Prosthetics Exam 1

Common techniques: length

-save as much length as possible -may need to sacrifice length to avoid scars or deformities, which would interfere with prosthetic fitting

The three most common predisposing factors for lower extremity amputation appear to be: ____________________________ Other predisposing factors include (4)

1) concurrent diabetes and hypertension 2) hypertension without diabetes 3) diabetes without hypertension -race -gender -history of smoking -previous vascular surgery

Compromised blood flow of the superficial veins as a result of perforating valves, increased systolic blood pressure, decreased blood flow, edema and cell death.

Chronic venous insufficiency (CVI)

__________ _________ _______ (____) and _______ _______ _________ (____) are noninvasive means of imaging that offer valuable information. They may replace conventional arteriography in the future. However, at this time, the applications for CTA and MRA remain limited.

Computed tomography angiography (CTA); magnetic resonance angiography (MRA)

_____________ _________________ is the most accurate test used to define the anatomy at this time, but it is indicated only when surgical intervention is considered. This is not a screening study.

Conventional arteriography

Etiology of CVI (2)

-1% general population -superficial and deep veins

Causes of amputation are divided into these 6 categories

1. PVD 2. Diabetes 3. Trauma 4. Infections 5. Tumors 6. Limb deficiencies

Amputation at the tarsal-metatarsal jt; foot goes into equines

Lisfranc amputation

Documenting lower-extremity sensory neuropathy is useful in patients who present with foot _______, since decreased sensation limits the patient's ability to protect the feet and ankles. If peripheral neuropathy is found, the patient should be made aware that ______ ______ (including daily foot examination) is very important for the prevention of foot ulcers and lower-extremity amputation.

ulcers; foot care

Clinical manifestations of CVI: -__________ ______: In addition to poor cosmesis, these serve as indicators of venous hypertension, the most common reason for patient complaints regarding CVI. -_____ _________: Venous hypertension in muscles and fascial compartments of the lower leg from exercise and prolonged standing results in the characteristic ache of CVI. The discomfort is described as pain, pressure, burning, itching, dull ache, or heaviness in affected calves or legs. -___________ _______: Typically, these lesions occur around the medial malleolus, where venous pressure is maximal due to the presence of large perforating veins. -_______ ________: Damage done to capillary basement membranes by white blood cells results in this. -_______________: These characteristic skin changes in the lower extremities include capillary proliferation, fat necrosis, and fibrosis of skin and subcutaneous tissues. Skin becomes reddish or brown because of the deposition of hemosiderin from red blood cells

varicose veins; leg discomfort; non-healing ulcers; leg edema; Lipodermatosclerosis

Symptoms of arteriosclerosis with diabetes (5)

-same as ASO -decreased foot sensation -renal complications -impaired vision -decreased strength

Etiology of PVD (7)

-50 years and older -Males > females -Tobacco -Obesity -HTN -Hyperlipidemia -Sedentary lifestyle

Symptoms of PVD (7)

-Intermittent claudication -Decreased pedal pulses -Dry skin and hair loss -Clubbing toe-nails -Ischemia -Ulceration -Pain relieved with standing

Common techniques flaps:

-decrease tension -provide cushion -must trim to prevent dog-ears

Symptoms of CVI (5)

-edema -dilated veins -dermatitis -ulcers -pain relieved by elevation

Upper limb deficiencies in children vary from minor to major limb absences. During the period of upper limb differentiation there is particular vulnerability to malformation. Potential contributing factors cited include: (8)

-exposure to chemical agents or drugs -fetal position or constriction -endocrine disorders -exposure to radiation -immune reactions -occult infections and other diseases -single gene or chromosomal disorders -unknown causes

Common techniques: nerves

-nerves are cut high -prevention of neuroma -not cut with scissor type instruments due to permanency of crushing sensation

Etiology of arteriosclerosis with diabetes (2)

-same as ASO -40 years and older

Six categories of limb deficiencies have been recognized: 1. ____________________, indicating a partial or complete arrest in limb development. 2. ______________________, when the basic structures have developed but the final form is not complete 3. _______________, such as polydactyly 4. __________, also gigantism, caused generally by skeletal overgrowth. 5. _____________ _________ (or "amniotic") ________ _________, characterized by constriction bands, which may compromise circulation to the distal part. 6. _________ _______ ___________.

