Assessment and problem solving: starting with a temporary prosthesis

Transcription

1 Assessment and problem solving: starting with a temporary prosthesis Stump assessment Skin Colour, temperature, appearance sensitivity and allergies to materials Integrity eg frail, thin, dry Abrasions, skin tears and location of same ie on weight bearing surfaces or under strap. Presence of skin grafts (especially traumatic) Wound and scar Healed or open MUST allow to close before fitting the prosthesis especially with vascular insufficiency. Consider location of wound high/low risk areas. Prominent/raised. Tethered or mobile Scar massage for 1min duration at each point where skin/scar is tethered. Patient to do daily when they bathe. Increase comfort, decrease pain and risk of skin breakdown 2 to rubbing within socket. Deep circular motions or frictions perpendicular to line of scar Oedema Palpate especially distal stump. Firm, soft, pitting etc Take circumferential measures at 3, 6, 9, 12cm (+/- 14/15cm) from inf. pole of patella weekly to monitor stump volume and shape. For AKA choose relevant landmark for consistency eg scar line. Once the stump is stable (consistent measures over 2+ weeks) it is suitable for the definitive. Managed with stump bandages or shrinker socks and effleurage type massage. Bandages and socks are to be applied at all times except when washing or massaging bandaging must be reapplied frequently throughout day (at least 6 hourly). Skin must be dry before reapplying bandages or socks. Consider wound condition prior to changing to shrinker sock Sensation Simple assessment of stump sensation.

2 Considerations with prothesis fit. - Is patient able to give feedback of incorrect fit or monitor as stump shape/size changes? Eg end bearing, dropping off, rubbing, scratching - If sensation is impaired patient must be v. diligent in checking stump/skin condition regularly. Stump pain - Sensitivity to touch/pressure. Tolerate prosthesis? - Consult with medical staff re pharmacological management. - Massage at least 5mins 3-4 times a day decease swelling increase stump tolerance, helpful in reducing phantom pain. Also important for reducing/treating neuromas. - Tapping and desensitisation. Done 2-3 minutes twice daily. Cotton ball paper towel terry cloth. Boney prominences Consideration for socket relief and padding. May utilize additional padding (silicon) for very sensitive areas. ROM Assessment Amputated AND intact limb. - Intact limb especially DF, knee extension and hip extension ranges sufficient to allow balanced standing and ambulation - Amputated limb depending on level knee ranges, hip ranges Presence of contractures hamstrings, hip flexors associated with prolonged wheelchair use. - Ideally minimised through good post op management however treated with stretching program eg prone lying and long sitting with overpressure. Surgical release. - TTA 20 knee flex contracture for prosthetic use. - TFA 5 hip flexion contracture for prosthetic use. Strength Amputated AND intact limb - Compensations for missing limb segments and contribution to gait pattern. - Hip extensors++ amputated side - PF, quads, hip extensors intact side. Power AND endurance - Manual muscle testing and functional testing eg STS (height, no. in 60sec, to fatigue), mob endurance, 10MWT etc

3 - Energy (oxygen) cost of mobility progressively increases the higher the level of amputation - Consider reason for amputation (traumatic vs vascular) and age of patient decreased physical work capacity and VO2 max associated with increased age and poor cardiovascular function. - Aerobic conditioning exercises have been shown to both increase walking speed (8%) and decrease rate of oxygen consumption (6-10%) with TT and TF amputations. (Waters RL, Mulroy S) Are they suitable/ready for a prosthesis Stump condition ROM and strength considerations (intact and amputated). Ability to hop prosthetic gait training. Medical issues preventing training. Cognitive function ability to learn complicated task of gait retraining and safety in using prosthesis, medical issues affecting cognitive function eg dementia, stroke. Social situation. Attitude and motivation. Basic principles of prosthetic alignment and adjustment BKA Weight bearing surfaces Patella tendon, medial tibial flare and lateral tibial muscle bulk. Triangular shaped socket, with counterpressure in popliteal fossa. Pressure intolerant areas end stump, boney prominences eg fibula head, tibial spine, distal tib or fib, tibial tuberosity, elsewhere. Alignment patellar shelf horizontal and level with popliteal counter pressure, knee in 5 flexion (plus contracture), central brim of socket 1cm anterior to pole, mid-pole 1cm medial to mid socket. AKA Weight bearing surfaces Ischial tuberosity with anterior counterpressure on quads, medial and lateral thigh surfaces. Quadrilateral shaped socket. Pressure intolerant areas end stump and boney prominences, adductor tendons, groin.

4 Alignment posterior brim is horizontal, medial brim horizontal and in line of progression (straight ahead), ischial tuberosity sits 1/3 of the way along the brim and 1.5cm medial to centre of the knee joint. Midline of brim should sit 1cm anterior to knee joint. Prosthetic fit Patient feedback comfort (will be somewhat uncomfortable/painful especially at first) areas of pressure location, height, movement within socket. Alignment on patient in balanced upright standing with even weight distribution (compared with bench alignment) adjust prosthesis with Allen keys. Inspection of stump sock marks and red marks (consider cast is total contact). Adjustment Add layers of socks end bearing, too loose, dropping off Grind/file out relief in areas of rubbing, tenderness Change alignment to alter weight distribution Medial Lateral

5 Build up or pad sections eg patellar shelf or counter pressure. New prosthesis contracture resolved and unable to change alignment any further, change in stump shape with oedema resolution. When can they take them home? Prosthesis fits properly good alignment, pressure in pressure tolerant areas, not rubbing. They or carer knows how and what to monitor on stump ie when to add socks, pressure areas, when to stop using. The patient or carer is able to don prosthesis correctly. Patient is compliant with exercise program and will follow instructions won t do anything stupid!