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major reason for LE amputations, and which is #1?
- #1: vascular disease
- infection (such as osteomyelitis, which is often linked with decreased circulation)
- blood clots
artificial device to replace a body part (includes THAs, TKAs, false teeth....)
4 types of LE amps that don't require a prosthesis
- big toe
- Lis Franc (removing all metatarsals)
- Chopart (removing all but talus and calcaneus)
what a pt with a big toe amputation needs
a rocker bottom shoe
2 problems that can come from trans-metatarsal amputations, and what this pt needs
- suture line is vulnerable to breakdown
- PF contracture (so work on DF)
needs a rocker bottom shoe to allow heel-toe gait which would otherwise be lost without the MTP joint
Lis-Franc amputation is what, pt requires what?
removal of all metatarsals, tarsals stay put
- rocker bottom shoe
- cushioned heel (for shock absorption and to control PF in heel-toe gait which would usually be controlled eccentrically by DFers)
why does a foot with some amputation veer towards PF?
- the DFers attach more distally, and their attachments will be disturbed (the tendon may be attached to a more proximal bone or else allowed to recede into the body)
- the PFers attach more proximally, so they remain and they pull the foot
chopart amputation is what, what does the foot need?
keep the talus and calcaneus, remove everything distal
- rocker bottom shoe, cushioned heel, shoe filler
- and lots of stretching to avoid a PF contracture
Syme's amputation is what?
- removal of talus and calcaneus (and everything distal to them)
- move the heel pad anteriorly
SACH foot - what is it? which amputation gets this?
- Solid Ankle Cushioned Heel
- Syme's amputation -- first put a brace on the stump, then attach this
if you do a Symes but keep the calcaneus what do you call it now?
- Boyd's amputation
- it requires extra surgery to fix the calc in place
BKAs, what do you think about length of stump?
- always cut above the lower 1/4, but other than that, leave it as long as you can
- if you leave <40% that's pretty bad because it'll reduce the control over the prosthetic
- cut fibula a bit shorter than tibia
where's the suture line in a BKA
anterior, bc the surgeon takes the skin and gastroc flap and folds them forward
knee disarticulation - what's removed?
- patella, tib, fib, etc
- the whole femur is retained
- pt will need a mechanical knee joint with prostesis
- it's harder to don a prosthesis with this amputation
AKA / trans femoral amputation -- tell me about length of stump?
get it as long as possible for best prosthesis control
AKA - where is suture line
it's inferior bc surgeons use a longer ant flap (of skin and quad heads) and wrap it posteriorly (though not that far post)
hip disarticulation - what's happening here? how to control prosthesis?
- femoral head comes out of acetabulum, and the whole leg is amputated
- pelvic tilting
hemipelvectomy - what is involved? how to control prosthesis?
- disarticulation at SI joint and pubic symphysis, so you can remove half of pelvis
- (sometimes the posterior part of the ilium is retained at SI joint)
- pelvic tilting, like with a hip disarticulation, but with much bigger energy expenditure, so these pts often use WCs for longer distances
hemicorporectomy aka translumbar amputation
where is it usually?
- btwn L4 and L5
- pt uses a "bucket prosthesis"
in a BKA, what to do about bone, nerves, blood vessels, muscle
- bone: shave it to get rid of sharp edges
- nerves: get them to recoil into soft tissue
- blood vessels: cauterize and ligate (tie)
- muscle: myodesis or myoplasty - and put the muscle on a bit of extra stretch to help it be functional
attaching tendon to bone
attaching muscle to soft tissue
in measuring calf length, what are your landmarks?
med tib plateau to med malleoli
sutures, if not the disolving type, stay in approx how long?
when should PT start for an amputation pt?
pre-op with edu about hopping, transfers, bed mobility, positioning in bed to prevent contractures....
note: when you're seeing pts early post-op be sure pt is medicated to decrease pain!
what covers sutures?
first a basic dressing, then either a soft one (guaze, ace wrap, a compressive garment, or a hard dressing (this'll have padded dressing over sensitive areas, wrap the whole area with gauze, then apply a hard cast)
what's the icing on the cake after a hard cast?
- a pole is attached, and then a prosthetic foot
- this is an IPOP - immediate post-op porsthesis
IPOP stands for...? why is it good?
- immediate post op prosthesis (like the pole and foot with a hard dressing)
- gets pt walking (partial wt bearing) earlier
- lets pt exercise in CKC
a bunch of things to think about in immediate care after an amputation
- prevent contractures
- suture line healing
- pain management
- bed mobility -- do bridges, rolling, supine <--> sit
- respiratory care -- insp spirometer, prevent pneumonia
AKAs are most susceptible to which contracture? why?
- bc the attachment sites for ADductors are gone
if sitting in a WC what should BKA pts have?
a board to elevate the calf and put the knee into extension
one technique for addressing a hip flexion contracture
stuff to work on day 1 post op (per pt's tolerance and skill)
- get into seated pos
- work on sitting balance
- work on transfers (stand-pivot or lateral)
- stand with walker
when not to do resistive exercises?
don't do them til sutures are removed
post op eval - what to look for in chart review
- PMHx (may be full if pt has vascular issue)
- recent medical course (look at recent nurse's note)
- home/social/occupational status (home w/whom? what kind of support? work?...)
- cognitive status (A+Ox4? -- if pt has sever dementia, inappropriate for prosthesis
post-op eval, some info to get from pt?
- home set-up (stairs, rugs, shower vs bath...)
- equipment or ADs at home
- pt's goals
- prior level of activity
post op eval get what vital signs?
HR, BP, SpO2
post-op eval - residual limb & intact limb inspection -- looking for what?
edema, shape (conical vs cylindrical), discoloration (if red do a capillary refill test) suture line, length, skin inspection, girth measurements, signs for starts of pressure ulcers/neuropathic wounds, ROM (use a goniometer on stump)
sensation to look for in post-op eval
- phantom pain
- phantom limb phenomenon (still feels limb as if it's there, but not painful)
some flexibility tests to try in a post-op eval for ROM info
- Thomas: pull good leg to chest, see if stump leg rises
- Ely's: prone, can foot get to butt? - tests rectus fem
- Ober's: tests for tightness in IT band
What would you like to do?
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