Amputation

Question 1

Surgical Consideration

Answer 1

Surgical consideration
- at most distal site compatible with wound healing
- Energy expenditure with walking inc. with more proximal amputation

Ankle/Brachial Index (ABI):
- compare BP in UL & LL
- Ratio<0.9= peripheral artery disease
*help determine level of amputation

Question 2

Vascular cause of amputation

Answer 2

1. Ischemia
2. Diabetes mellitus
3. Arterial insufficiency
4. Peripheral vascular disease (the leading cause of lower limb amputation)

Question 3

Level of amputation

Answer 3

1. Hip disarticulation
   - removal of entire limb at hip joint
   - Extremely high energy expenditure to walk - but ambulation is still possible
2. Transfemoral (TF)/above knee (AK)
   - WC if geriatric (esp. bil. amputations)
   - short moment arm–>difficulty to walk
3. Knee disarticulation
   - Femur intact
   - Sagittal skin flaps come togehter bewteen femoral condyles
   - Adductor magnus present–>stability in stance
   - Durable bulbous end for WB
   - Cons: larger prothesis needed with a knee/ankle joint
4. Transtibial/below knee
   - varying lenght of residual stump
   - shortest: must include tibial turbecle for Quad
   - posterior skin pulled under and to the front (post. flap)
5. Ankle disarticulation/Syme’s
   - Calcaneus and talus removed
   - Heel flap with fat pad –>folded up over stump for cushion
   -excellent wieght-bearing
   -Cons:
   *Risk of poor healing, bone spur, migrating heel pad, neuroma
   *need large prosthesis
6. Tarsometatarsal/Lisfranc
   - at TMTJ line
7. Transmetatarsal
   - Metatarsal heads cut on angle
   - Stiff rocker shoe–>push off at MTPJ
   - Toe filler prosthesis–>fill the shoe

Question 4

Contracture management:

Answer 4

Hip/knee flexion contracture >20º –> can’t use prosthesis

Common contracture:
Transfemoral: hip flexion, abduction and external rotation
Transtibial: knee and hip flexion

Education at POD 1
- Prone lying (if possible)
- No pillows under knees or thighs in supine
- No pillow between thighs for TF amputee
- Do not raise foot of the bed on electric beds
- Head of bed as flat as tolerable
- Use amp board for TT amps to keep knee in extended position
- No prolonged sitting
For every 1 hour sitting = 10-15 minutes flat

Question 5

Pain management

Answer 5

Type of pain:
Stump/incisional pain: tenderness in the incision of the stump

Phantom pain:
Painful/noxious sensation:
Sawing, sticking, knife-like
in missing limb

Phantom sensation:
tingling, pressure, itching/tickling in the part of the limb

Neuropathic pain:
mild to severe burning, squeezing, cramping/ stabbing pain in stump

Treatment:
- Exercise
- Relaxation/ visualization
- Desensitization (Compression/massage)
- TENS

Question 6

Stump shaping

Answer 6

-Worn all time, re-wrapped every 4 hours
-Distal to proximal pressure gradient
-Diagonal wrap
-Remove bandage if limb is throbbing/painful/cold
-Tensor in extension, back to front

Question 7

Stump care

Answer 7

DO:
- Daily skin checking with mirror on the back of stump
- Check signs of pressure/infection
- Clean cotton swab–>for skin folds
- Touch/gentle massage stump regularly to decrease the sensitivity

DO NOT:
-Put any chemical/strong ointment on stump
- Use Heat/Ice on stump
- Touch open/broken skin

Question 8

Exercise Choice

Answer 8

ROM:
- Positioning
- major focus on extension (hip and knee)
- Hip abd/add –> keep patient centered over stance leg during ambulation

Strength:
- Core, unaffected LL, Shoulder
- TF focus on: hip extension/flexion, add/abd
TT focus on: above + knee flex/ext

Question 9

Pressure Tolerant and Sensitive Areas of Stump: Transtibial

Answer 9

Pressure Tolerant:
Patellar tendon
Anterior compartment
Medial flare of the tibia
Shaft of the fibula
Gastrocnemius
Popliteal fossa

Pressure sensitive:
Anterior distal tibia
Fibular head
Crest of tibia
Peroneal nerve
Distal end of fibula
Lateral tibial condyle
Distal end of the stump
Patella
Tibial tubercle

Question 10

Pressure Tolerant and Sensitive Areas of Stump: Transfemoral

Answer 10

Pressure tolerant:
Ischial tuberosity
Gluteal muscles
Lateral sides of stump

Pressure sensitive:
Pubic symphysis
Perineal area
Distal end of the stump
Adductor tendon

Question 11

Prosthetic management

Answer 11

-Pistoning: residual limb slip up and down inside hte socket while walking–>poor suspension

-Area of pressure (redness >20min)
Mild redness over pressure tolerant area=normal
No redness over pressure sensitive area

-Leg apprears too short/long (level of pelvis)

Question 12

Circumduction

Answer 12

• Prosthesis swings out to the side in an arc

Cause:
- prosthesis too long
- locked knee (in extension)
- loose socket
- foot set in too much plantarflexion
- poor knee control
- abduction contracture

Question 13

Vaulting

Answer 13

• Rises up on the sound limb to swing prosthesis through

Cause:
- prosthesis too long
- poor suspension
- foot set in too much plantarflexion
- too little knee flexion

Question 14

Lateral trunk bending during stance

Answer 14

• Side flexes towards prosthetic side in stance

Cause:
- prosthesis too short
- weak hip abductors
- hip abductor contracture
- hip pain

Question 15

Forward flexion during stance

Answer 15

• Forward flexion during stance

Cause:
- unstable knee
- hip flexion contracture
- gait aids too short

Question 16

Swing phase whips

Answer 16

• toe-off: heel moves either medially or laterally

Cause:
- socket rotated
- foot misaligned

Question 17

Toe catching during swing

Answer 17

Cause:
- suspension issues
- prosthesis too long
- foot set in too much plantarflexion
- not using hip abductors on sound side

Question 18

Uneven step length

Answer 18

• favors unaffected limb
• limits weight-bearing time on prosthesis
  –> Dec. step length of unaffected limb

Cause:
- pain
- hip instability
- hip flexion contracture