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42 Cards in this Set
- Front
- Back
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Guillotine incision |
saves the life. Used in emergent situations. Temporary (in the modern world) restoration of hemostasis. Followed by revision. |
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fish mouth incision |
Scar directly at end of bone- 1" above the segment. Posterior flap of skin wraps forward. End of stump well covered and healing incision more ant- to see. Without secure myoplasty-myodesis, rehab potential is minimal. |
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myofascial closure |
not used in modern medicine. Minimal muscle stabilization. Avoided in modern medicine. |
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myodesis |
Transected muscle sutured directly to bone or tendon. Greatest stability- but still need something to weight bear through. |
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myoplasty |
(use a combo of myodesis and myoplasty). Transected muscles sutured together and placed over the end of the bone. Less commonly used, but better for poor vascular health. |
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wound care |
Absolute most critical rehab goal. Unhealed wounds account for 70% of non-ambulators. Big reason many surgeons prefer removable/changeable soft tissue dressings. Protect incision, may have sutures, staples, or glue. Observe for infection- Feverish. Smell. Drainage. Intense localized pain. Debridement, topical agents, dressing changes, modalities, whirlpool… |
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edema control |
important and immediate goal, progress is limited by edema management. Measure girth over time. Describe edema. Bulbous. Dog ears- over the edge of the scars. Adductor rolls (TFA)- if not fulling wrapping up the soft tissue- lymphatic port in femoral areas, if we really want it to drain need it to get that up there. soft, rigid, semi-regid, IPOP, shrinker |
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soft dressings |
Elastic “ACE-type” wraps, tubular compressive gauze, gel liners… Wraps over gauze bandage. +: cheap, easy to apply, frequent monitoring of wound site. - : Poorly supported in research for healing rate/edema control, possible tourniquet effect. Inconsistent P. Skin breakdown.Pt compliance/participation. PROLONGS TIME TO HEALING AND WB |
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soft dressing application |
Must approximate incision, do NOT apply the bandage to distract incision- usually post to ant over scar. Wrap ENTIRE limb. Keep constant tension for constant pressure. Wrap in crossing over oblique pattern- 50% overlap, helps prevent tourniquet. Avoids tourniquet. Always cross the superior joint with a circumference for suspension. |
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rigid dressing |
Generally applied at conclusion of surgery before tourniquet is removed. Thus, edema is immediately controlled. Remains on for 5-7 days. +: total contact, faster healing, decreased flexion contracture, protection. - : special training for practitioner, patient compliance, skin breakdown. |
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IPOP |
(immediate post operative prostheses) possible w/ rigid dressing. We still typically limit weight bearing until sufficient healing, but may be psychologically satisfying to have full length leg. Frequently allow TTWB. Indications: cancer, simple trauma, peds. Contraindications: vascular disease (decreased sensation), decreased sensation, infection risk. |
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semi rigid dressing |
Unna’s boot = compressive therapy technique utilizing semisolid mold. Does not allow expansion. Looks like a cast, but moves a bit. Compressive dressing containing zinc oxide paste to ease skin irritation, keep area moist, and promote healing. it does not allow expansion. +: better than soft and rigid. |
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semi rigid dressing + |
Total contact – improved healing v soft. Protection. Easily applied with simple training. Can use with a temporary prosthesis. Shorter hospital stay, better ambulation outcome, especially good for TFA. |
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shrinkers |
Highly elastic sock for edema reduction/maintenance. NOT for immediate post-op stage. Staples must be removed. +: Simple to don, washable, sensory input for avoidance of dysregulation, long term application. -: Stretches out. Less effective for edema reduction vs soft dressing. |
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post op contractures do NOTs |
Do NOT: Lie on overly soft mattress. Use pillow under back (pseudo hip flexion), thigh (TFA) or knee (TFA). Use pillow between legs or lie with femoral gap - abduction contracture. Have head of bed elevated. Stand in flexed posture (leaning on crutches). Lie hanging leg over edge of bed. Sit with leg hanging (use knee extension on w/c). |
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post op contractures |
Easy to prevent and difficult to correct, all about positioning. Hip flexors, PF, ABD, knee flexor. DO: lie prone 15 min at least 3 times a day. |
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psychological assistance |
Assess support sources. Stages of denial – meet them where they are. Depression very common. Validate, don’t minimize. set goals even if not focused on limb. depression does not end w/ prosthetic. motivate. mentors. support. activities. edu. |
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factors for depression |
Etiology: trauma. Physical: severe pain. Social: divorced/separated. Economic: poor. Education: less educated. depression does not end w/ prosthetic. |
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strengthening |
avoid muscle wasting! Isometrics (especially quad and glut sets). AROM: KTC, clamshell, sidelying hip abduction. PROM: maintains mobility. Best to avoid adding weights to stump (open chain). Best to encourage bolster use for closed chain. Upper extremity. |
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balance |
Standing 1 leg eyes open for 10 seconds is big predictor of mobility. 10 seconds at post op 2 weeks strongest predictor. Work on unaffected limb right away. |
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phantom limb pain |
Cortical reorganization? Hypersensitive? Don't really know. 60-80% of amps. Higher w/ UE and proximal. Usually cramping, squeezing, aching, or burning sensation in amp segment. Occasional/mild to constant/severe. No clear evidence supports 1 tx. Mirror therapy, desensitization tech, meds, heat/cold, wrapping in shrinker, sleeping in prosthesis, acupuncture and TENS can all help. Shrinker. |
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hyposensitivity |
very common among diabetic etiology. At large risk for tissue injury, regular checking and skin nutrition is key. Keep an eye on. |
