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7/26/2019 Lower Extremity Amputations
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Lower Extremity AmputationsLower Extremity Amputations
Orthopedic Rounds
MUMC
February 21, 2007Presenters:
Dan Mead – prosthetistDr. Sharon Grad - physiatrist
Orthopedic RoundsMUMC
February 21, 2007Presenters:
Dan Mead – prosthetistDr. Sharon Grad - physiatrist
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Classification of AmputationsClassification of Amputations
1) Traumatic (~ 15%)- Usually healthy
- Limb salvage- Often grafted tissues
- May require revision surgery/debridement
1) Traumatic (~ 15%)- Usually healthy
- Limb salvage- Often grafted tissues
- May require revision surgery/debridement
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Classification of AmputationsClassification of Amputations
1) Traumatic- Limb salvage can lead to multiple
surgeries
- End result may be a fragile limb with lessfunction than with an amputation
- Complications of infection and fractureare common
1) Traumatic- Limb salvage can lead to multiple
surgeries
- End result may be a fragile limb with lessfunction than with an amputation
- Complications of infection and fractureare common
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Classification of AmputationsClassification of Amputations
1) Trauma- A lower limb without sensation functions poorly
- Limb salvage may be worse than prosthetic
replacement unless the residual limb:-can tolerate full weight bearing
-is painfree
-has durable skin and soft tissue coverage thatdoesn’t break down when walking is attempted
1) Trauma
- A lower limb without sensation functions poorly
- Limb salvage may be worse than prosthetic
replacement unless the residual limb:-can tolerate full weight bearing
-is painfree
-has durable skin and soft tissue coverage thatdoesn’t break down when walking is attempted
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Classification of AmputationsClassification of Amputations
1) TraumaDecision Making in Trauma
- Base decision on providing a limb that cantolerate weight bearing; have enough
sensation to provide protective feedback;
and have durable skin and soft tissuecover
1) TraumaDecision Making in Trauma
- Base decision on providing a limb that cantolerate weight bearing; have enough
sensation to provide protective feedback;
and have durable skin and soft tissuecover
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Classification of AmputationsClassification of Amputations
2) Tumor (~ 5%)- Amputation level is determined by extent of
cancer
- Goal is to avoid violating anatomic
compartments where the tumor is located
2) Tumor (~ 5%)- Amputation level is determined by extent of
cancer
- Goal is to avoid violating anatomic
compartments where the tumor is located
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Classification of AmputationsClassification of Amputations
3) Vascular and Diabetic (~ 70 -80%)- Pre-op evaluation very important
- Vascular assessment necessary
3) Vascular and Diabetic (~ 70 -80%)- Pre-op evaluation very important
- Vascular assessment necessary
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Classification of AmputationsClassification of Amputations
Ask: Is the foot worth saving?-soft tissues – will ulcer heal, stay healed, or new
ulcers form?
-deformities – claw toes, bunion, Charcot collapse
-sensation – to protect after salvage
-contractures – Achilles tendon, knee, toes-rehab goals – does/will patient ambulate?
Ask: Is the foot worth saving?-soft tissues – will ulcer heal, stay healed, or new
ulcers form?
-deformities – claw toes, bunion, Charcot collapse
-sensation – to protect after salvage
-contractures – Achilles tendon, knee, toes-rehab goals – does/will patient ambulate?
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The Most Distal Amputation is not
Always the Wisest!