1. failure of formation of parts 2. Failure of differentiation or separation of parts 3. Duplication of parts 4. Overgrowth 5. Congenital constriction band syndrome 6. Generalized skeletal abnormalities

In partial traumatic amputations, at least ________ the diameter of the injured extremity is severed or significantly damaged. A second type of traumatic amputation occurs when the limb becomes completely detached from the body. As much as one liter of blood can be lost before the arteries spasm and vasoconstrict. For optimal outcome, surgical intervention is usually necessary within the first _____ hours after the accident for revascularization.

1/2; 12

Chronic venous insufficiency (CVI) is a common condition affecting ______% of Americans. Historically, CVI was known as postphlebitic syndrome and postthrombotic syndrome, both of which refer to the etiology of most cases. However, these names have been abandoned because they fail to recognize another common cause of the disease, the congenital _________ of venous ________.

2-5%; absence; valves

Congenital limb deficiencies and the amputations used to adjust or correct them, are relatively rare. Approximately _____% of the amputations are related to this etiology and that number is expected to remain _____.

2.8% (0.8%); stable

Transfemoral amputations account for approximately _____% of all amputations. Because PVD typically affects both lower extremities, a _____________ number of individuals will eventually undergo amputation of both lower extremities. Between ________% of persons with amputations have had amputations of both lower extremities, most often at the __________ level.

27; significant; 25-45%; transtibial

Epidemiology of PVD: In the US: Based on ankle-brachial blood-pressure ratios, the prevalence of lower-extremity peripheral arterial disease (LEPAD) is approximately ____% in people younger than 60 years. The prevalence increases to _____% in people older than 70 years.

3%; 20%

Amputations related to tumors accounted for ______% of amputations. The tumor most commonly cited was ______________, which primarily affects children and adolescents. Currently, with the development of new surgical techniques, amputation is no longer the primary intervention for this. The incidence of amputation secondary to cancers and tumors is expected to __________.

4.5% (0.9%); osteosarcoma; decline

The mortality associated with PVD results from associated cardiovascular and cerebrovascular pathology. The mortality rate in patients with LEPAD is ____ times higher than that of age-matched control subjects, and it is almost exclusively the result of death due to myocardial infarction and stroke. The 10-year survival rate decreases from _____% to _____% in healthy individuals (average age, 66 y) compared with patients with symptoms of LEPAD.

6; 80% to 55%

Problem: In addition to poor cosmesis, CVI can lead to chronic life-threatening ________ of the lower extremities. ______, especially after ___________, is a hallmark of the disease. CVI causes characteristic changes, called _____________________, to the skin of the lower extremities, which lead to eventual skin ___________.

infections; pain; ambulating; lipodermatosclerosis; ulceration

Retains heel pad; bones may not unite; too long for prosthetic replacement

Amputation across calcaneus bone

-Both malleoli are removed. -Heel pad reserved and anchored to distal end of the tibia and fibula. -Good end WB stump. -Poor cosmesis. -Good surgical procedure, but not usually successful on person with vascular disease.

Ankle disarticulation - Symes

_____________ remains the most accurate and informative test. This is the criterion standard, but it is considered an invasive diagnostic method. This examination is associated with complications such as hematoma at the puncture site, those due to radiation exposure, intimal flap dissection, or arterial wall rupture, and nephrotoxicity due to the intravenous contrast material (which poses greater risk because of the common association of LEPAD with renal arterial disease and renal disease). Therefore, this is preserved for preoperative evaluation only.

Arteriography

Narrowing of the medium and smaller arteries often associated with neuropathic changes.

Arteriosclerosis Obliterans (ASO)

_________________ is the leading cause of occlusive arterial disease of the lower extremities. This is also a leading cause of death and disability in the developed world. The term is derived from the Greek ________, which refers to the thickening of the arterial intima and ______, the accumulation of lipid that characterizes the typical lesion (Latin, literally meaning porridge). These lesions affect _______ and _______-sized arteries. Despite the familiarity of this disease, some of its fundamental characteristics remain poorly recognized and understood.

