POSTPOST- OP MANAGEMENT FOLLOWING LOWER LIMB AMPUTATION

Post op management PRE PROSTHETIC PHASE POST PROSTHETIC PHASE

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AMPUTATION
Should not be thought of as a failure of Treatment, but as a Treatment of choice.
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Physio Role in Early Post-OP

1. 2. 3. 4. 5. 6. 7. 8. 9. Post- OP dressings Prevent chest Complication Maintenance of Strength Maintain Range of Motion To train Transfer Prevent Contracture and deformities Balance training and Gait Residual Limb care Pain management
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1. Post Operative Dressing.

Rigid Removal Dressing. Immediate post operative prosthesis. Soft dressing. Semi rigid Post op dressing.

Rigid removal dressing (RRD)

Used in trans tibial Made of POP or fiber glass USES: Control oedema Decrease pain Promotes wound healing Protects limb from trauma Desensitizes limb Allows daily inspection of limbs
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IMMEDIATE POST SURGICAL PROSTHETIC FITTING

A plaster cast mould is applied over the amputation stump immediately after day Advantages
Plaster cast forms a protective cover over the stump, prevent infection Improves circulation in the stump, there by facilitating healing Imbibes confidence in the patient and increase the chance of early acceptability of a permanent prosthesis

surgery to which a

temporary prosthesis (pylon) is attached the next

Oldest method Elastic wrap & Elastic shrinker Advantages: Inexpensive Light weight & Readily available Able to laundered

Soft Dressing
Disadvantages Relatively poor control of Oedema Need skill for application Needs Frequent applications. Slip Frequent change is needed, if stump shrinks. Shrinker cant be used until the sutures have B.ARUN.,MPT,CMPT,COHS been removed.

SEMIRIGID DRESSINGS
Unnas dressing.
Advantage Control odema Limit joint motion Prevent contracture. Disadvantage May loosen easily & is not as rigid as POP dressing.
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2.Chest Complication Preventions

Deep breathing Exercise. Coastal Breathing Exercise. Huffing &Coughing Technique Postural Drainage Incentive spirometry Chest expansion exercises Aerosol therapy
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3. Maintenance of Strength
Isometrics Isotonic PNF Bridging Rolling Strengthening exercise to Lower limb and Upper limb.
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4. Maintain ROM
Active movements are encouraged Active exercise includes Push ups Moving Up & Down in Bed Passive extension of Trans Tibial residual limb AROM Active transtibial exercise
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5. Transfer techniques
Bed activities Bridging Rolling Transfer Bed to Wheel chair, Wheel chair to bed, Wheel chair to toilet.

Transfer Technique

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6. Gait Training
Gait training 3 point at initially. 4 point with temporary prosthesis.

Weight Bearing exercise

Initially graded weight bearing on the stump in parallel bars. Kneeling exercise with manual resistance Four point and Two point.

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7. Prevention of Contractures & Deformities

1. 2. 3. 4. Positioning Exercise Mobility Manual Mobilisation 5. Active movements 6. Stretching

Hip Flexion and Abduction AK Knee Flexion BK

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Positioning
Below Knee. Lying with Hip and Knee extension Sitting with Knee in full extension Wheel chair sitting Posterior splint / Board attach to wheel chair.

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Positioning
Above Knee Prone lying for 10 30 mins Pillow on the lateral side.

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Positions to be Avoided
Knee in flexion Pillow under the knee Sitting with knee flexion in wheel chair Prolong Supine lying and Sitting in AK

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Manual Mobilisation

Stretching
Passive stretching PNF Hold & Relax Active stretching Post Isometric relaxation exercise.

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Stretching exercise

PHYSIO ROLE IN EARLY POSTPOST-OP

1. 2. 3. 4. 5. 6. 7. 8. 9. Post- OP dressings Prevent chest Complication Maintenance of Strength Maintain Range of Motion To train Transfer Prevent Contracture and deformities Balance training and Gait Residual Limb care Pain management
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RESIDUAL LIMB CARE

Prevent Oedema Building shape of stump Earlier fitting of Permanent prosthesis Conditioning & Shaping the stump. Maintain the Circulation.

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LIMB CARE
Elevation Exercise Elasto creepe Bandaging Stump Massage Stump Hygiene

ELEVATION
Elevate the foot of the BED. (above Heart level). BK stump is elevated by stump board in Wheel chair. Occasional removal of prosthesis should elevate the residual limb in stool or chair.