The Most Distal Amputation is not
Always the Wisest!1) Biologic Healing Level
-the lowest level the skin will heal
2) Functional Level
-the amputation level the patient will function best with
--previous level of ambulation--intelligence
--cognitive status
--motivation
--cardio-pulmonary capacity--spasticity or contractures
--rehabilitation goals
1) Biologic Healing Level
-the lowest level the skin will heal
2) Functional Level
-the amputation level the patient will function best with
--previous level of ambulation--intelligence
--cognitive status
--motivation
--cardio-pulmonary capacity--spasticity or contractures
--rehabilitation goals
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Classification of AmputationsClassification of Amputations
4) Congenital Amputation (~ 5%)- Revision of lower extremity deformity to
improve the weight bearing capacity and
durability
- Usually don’t revise upper extremity
deformities – even rudimentary digits canhave useful function
4) Congenital Amputation (~ 5%)- Revision of lower extremity deformity to
improve the weight bearing capacity and
durability
- Usually don’t revise upper extremity
deformities – even rudimentary digits canhave useful function
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Goals of Prosthetic RehabilitationGoals of Prosthetic Rehabilitation
Restoration of functional mobility Maintain/increase ROM
Attempt return to independent lifestyle Pain management
Wound management Psychosocial counselling and support
Restoration of functional mobility Maintain/increase ROM
Attempt return to independent lifestyle Pain management
Wound management Psychosocial counselling and support
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Levels of Amputation in the
Lower Extremity
Levels of Amputation in the
Lower Extremity
Partial Foot Symes (ankle disarticulation)
Transtibial Through knee (knee disarticulation)
Transfemoral Hip Disarticulation
Partial Foot Symes (ankle disarticulation)
Transtibial Through knee (knee disarticulation)
Transfemoral
Hip Disarticulation
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Physical AssessmentPhysical Assessment
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AssessmentAssessment
Assess
- Wound/incision line
- Sensation
- Adhesions- Contractures
- Strength
- Balance
- Endurance
Assess
- Wound/incision line
- Sensation
- Adhesions- Contractures
- Strength
- Balance
- Endurance
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Post operative EdemaPost operative Edema
Goal:-reduce swelling
-shape residual limb
Goal:-reduce swelling
-shape residual limb
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Stump ShrinkersStump Shrinkers
Elastoband wrap (figure 8) Tubi-grip
Compression Stocking measure to fit T/T orT/F
Elastoband wrap (figure 8) Tubi-grip
Compression Stocking measure to fit T/T orT/F
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BandagingBandaging
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Transtibial AmputationTranstibial Amputation
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Biomechanics of Socket FitBiomechanics of Socket Fit
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Biomechanics of Socket FitBiomechanics of Socket Fit
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Length ComparisonLength Comparison
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Exposed BoneExposed Bone
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Bevel TibiaBevel Tibia
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Transtibial Foot SelectionTranstibial Foot Selection
Consider
Activity level, weight of amputee, weight offoot, action at heel strike and toe-off,
function demands (terrain, lifestyle, etc.)
Consider
Activity level, weight of amputee, weight offoot, action at heel strike and toe-off,
function demands (terrain, lifestyle, etc.)
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Transtibial Feet CategoriesTranstibial Feet Categories
SACH – simple, low activity/function, rigid
Single Axis – Rapid foot flat, increases knee
stability
Multi-Axis – Adapts to uneven terrain, good forwalking outdoors, may reduce impact on skin
Elastic Keel/Dynamic – Smooth rollover, comfort,responsive, may not propel
Energy Storing – Carbon keel, stores energy inearly stance, gives back at toe off, good for higheractivity levels
SACH – simple, low activity/function, rigid
Single Axis – Rapid foot flat, increases knee
stability Multi-Axis – Adapts to uneven terrain, good for
walking outdoors, may reduce impact on skin
Elastic Keel/Dynamic – Smooth rollover, comfort,responsive, may not propel
Energy Storing – Carbon keel, stores energy inearly stance, gives back at toe off, good for higheractivity levels
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SACHSACH
Solid Ankle, Cushioned Heel Impact absorbed at heel strike, simulated PF
Simple, low activity/function, rigid
Solid Ankle, Cushioned Heel Impact absorbed at heel strike, simulated PF
Simple, low activity/function, rigid
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Single AxisSingle Axis
Foot plantar flexes at heel strike, to foot flat Move line of action of GRF anteriorly
Increased knee stability, important for TF
Heavier, rigid rollover
Foot plantar flexes at heel strike, to foot flat Move line of action of GRF anteriorly
Increased knee stability, important for TF
Heavier, rigid rollover
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Multi AxisMulti Axis
Adapts to uneven terrain, good for walkingoutdoors, may reduce impact on skin