Atherosclerosis; sclerosis; athero; large and medium

Amputation leaving calcaneus and talus intact; foot goes into equines

Chopart amputaiton

_________ ____ is a valuable diagnostic test; it is inexpensive and widely available, but does not offer detailed description of the length, severity, or type of the diseased portion of the vessel, all of which help in planning surgical or endoluminal intervention. Although vascular mapping can be performed to evaluate the iliac vessels and the femoropopliteal arterial segments, it is time and labor consuming (with examinations sometimes requiring as long as 2 h). It is also operator dependent.

Doppler US

____________ _______________ (_____) has become the second line in the evaluation of lower extremity arterial disease. These findings provide good information about the anatomy and physiology of the vessels.

Doppler ultrasonography (US)

-Blood loss can be a problem -Genitalia may shift to one side and if prosthesis is used, toileting must be addressed in prosthetic fitting and rehabilitation -Symphysis pubis is divided. -anterior--above and parallel to inguinal ligament -posterior--preserves variable portion of gluteus maximus. -In hemipelvectomy, all or part of the ilium is removed.

His disarticulation and hemipelvectomy

The most common presenting symptom in patients with peripheral vascular disease is __________ ____________. The patient complains of pain, cramping, or muscle fatigue, which occurs during exercise and is relieved by rest. The site of claudication is _______ to the location of the narrowed (stenotic) vessel. With progression of the disease, _______ pain develops. At this stage, patients complain of pain or numbness of the foot, which frequently occurs at night while the foot is not in a __________ position. Symptoms improve when the foot is placed in a dependent position. With more severe disease, resting pain may be present continuously.

Intermittent claudication; distal; resting; dependent

-Allows for good comfort and function; poor cosmesis; uncommon in adults -patellar T sutured to remnants of cruciate ligaments -HS tendons sutured together under slight tension in intercondylar notch or remaining part of fibrous capsule. -Sufficient skin left for loose closure -Very few muscles and no bone cut.

Knee disarticulation (KD); through knee

The levels of amputation surgery that are most commonly preformed at present involve the ______________________________ accounting for approximately _____% of all amputations. This high percentage reflects the prevalence of _______ of the lower extremity.

LE below the knee; 70%; PVD

_________ is a rapidly developing and a promising study that may replace diagnostic angiography in the future. It is noninvasive, it does not require the use of ionizing radiation, and the contrast agent used is relatively non-nephrotoxic. This modality is associated with limitations such as its cost, its availability, the limited depiction of small vessels, its contraindications, and the possible overestimation of the degree of stenosis.

MRA

_____________ _________ is the leading cause of death in patients with diabetes, causing 75% of deaths in this population but only approximately 35% of deaths in patients without diabetes. Diabetes alone causes a higher risk of __________ _________ (2-fold increase in men, 4-fold increase in women), and many diabetic patients have other risk factors for MI as well. The risk of stroke is ______ that of nondiabetic patients and the risk of peripheral vascular disease is ________ higher in diabetic patients than in nondiabetic patients. Subtle differences in the pathophysiology of atherosclerosis in patients with diabetes result in both earlier development and a more malignant course.

Macrovascular disease; myocardial infarction; double; 4-fold;

Common techniques: myoplasty vs myodesis

Myoplasty: suturing muscle to muscle Myodesis: suturing muscle to bone -muscle stabilization -more stable shape -more function

Narrowing and occlusion of the arterial lumen of the large arteries, associated with hypertension and coronary artery disease (CAD)

PVD

__________ is significantly more common in persons with diabetes than in those without diabetes. The Framingham Heart Study found a _______x greater relative risk of intermittent claudication in persons with diabetes, even when controlled for blood pressure, cholesterol, and smoking. The age-adjusted rate of lower extremity amputation among people with diabetes in the United States is approximately ______ times that of the non-diabetic population. More than _____% of the lower limb amputations are diabetes related, although persons diagnosed with diabetes represent only _____% of the population. The risk of any first lower extremity amputation in individuals with non-insulin dependent diabetes was nearly _____ times higher than that of the general population.

PVD; 4-5x; 15x; 50%; 3%; 17x

-Usually done at or above musculotendinous junction of calf muscles. -all muscles that cross the knee jt (except gastro) are preserved. -fibula cut approx 1/2 to 3/4 inch above tibia. -anterior aspect of tibia is beveled. -very short anterior flap--very long posterior flap (skin over posterior leg has better blood supply) -posterior muscle mass beveled to permit muscle flap to be brought forward and sewn in front. -Flaps of equal length are used for amputations that are done with the exception of vascular pathology. flaps of equal length have a scar at the distal end of the limb. Equal length flaps allow for less redundant tissue at the end of the residual limb.

