Basics

Question 1

Old terminology:

• AK - above knee
• BK - below knee
• Stump

Answer 1

New terminology:

• transfemoral (AK)
• transtibial (BK)
• residual limb (stump)

Question 2

causes of amputations

Answer 2

• PVD (75%): dec. b/c of vascular sx and wound healing techniques; 2/3 also have diabetes
• trauma: MVA, war, GSW
• tumors: limb salvage more prevalent due to chemo and imaging

Question 3

levels of UE amputation

Answer 3

• Partial hand disarticulation (Loss of thumb - index finger or toe transfer should be considered)
• Wrist disarticulation
• Transradial
• Transcarpal (includes metacarpal bones)
• Elbow disarticulation
• Transhumeral
• Shoulder disarticulation (removal of entire humerus)
• Interscapulothoracic (removal of humerus, scapula, and part of clavicle)
• Note: in UE amputations, soft tissue coverage at the end of the residual limb is not as important as a LE amputation b/c UE are NWB

Question 4

levels of LE amputation

Answer 4

• Partial toe (excision of any part of 1+ toes)
• Toe disarticulation (disarticulation at the 3rd MTP joint)
• Partial foot/ray resection (resection of the 3rd, 4th, 5th metatarsals and digits)
• Transmetatarsal (amputation through the midsection of all metatarsals; Lisfranc - before tarsal bones; Chopart - after tarsal bones)
• Ankle disarticulation (Syme’s)
• Transtibial (short, standard, long)
• Knee disarticulation (amputation through the knee joint; femur intact)
• Transfemoral (long, standard, short)
• Hip disarticulation (amputation through hip joint; pelvis intact)
• Hemipelvectomy (resection of lower half of pelvis)
• Van Ness Rotationplasty
• Hemicorporectomy (amputation both lower limbs and pelvis below L4-5 level)

Question 5

Syme’s ankle disarticulation

Answer 5

• attachment of heel pad to distal end of tibia
• may include removal of malleoli and distal tibial/fibular flares
• Functionally a WB level (but not cosmetically favored)

Question 6

levels of transtibial (BK) amputations

Answer 6

• Long transtibial > 50% of tibial length
• Transtibial 20-50% of tibial length; standard; preferred level is at taper of gastroc
• Short transtibial < 20% of tibial length
• determine % length by comparing opposite side
• fibula best when 1cm shorter than tibia

Question 7

levels of transfemoral (AK) amputations

Answer 7

• Long transfemoral >60% of femoral length
• Transfemoral 35-60% of femoral length
• Short transfemoral < 35% of femoral length
• determine % length by comparing opposite side

Question 8

Van Ness Rotationplasty

Answer 8

• ankle joint becomes a functional knee joint
• can run and jump with a prosthesis
• often used in situations of cancer

Question 9

why would a knee disarticulation not be a great idea

Answer 9

need room for componentry and want at least 4 inches for a good lever arm; the longer the lever arm, the better

Question 10

energy requirements for TT vs TF

Answer 10

TT = 33% greater energy required
TF = 66% greater energy required

Question 11

surgical process goals

Answer 11

• Remove necessary part
• Allow for good wound healing
• Create a residual limb for optimal prosthetic fit and function
• Skin flaps: broad as possible
• Scar: pliable, painless, nonadherent

Question 12

types of surgical closures

Answer 12

• Equal length posterior and anterior flaps
• Long posterior flaps
• Skew flap

Question 13

equal length posterior and anterior flaps (closure)

Answer 13

• Scar is at bottom of the residual limb

- For well-vascularized patients/no vascular impairment

Question 14

long posterior flap (closure)

Answer 14

• Scar is anterior over distal tibia (beware of bone adherence)
• For compromised circulation b/c posterior tissues have better blood supply than anterior tissues

Question 15

skew flap (closure)

Answer 15

• Scar is angular medial-lateral, thus places scar away from bony prominences
• May be better than long posterior flap
• Also for compromised circulation

Question 16

surgical stabilization of major muscles

Answer 16

• allows for max retention of function
• combo of myofascial and myoplasty most common b/c it ensures that the muscles are properly stabilized and do not slide over the end of the bone
• Need muscle to be under some tension

Question 17

types of surgical stabilization

Answer 17

• Myofascial closure: attach muscle to fascia for closure
• Myoplasty: muscle to muscle closure
• Myodesis: muscle to bone/periosteum (transtibial)
• Tenodesis: tendon to bone (rare)

Question 18

surgical resection of peripheral nerves

Answer 18

• Identify major nerves, pull them down under tension, cut clean/sharp, allow retraction into soft tissue of the residual limb

Question 19

neuromas

Answer 19

• collection of nerve ends
• Must be surrounded by soft tissue to prevent pain and interference with prosthetic wear
• If they form close to scar, tissue or bone causes pain and may require revision

Question 20

veins and arteries

Answer 20

• Major vessels are ligated (tied up/closed off) creating hemostasis
• Smaller vessels are cauterized

Question 21

ideal residual limb

Answer 21

• No excessive or redundant tissue
• Incision is not under tension
• Circulation is good to all distal tissues, especially the skin flaps
• Bone ends are smoothed and rounded: distal tibia is beveled to reduce pressure between the bone and prosthetic socket
• Save as much bone length as possible

Question 22

What slows or prevents healing of an amputation?

Answer 22

• Infection
• Smoking
• Severity of vascular problems
• Diabetes
• Renal dysfunction
• Heart disease
• *Note: PTs can facilitate wound healing by teaching bed mobility, positional changes, and way to avoid pressure upon the residual limb in various positions

Question 23

types of post-surgical dressings

Answer 23

• Elastic bandage (ACE wrap); soft
• Shrinker; soft
• semi-rigid dressing (Unna’s, air splint); semi-rigid
• IPOP/EPOP (immediate/early post-surgical prosthesis); rigid

Question 24

advantage of elastic bandage (ACE wrap)

Answer 24

• easy to apply
• inexpensive
• easy access to incision

Question 25

disadvantages of elastic bandange (ACE wrap)

Answer 25

- Little edema control - Minimal RL protection - Requires frequent re-wrap (every 2 hrs)

Question 26

advantage to shrinker wrap

Answer 26

- Easy to apply - Inexpensive - Easy access to incision - can be applied by patient

Question 27

disadvantage of Shrinker wrap

Answer 27

- Little edema control - Requires changing as RL shrinks - Not used until sutures/staples are removed

Question 28

advantage of semi-rigid dressing (Unna's, air splint)

Answer 28

- better edema control | - RL protection

Question 29

disadvantage of semi-rigid dressing (Unna's, air splint)

Answer 29

- Needs frequent changing - Cannot be applied by patient - No access to incision

Question 30

advantage of IPOP/EPOP

Answer 30

- Excellent edema control - Excellent RL protection - Control of RL pain

Question 31

disadvantage of IPOP/EPOP

Answer 31

- No access to incision - Most expensive - Requires proper training for use - Not adjustable or removable

Question 32

residual limb wrappiing

Answer 32

- No circular wrapping( creates tourniquet and a bulbous end) - Don’t use clips to secure; use tape instead - Effective bandage - Use system of figure-of-eight turns - All patients need to learn proper technique - Worn 24 hours/day except when bathing - Use firm even pressure when wrapping - Re-wrap every 2 hours - Wash when soiled or at least every 48 hours (hand wash with mild soap and air dry; Do not ring out!) - Use elastic shrinker after staples are removed

Question 33

effective bandage

Answer 33

= smooth, wrinkle-free, emphasizes angular turns, provides pressure distally, encourages proximal joint extension