Rubber or Urethane may serve as material
being deformed
Adapts to uneven terrain, good for walkingoutdoors, may reduce impact on skin
Rubber or Urethane may serve as material
being deformed
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Energy StoringEnergy Storing
Carbon Keel
Stores energy in early stance, gives back attoe off
Good for higher activity levels
Significantly higher cost
Carbon Keel
Stores energy in early stance, gives back attoe off
Good for higher activity levels
Significantly higher cost
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Suspension (T/T)Suspension (T/T)
Fork Strap and waist belt Cuff Suspension
Supracondylar (PTS)
Sleeve (Neoprene, Silicone), (2S)
Liner and Pin (3S)
One way valve and Sleeve (suction)
Harmony (elevated vacuum)
Fork Strap and waist belt Cuff Suspension
Supracondylar (PTS)
Sleeve (Neoprene, Silicone), (2S)
Liner and Pin (3S)
One way valve and Sleeve (suction)
Harmony (elevated vacuum)
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Fork Strap and Waist beltFork Strap and Waist belt
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Fork Strap and Waist beltFork Strap and Waist belt
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Supracondylar (PTS)Supracondylar (PTS)
Medial wedge iscreated overadductor
tubercle Self suspends
Increase height
of brim,improving MLknee stability
Medial wedge iscreated overadductortubercle
Self suspends
Increase height
of brim,improving MLknee stability
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Cuff Suspension (T/T)Cuff Suspension (T/T)
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What are Interface Liners?What are Interface Liners? Interface – a surface forming a common boundary
of two bodies, spaces, or phases; to connect bymeans of an interface
Liner – one that lines or is used to line or back
something
Interface – a surface forming a common boundary
of two bodies, spaces, or phases; to connect bymeans of an interface
Liner – one that lines or is used to line or back
something
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What are Interface Liners?What are Interface Liners? Interface liners relating to prosthetics, refers to a
lining that is placed on the residual limb whichwill act as a boundary between the skin and the
hard weight bearing socket
Many different types of liners
Polyurethane
Silicone
Gel
Elastic Polymers
Interface liners relating to prosthetics, refers to a
lining that is placed on the residual limb whichwill act as a boundary between the skin and the
hard weight bearing socket
Many different types of liners
Polyurethane
Silicone
Gel
Elastic Polymers
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General DescriptionGeneral Description Liners act as excellent forms of protection vs
friction, they distribute dynamic pressure due tothe flow characteristics of the liner, and they may
act as a form of suspension
4 goals: ⇓ average and peak pressures on the limb
⇓ rate of skin breakdown
⇑ weight bearing capabilities
Improves comfort and suspension
Liners act as excellent forms of protection vs
friction, they distribute dynamic pressure due tothe flow characteristics of the liner, and they may
act as a form of suspension
4 goals: ⇓ average and peak pressures on the limb
⇓ rate of skin breakdown
⇑ weight bearing capabilities
Improves comfort and suspension
Li d Pi (3S)Li d Pi (3S)
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Liner and Pin (3S)Liner and Pin (3S)
• Liner has pin attachment
• Different pin types exist
Li d Pi (3S)Li d Pi (3S)
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Liner and Pin (3S)Liner and Pin (3S)
Locking Liner Suspension
Techniques Locking Pin systems
a serrated pin engages a gear
in locking mechanism a smooth pin engages a clutch
mechanism
Pin systems can take upsignificant space
problems with elongation of
liner simple and can be effective
Locking Liner SuspensionTechniques
Locking Pin systems
a serrated pin engages a gearin locking mechanism
a smooth pin engages a clutchmechanism
Pin systems can take upsignificant space
problems with elongation of
liner simple and can be effective
U th liU th li
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Urethane linersUrethane liners
available from some manufacturers in standard sizes andcan be custom fabricated by TEC Interface Systems
cannot currently be manufacture in-house
University of Minnesota study showed that urethane behaves more like human tissue than silicone or mineraloil gel when stressed
Excellent results with very delicate skin
Can be used with Vacuum Assisted fittings (Harmony) Cast mods are very different from any other socket type
available from some manufacturers in standard sizes andcan be custom fabricated by TEC Interface Systems
cannot currently be manufacture in-house
University of Minnesota study showed that urethane behaves more like human tissue than silicone or mineraloil gel when stressed
Excellent results with very delicate skin
Can be used with Vacuum Assisted fittings (Harmony) Cast mods are very different from any other socket type
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Custom Urethane Liner Custom Urethane Liner
H ( l d )H ( l d )
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Harmony (elevated vacuum)Harmony (elevated vacuum)
ROTATING - The new rotational feature allowswearers to move more naturally — whether they
are walking, running errands or golfing. INCREASED RELIABILITY - Offered through
a double filtration system, shorter tubing and
fewer in-line connections.