TT transtibial; below knee (BK)

These amputations are performed for such problems as congenital anomalies, gangrene, frostbite, neoplasms, etc.

Toe or ray amputations

Foot may go into equines, need toe filler in shoe.

Transmetatarsal amputation

Limb deficiencies that are present at birth are classified according to an international standard based on skeletal elements. These deficiencies are referred to as transverse or longitudinal. ________________ deficiencies are described by the level at which the limb terminates. In __________ deficiencies, a reduction or absence occurs within the long axis of the limb, but normal skeletal components are present, distal to the affected bones.

Transverse; longitudinal

The second leading cause of amputation is _______. This accounts for _____% of the amputations and is most common in the ______ adult population. The incidence of traumatic amputation is dropping because of the implementation of new safety regulations.

Trauma; 33% (16.4%); young

________ _____ _______ generally occurs in young, lean patients and is characterized by the marked inability of the pancreas to secrete insulin because of autoimmune destruction of the beta cells. The distinguishing characteristic of a patient with this disease is that if insulin is withdrawn, ketosis and eventually ketoacidosis develop. These patients are, therefore, dependent on exogenous insulin to sustain their lives.

Type I diabetes

_______ _____ _________ is non-insulin dependent diabetes mellitus. It typically presents later in life. In these patients glucose enters cell in adequate amounts, but the cells are not able to utilize it correctly. These patients are usually overweight.

Type II diabetes

Congenital __________ of or ________ to venous valves can cause CVI. Venous incompetence due to thrombi and formation of thrombi favored by the _________ triad (venous stasis, hypercoagulability, endothelial trauma) also can cause CVI. Varicose veins _______ are associated with the development of CVI.

absence or damage; Virchow; rarely

In individuals with diabetes, the prevalence and severity of PVD increased significantly with ______ and with the ___________ of diabetes, particularly in _____. Also a diagnosis of PVD _______ the risk for non-healing neuropathic ulcer, infection, and or gangrene, all of which _________ the likelihood of amputation or subsequent amputation.

age; and the duration; men; increased; increase

The first step in assessing a PVD patient is to record pulse-volume (plethysmography) and blood pressure measurements in the upper and lower extremities to compare the pressures. An ________-_______ ________ (____) is determined. This index is usually calculated by dividing the ______ _______ measurement in the ________ extremity by the measurement in the _______ extremity on the same side. An ABI of less than ______ is a strongly predictive sign of lower-extremity perfusion compromise. This noninvasive test provides information regarding the intravascular blood flow at different sites of the leg (upper thigh, lower thigh, above the ankle) as a waveform.

ankle-brachial index (ABI); highest systolic; lower; upper; 0.95

An epidemiological study examined the relationship between the diagnosis of diabetes and PVD. On initial diagnosis of diabetes, 8% of subjects had clinical evidence of ___________ __________. As the duration of diabetes lengthened, the prevalence of PVD increased to 15% at ten years and 45% at 20 years. Patients with diabetes who were 65 years of age or older accounted for _____% of all diabetes related lower extremity amputation.

ateriosclerosis obliterans (ASO); 61%

Pathophysiology of CVI: Two major mechanisms in the body prevent venous hypertension. First, _________ _______ in the veins prevent backflow and venous pooling. ________ commonly occur at these valves, causing irreversible damage to the valve. Second, during normal ambulation, _______ _________ decrease venous pressures by approximately 70% in the lower extremities. With rest, pressures return to normal in approximately ___ seconds. In diseased veins, ambulation decreases venous pressures by only 20%. When ambulation is stopped, pressure in the vein lumen increases ________, returning to normal over a period of minutes.

bicuspid valves; DVTs; calf muscles; 30; slowly

Amputation due to _______ is generally a result of osteogenic sarcoma, which occurs most frequently in the adolescent and young adult years. Since the early 1990s, the need for amputation in osteosarcoma has been _________ by advances in early detection, improved imaging techniques, more effective chemotherapy regimens, and better limb resection and salvage procedures. Tumor resection followed by limb reconstruction frequently provides a functional extremity. If this is the case, weight bearing is limited and the limb is protected by an orthosis early in rehabilitation. Once satisfactory healing occurs, full weight bearing and near normal activity can be resumed.

