knee
0
1
2
3
4
Identify four possible forms of compression bandaging commonly used after amputation.
ace wrapping
shrinker socks
rigid removable dressing
semi-rigid dressing
What is the purpose of compression bandaging for the amputee? (5)
What is the significance of the medicare funcitonal levels?
helps guide decisions regarding prosthetic design and appropriate componentry based on the pt's projected level of funcitioning
Strategies to avoid contractures? (6)
amputee board in wc, exercises, avoid using pillows, prone lying, education
True or false: application of ground force reaction vectors applies to prosthetic alignment and can greate gait deviations?
Ankle PF in a transtibial prosthesis can creat a knee ____ moment.
true
extension
What is the most common cause of amputation?
PVD
Identify two shortcomings with ace wrapping for compression?
need good dexterity and cognitive function
rewrapped frequently
can create choking
23/24 hours a day
What bony landmark might serve as a good reference for measurement of residual limb length in a transfemoral amputee? (2)
greater trochanter, ishcial tuberosity
What bony landmark might serve as a good reference point for measurement of a residual limb length in a transtibial amputee? (2)
tibial tubercle, joint line
Can you complete a full MMT test day 3 following amputation?
no, wait for incision to heal
Your patient had arecent amputation, what is important in terms of skin checks to instill in your patients?
check every 15 minutes for edema, blisters, abrasions etc. If it persists greater than 15 mins, leave prosthesis off and contact prosthetist. Look for uniform sock lines. Monitor sound limb.