IMPROVED VOLUME CONTROL - TheHarmony System’s elevated vacuum pullsoxygenated fluids into the residual limb during
swing phase and pushes fluids out during weight bearing. The result is less than 1% volume lossduring the course of the day.*
ROTATING - The new rotational feature allowswearers to move more naturally — whether they
are walking, running errands or golfing. INCREASED RELIABILITY - Offered through
a double filtration system, shorter tubing and
fewer in-line connections.
IMPROVED VOLUME CONTROL - TheHarmony System’s elevated vacuum pullsoxygenated fluids into the residual limb during
swing phase and pushes fluids out during weight bearing. The result is less than 1% volume lossduring the course of the day.*
H ( l d )H ( l d )
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Harmony (elevated vacuum)Harmony (elevated vacuum)
Linkage - Not only does the elevated vacuum
between the socket and the liner control volume,
it helps the prosthesis become one with the user.
Improved Volume Control controlling volume
fluctuations can improve fit for many amputeeshelping reduce pressure points on the limb.
Proprioception - Elevated vacuum leads toheightened proprioception, the awareness a user
has of her or his leg in space. This leads to
increased balance, stability and control over the prosthesis.
Linkage - Not only does the elevated vacuum
between the socket and the liner control volume,
it helps the prosthesis become one with the user.
Improved Volume Control controlling volume
fluctuations can improve fit for many amputeeshelping reduce pressure points on the limb.
Proprioception - Elevated vacuum leads toheightened proprioception, the awareness a user
has of her or his leg in space. This leads to
increased balance, stability and control over the prosthesis.
C S dC S d
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Case Study
Mr. R. F.
Case Study
Mr. R. F.
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Harmony (elevated vacuum)Harmony (elevated vacuum)
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Harmony (elevated vacuum)Harmony (elevated vacuum)
Uses TEC urethane
liner, harmony pump
and urethane sleeve
Patient has donnedurethane liner and is
now donning socket
Uses TEC urethane
liner, harmony pump
and urethane sleeve
Patient has donnedurethane liner and is
now donning socket
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Harmony (elevated vacuum)Harmony (elevated vacuum)
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Harmony (elevated vacuum)Harmony (elevated vacuum)
Seal is created
between liner, leg and
sleeve
Suspends prosthesiswith up to 25mmHg
Accurate “Total
Surface WeightBearing” fit is critical
Seal is created
between liner, leg and
sleeve
Suspends prosthesiswith up to 25mmHg
Accurate “Total
Surface WeightBearing” fit is critical
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Transfemoral AmputationTransfemoral Amputation
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Suspension (T/F)Suspension (T/F)
Silesian Bandage & Billet
Liner and Pin
Seal-In Liner
Suction
TES Belt
Hip Joint and Pelvic Band
Silesian Bandage & Billet
Liner and Pin
Seal-In Liner
Suction
TES Belt
Hip Joint and Pelvic Band
S i (T/F)S i (T/F)
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Suspension (T/F)Suspension (T/F)
Billet attachment
-Anteromed 1/3
-at level of IT
Billet attachment
-Anteromed 1/3
-at level of IT
Silesian attachment
-posteroprox to GT
Silesian attachment
-posteroprox to GT
S l I LiS l I Li
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Seal-In Liner Seal-In Liner
Used with Icelock
Expulsion Valve
Good for all
impact levels Available for both
TT/TF patient
Used with Icelock
Expulsion Valve
Good for all
impact levels Available for both
TT/TF patient
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Prosthetic Knee CategoriesProsthetic Knee Categories Locked
Safety (stance control)
Polycentric
Single Axis, Friction
Fluid Controlled (pneumatic or hydraulic)
Microprocessor Hybrid (ie. 4 bar with hydraulic)
Locked
Safety (stance control)
Polycentric
Single Axis, Friction
Fluid Controlled (pneumatic or hydraulic)
Microprocessor
Hybrid (ie. 4 bar with hydraulic)
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Manual Locking KneeManual Locking KneePROS
Safety
PROS
Safety
CONS
Gait Deviations
CONS
Gait Deviations
Safety KneeSafety Knee
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Safety Knee
(Weight-activated Stance Control)
Safety Knee
(Weight-activated Stance Control)PROS
Inexpensive
Foot clears in swing
PROS
Inexpensive
Foot clears in swing
CONS
Possibility of falling if
user is distracted
Brake wears over time
Gait deviations
Single cadence
CONS
Possibility of falling if
user is distracted