cancer; reduced;

Finally, the progression of PVD is closely associated with __________ __________ and ________ ________. Smoking cessation improves the patient's symptoms, especially the pain. Also, along with diabetic control, smoking cessation slows the progression of the disease.

cigarette smoking; and diabetes mellitus

In the third stage, a __________ _________ ensues when fibrous plaques are altered over time by hemorrhage, calcification, and mural thrombus. The intimal surface may become ulcerated as the lipid-laden plaque enlarges and hardens, and this can lead to embolism. This lesion is often a cause of vessel obstruction.

complicated lesion

The actual incidence of ________ _______ _________ is difficult to determine because of lack of a common definition and reporting mechanism. Some estimates suggest an incidence of 1 per 2,000 births; other studies indicate a slightly higher ratio of 1 per 1,692 live births.

congenital limb deficiencies

Signs of peripheral vascular disease encountered on physical examination include the following: __________ or _________ distal pulses; ______ over a tightly narrowed artery; hair ______; _________ nails; ________ skin; a ___________ appearance; pallor on _________; rubor on __________; and, in advanced disease, ______ and ________.

decreased or absent; bruit; loss; thickened; shiny; skeletonized; elevation; dependency; ulcers and gangrene

In the US: Approximately 10.3 million people have been diagnosed with _______; an estimated additional 5.4 million have ___________ __________. Approximately ____% have type 1 diabetes and the remainder has type 2.

diabetes; undiagnosed diabetes; 10%

Between 50% and 70% of all nontraumatic lower-extremity amputations occur in ________ patients. The insensate, poorly perfused foot is at risk for ulcers from pressure necrosis or inflammation from repeated skin stress and unnoticed minor trauma. Either can evolve into _______, ___________, or __________ ________ and end in ____________.

diabetic; cellulitis; osteomyelitis; nonclostridial gangrene; amputation

Amputations can be performed as a _____________ of a joint or as a __________ of a long bone. The level of amputation is usually named by the joint or long bone through which the amputation is made.

disarticulation; transection

Of the many types of diabetic neuropathy, both peripheral and autonomic, ________ _________ __________ ______________ (in a 'glove and stocking' distribution) is the most frequent. Besides causing pain in its early stages, this type of neuropathy eventually results in the loss of peripheral sensation. The combination of decreased sensation and peripheral arterial insufficiency often leads to foot _________ and eventual _________.

distal symmetric sensorimotor polyneuropathy; ulceration; amputation

The _________ ________ and __________ _______ pulses should be palpated and their presence or absence noted. This is particularly important in patients who have foot infections, since poor lower-extremity blood flow can delay healing and increase the risk of amputation.

dorsalis pedis; posterior tibialis

-Race: No racial predilection exists for the development of LEPAD. -Sex: Males and females have an _______ risk of LEPAD; however, atherosclerosis of the lower extremities is seen most frequently in elderly _____. -Age: The highest incidence occurs in those aged ____-____ years.

equal; men; 50-70

The ______________ stage involves the formation of lipid-filled smooth muscle cells in the tunica intima, and it is believed to be reversible. No obstruction is present in the affected vessel.

fatty-streak

Although the most common site of occlusion is the distal superficial _________ _________ (at the level of the adductor canal), more than 1 location usually is involved at the same time. The ________ artery alone is less likely to be involved. The ________ _________ artery is involved primarily in patients with diabetes.

femoral artery; popliteal; anterior tibial

During the second stage of ________ __________ _________, lipid-laden smooth muscle cells are surrounded by collagen, elastic fibers, and mucoprotein matrix. The lesion can protrude into the lumen of the artery and cause obstruction. This lesion occurs at the level of the tunica intima, and it may also involve the muscular tunica media. Frequently, the lesion is located at arterial bifurcations.

fibrous plaque formation

The use of prosthetics is a common intervention for children with congenital limb deficiencies. Sometimes surgery is necessary to prepare the existing limb for the most effective use of a prosthesis, especially after periods of rapid growth. The goal of prosthetics training for the child should be to enhance the ________ of the limb and to provide a cosmetic replacement for a missing limb. Rehabilitation efforts are designed with the child's cognitive, motor, and psychological development in mind.