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hypersensitivity |
Thought to be related tonn damage from amp surgery. More debilitating. Effectively managed by bombarding residual limb w/ tactile stimuli. Vary textures and P. Tapping, skin rolls, massage w/ lotion, touch w/ soft fabric, roll w/ ball, progressive aggression/fabric roughness. Physiologically we believe progressive overloading habituates NS via downregulation of neural receptors. |
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neuroma |
growth of nerve tissue and common in amputees. Palpable nodule and tapping will send shock of pain up leg. Treated with injection and possible surgical excision. |
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criteria for prosthetic fitting |
Incision sufficiently healed: Adherent scar. Minimal serosanguinous drainage OK- can't wait for complete healing, want to get them moving. Stable girth. Conical (preferred) or cylindrical. Not bulbous. Ambulatory on sound limb (with AD). Or Independent in transfers if bilat amputee. |
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initial gait training |
First build confidence. Walk however they want. GUARDING. Get used to prosthetic. Assure that they will actually walk. Then focus on quality, not distance. Skilled care Both feet are vulnerable, gain confidence and utility. Distance will come through self practice. |
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wear schedule |
Start w/ 2h- any day successful w/ 2h add 1h the next day. Standing/gait start w/ 1/2h, add 1/4h every day. Only progress when each previous session is tolerated well for full time. Wear shrinker whenever not in prosthesis for first 2 weeks. |
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wear schedule and PT |
When in doubt, discontinue and contact prosthetist. If bloody drainage > size of a quarter occurs, discontinue use. If this happens 5+ consecutive days, discontinue use and contact prosthetist. Checking the limb every hour of use is advised for the first 2-4 weeks. |
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weight shift |
Begin in parallel bars. Wean off helping hands. Progress different planes- ML: tap hips to bars. AP: spine/shoulder extension, trunk/shoulder flexion . Reaching can be plenty challenging. Diagonals. Repeat in staggered stance. Reaching for objects or PNF pushes can make for excellent trickery. |
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load acceptance |
Begin in // bars, standing tolerance/endurance likely limited. Activities w/ sound limb work best- Stool stepping progression Higher steps. Narrow steps, far away steps, unstable surfaces. Back steps, side steps, variable directions. Pivot to side, incorporate UE and trunk rotations. PNF pushing patterns to encourage hip strategy. Ball catching good if they actually shift to prostheses. |
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sound limb stepping IC-->midstance |
Initial contact -> midstance: step sound limb and wt shift fwd, reset and repeat. Avoid just walking down parallel bars. Midstance: stool stepping. Midstance -> heel off: work on adequate wt acceptance. |
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sound limb stepping TSt-->swing deceleration |
Terminal stance -> swing acceleration: practice pelvic anterior elevation and drive of swing. Begin with prosthesis under them, progress by positioning behind them. Midswing: prosthetic leg stool stepping. Midswing deceleration: pelvic anterior depression. HIT INTO THE GROUND. |
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knees and stepping |
Micro- Initiate swing w/ forefoot WB (need for knee to know to bend). ROLL OVER TOE!!! Hydraulic- Initiate swing w/ knee ext, will come natural w/ forward propelling of thigh. Work on propelling. Polycentric- Initiate swing w/ hipant elevation. PNF- P at ASIS. Weight activated friction- Must strike in last 20 degrees. Free swinging- Prepare for stance with sufficient momentum. |
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Doc Cool's kick catch |
More advanced pre-gait training. Start in spit stance with prosthetic leg behind. Swing forward and contact ground by forcefully pushing back wards in socket. Helps to gain prosthetic trust (it will be there) and train actively using prosthetic. Prepare for swinging, contacting ground, for follow through, trust. |
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Doc Cool's kick catch progression |
Pushing through for 1 more step (active stance phase posterior socket pressure). Starting with prosthetic forward (initiating gait by active posterior socket pressure). Take 2 steps (practice repetition more like walking). Slopes. |
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cueing w/ gait training |
Cue for arm swing- pseudo energy drive. Cue for reaching contra leg forward (increasing ipsi extension). Cue for driving into back of socket. dig foot in. |
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stair training |
Mastery needed for true community independence. First time users and friction knee: sound limb up first and down last. Practice driving socket back- add resistance. Start w/ really small steps. |
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stairs and TTA, TFA hydralic, TFA MPK. |
TTA: descend/ascend normal step over pattern. Ascending harder but mostmaster. TFA hydraulic: max descend normal, toe off step. Ascent very diff, min resistance to knee flex. TFA MPK: max descend normal pattern, heel on step. Ascent very diff, most don’t provide ext, must push into socket w/ force, power knee assists extension (rare). |
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incline/decline |
The most challenging common gait task. Down harder. Options: zig-zag the slope. Sideways ascend with sound leg leading. Sideways descend with sound leg trailing. Go with what’s safest and most natural! General Mechanics. Ascend with PF moment/knee extension. Descend with DF and knee flexion moment. |
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turning |
Turning on sound side in 2 steps: Cross prosthesis over sound leg at 45 degrees. Rotate sound leg 180 degrees. Step around with prosthesis. Turning on prosthetic side in 3 steps: Cross sound limb 45 degrees around prosthesis. Rotate prosthesis maximally (~135). Sound limb completes turn. Prosthesis rotates last bit. |
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falls |
It will happen, don’t beat yourself up. Within the community, incidence is 52%. Don’t lie to the pt, prepare the pt! Insurance will cover. Fall recovery training. |
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general ther ex |
Clamshell. Stand w/ non-involved leg up on table w/ PT pushing into it- helps them train to WB during stance. Bridge. Side lying leg raise. Squat, sink squat. Deadlifts especially TFA. Side planks. Transverse abdominus training. Never stop stretching hip flexors. Advanced balance training. Advanced squat training. Advanced transverse training. |