Brake wears over time
Gait deviations
Single cadence
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Polycentric Knee (aka: 4 bar)Polycentric Knee (aka: 4 bar) PROS
Stability
Sitting cosmesis for
long residual limb Improved swing
clearance
PROS
Stability
Sitting cosmesis for
long residual limb Improved swing
clearance
CONS
Weight
Cost
Must be a hybrid forvariable cadence
Some 4 bar designs
have up to 15 degreesof stance flexion builtin for loading response
CONS
Weight
Cost
Must be a hybrid forvariable cadence
Some 4 bar designs
have up to 15 degreesof stance flexion builtin for loading response
Fluid ControlledFluid Controlled
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Fluid Controlled
Pneumatic or Hydraulic
Fluid Controlled
Pneumatic or Hydraulic
PROS
Variable Cadence
Stance and Swing
control More ‘normalized’gait
Good for higher
activity levels
PROS
Variable Cadence
Stance and Swing
control More ‘normalized’gait
Good for higher
activity levels
CONS
Weight
Cost
Maintenance
CONS
Weight
Cost
Maintenance
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Microprocessor Controlled KneeMicroprocessor Controlled Knee PROS
Variable Cadence
Stumble recovery
Stability in Stance
Ability to walk down
stairs/ramps step over step
Second mode
Improved confidence
PROS
Variable Cadence
Stumble recovery
Stability in Stance
Ability to walk down
stairs/ramps step over step
Second mode
Improved confidence
CONS
Cost
CONS
Cost
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C Leg Case StudyC Leg Case Study
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Symes AmputationSymes Amputation
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SymesSymes Symes Amputations have many unique
Advantages
Heel pad retention
Bulbous distal configuration Self suspension
Length advantageous Longer lever arm
Increased ability to perceive distal pp & increased SA
of Pros/residual limb contact, therefore: >proprioception
>prosthetic control
Symes Amputations have many uniqueAdvantages
Heel pad retention
Bulbous distal configuration Self suspension
Length advantageous Longer lever arm
Increased ability to perceive distal pp & increased SA
of Pros/residual limb contact, therefore: >proprioception
>prosthetic control
SymesSymes
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yy
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Thank you!!Thank you!!
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RESIDUAL LIMBSKIN CONDITIONS
RESIDUAL LIMBSKIN CONDITIONS
Skin Problems of the Amputee Page 56
7/26/2019 Lower Extremity Amputations
http://slidepdf.com/reader/full/lower-extremity-amputations 67/78
UlcerationUlcerationSkin Problems of the Amputee, Page 56
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7/26/2019 Lower Extremity Amputations
http://slidepdf.com/reader/full/lower-extremity-amputations 68/78
Keloid ScarringKeloid Scarring
7/26/2019 Lower Extremity Amputations
http://slidepdf.com/reader/full/lower-extremity-amputations 69/78
UlcerationUlceration
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7/26/2019 Lower Extremity Amputations
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UlcerationUlceration
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7/26/2019 Lower Extremity Amputations
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Delayed Wound HealingDelayed Wound Healing
7/26/2019 Lower Extremity Amputations
http://slidepdf.com/reader/full/lower-extremity-amputations 72/78
Choking of Residual LimbChoking of Residual Limb
7/26/2019 Lower Extremity Amputations
http://slidepdf.com/reader/full/lower-extremity-amputations 73/78
UlcerationUlceration
Skin Problems of the Amputee, Page 149
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7/26/2019 Lower Extremity Amputations
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HemorrhageHemorrhage
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Skin Problems of the Amputee, Page 137
7/26/2019 Lower Extremity Amputations
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Contact DermatitisContact Dermatitis
Skin Problems of the Amputee, Page 137
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7/26/2019 Lower Extremity Amputations
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Stasis DermatitisStasis Dermatitis
Skin Problems of the Amputee, Page 56
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7/26/2019 Lower Extremity Amputations
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Verrucose HyperplasiaVerrucose Hyperplasia
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7/26/2019 Lower Extremity Amputations
http://slidepdf.com/reader/full/lower-extremity-amputations 78/78
Distal Bursa with Chronic InfectionDistal Bursa with Chronic Infection