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BANDAGING
Circular Bandaging should be avoided Spiral, Oblique bandaging is applied Equal pressure Extra pressure must be applied at the corners 6 for AK, 4 BK Conical shape B.K Quadrilateral A.K
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Below Knee amputation Bandaging

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Above Knee amputation Bandaging

Improper Bandaging

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Oedema Reduction
Shrinker Shocks Intermittent variable air pressure machines Exercises Massage Effleurage.Kneading,Tapping.

Post Pneumatic Prosthesis

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EXERCISE
Hip Movements Knee Movements Regular intervals throughout the day 10 repetitions / hourly.

AMPUTATION EXERCISES STRENGTHENING

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HIP ABDUCTORS

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PARTIAL SITUPS

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ALTERNATE FORM OF EXERCISES

ALTERNATE FORM OF EXERCISES

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ADVANTAGES OF STUMP EXERCISES

Improves circulation Increase venous return Prevent odema Prevent deformity Prevent stiffness Strengthen stump muscles Prevent phantom pain
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STUMP STRETCHES
HAMS STRETCHES

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ALTERNATE HIP FLEXOR STRETCH

HIP FLEXOR STRETCHES

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HIP ADDUCTOR STRETCHES

RANGE OF MOTION EXERCISES

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ROM

HIP EXTENSION EXERCISES

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HIP EXTENSION EXERCISES

HIP ABDUCTION

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HIP ADDUCTION

PELVIC TILT

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STUMP HYGEINE
Regular wash Proper drying Pressure areas should be noted. Red spot should be marked

STUMP CONDITIONING
Care of the Stump is very important Regular massage Electrical muscle stimulation

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WRONG POSITIONS
BELOW KNEE AMPUTATION

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WRONG POSITIONS
ABOVE KNEE AMPUTATION

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HEMATOMA
Delays Wound Healing Act as a Cultural media for Growing of Organism

NECROSIS
Necrosis occurs due to Insufficient Circulation Management is done by Revision Surgery.

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SKIN COMPLICATIONS
Improper Fit Prosthesis resulting in
Irritation, Abrasion & Ulceration of Skin.

CHOKE SYNDROME
Oedema in the Residual limb cause lack of Contact between Skin & Prosthesis. Pressure Variation occurs Between Skin & Socket result in Skin Break down. TREATMENT: Shirnkers

Adherent skin cause break in the Skin Bony prominence contact with Socket Result in Skin Damage

TREATMENT: Adding Pad to Socket Improve Suspension Proper Hygiene.

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Exercises

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INFECTION
CONTACT DERMATITIS: Antiseptic Cleanser, Due to lotion, Soap, Prosthesis Topical antibiotics. TREATMENT: Steroids FOLLICULITIS : Infection of Hair Follicules Occur due to Poor Hygiene, Sweating, Poor Socket, Poor position of Limb. TREATMENT: FUNGAL INFECTIONS Tinea Corporis, Tinea Crusis Caused by excessive Moisture & Poor Hygiene TREATMENT: Antiseptic Cleaner Oral Antibiotics Topical Fungicides.
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BONY PROBLEMS
Incorrect Stripped Periosteum during surgery or Treatment. Severe OA hip or Knee

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NEUROMA
Bulging of Nerve at end Potential source of Phantom Pain Direct palpation reproduce pain Pain due to traction of nerve by Scar tissues. TREATMENT: US Steroids Surgical Excision.
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PHANTOM LIMB PAIN

Phantom pain is described as "cramping, shooting, aching, hand clenched in a tight fist, toes out of joint, frozen or rigid joints, or any combination of these" and usually subsides within a year after surgery.

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CAUSES
Prior experience with pain prior to amputation Incorrect surgical procedure Climatic conditions Stress Inactivity Improper Stripping of Bone
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How to Treat ?
Psychological Counseling Increased blood flow to the amputated area will reduce the amount of pain. P.T Modalities like TENS, US, Massage Bandaging, Acupuncture. Constant exercise, Like stretching, running, walking, bike riding can provide relief from phantom pain.
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CONTRACTURES
Mal position result in Contractures Knee & Hip have Flexion Contracture KNEE : Less than 10 is treated by lengthening , Stretching & US More than 25 is treated by Lengthening Post Knee capsule or Wearing Bend Knee Prosthesis.
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HIP 15 or More in Long AK increases Lordosis Short AK accommodate up to 25. TREATMENT; Avoid Mal Positioning. Avoid Pillow under Knee or Hip. Stretching
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Psychological Issues:
Decrease Performance of individuals

SIVA KUMAR. MPT. SIKHA.S

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