function

The morbidity and mortality associated with diabetes are related to the short- and long-term complications. These complications include ___________ and __________, increased risk of _________, ______________ complications (i.e., retinopathy, nephropathy), ___________ complications, and ________________ disease. Diabetes is the major cause of ___________ in adults aged 20-74 years, as well as the _________ cause of non-traumatic lower-extremity amputation and end-stage renal disease (ESRD).

hypoglycemia and hyperglycemia; infections; microvascular; neuropathic; macrovascular; blindness; leading

___________ cause considerable morbidity and mortality in patients with diabetes. Patients with long-standing diabetes also tend to develop microvascular and macrovascular disease with resulting poor tissue perfusion and increased risk of infection. The ability of skin to act as a barrier to infection may be compromised when the diminished sensation of diabetic neuropathy results in unnoticed injury.

infections;

Diabetic patients presenting with wounds, infections, or ulcers of the foot should be treated __________. In addition to appropriate use of antibiotics, avoidance of further trauma to the healing foot through use of crutches, wheelchairs, or bed rest is mandatory. Patients should be treated by a podiatrist or an orthopedist with experience in the care of the diabetic foot. Many patients need a vascular evaluation in conjunction with local treatment of the foot ulcer, since in some cases a revascularization procedure may be required to provide adequate blood flow for wound healing.

intensively

Diabetes can affect the lens, the vitreous, and the retina, causing visual symptoms that may prompt the patient to come to the ED. Visual blurring may develop acutely as the _______ changes shape with marked changes in _______ ________ concentrations. This effect, which is caused by osmotic fluxes of water into and out of the lens, usually occurs as hyperglycemia increases but also may be seen when high blood glucose levels are lowered rapidly. In either case, recovery to baseline visual acuity can take up to a month, and some patients are almost completely unable to read small print or do close work during this period.

lens; blood glucose

Pathophysiology of PVD: ________ ___________ is an early event in atherogenesis and it occurs when influx and deposition of cholesterol into the arterial wall exceed efflux. Development of an atherosclerotic lesion can be divided into 3 stages in which the following form: 1)______________ 2)______________ 3)______________

lipid deposition; 1) fatty streak; 2) fibrous plaque; 3) complicated lesion

More amputations occur among ______ than _______. Some studies suggest the ratio of men to women for amputations related to trauma is _:_ and for amputations related to disease is _______. The majority of amputations are due to __________, approximately 70% (82%). The highest percentage of disease related amputations occurs in the __________ year of age population. Most of these are ______ extremity amputations, which are performed 11 times more frequently than ________ extremity amputations.

men; women; 9:1; 2.5:1; disease; 61-70; lower; upper

Epidemiology of diabetes: -Race: Whites seem to be affected ______ often than blacks, who have the lowest overall incidence of type 1 diabetes. -Sex: The male-to-female ratio is approximately ______. -Age: Long called juvenile-onset diabetes, type 1 diabetes is typically diagnosed in childhood, adolescence, or early adulthood. Type 1 diabetes may also develop in older adults and is increasingly being recognized through the measurement of islet-cell antibodies. Its incidence peaks in __________.

more; 1:1; adolescence

Morbidity in PVD is usually the limitation of physical activities because of _____ (claudication), _______, or ________. The most frequent complications include unhealed ulcer, gangrene, and eventual amputation.

pain; ulceration; amputation

The disease that is most frequently related to amputation is _________ ___________ _________ (____) and complications of neuropathy. Although this and neuropathy are frequently associated with long-term adult onset (type II) diabetes, it is important to note that vascular disease also occurs independently of diabetes. Of disease related amputations, _________ are attributed to complications of diabetes. The projected increased frequency of amputation for PVD may be a reflection of the increased growth in the ______ population.

peripheral vascular disease (PVD); 50-70%; older

Persons with trauma related amputation undergo extreme __________ changes as well as __________ trauma. With sudden loss of a body part, the patient may experience an extended period of grieving. Addressing the patient's psychological needs as well as physical needs are equally important for optimal outcome.

physiological; psychological

Risk factors associated with chronic venous insufficiency: -Age: Incidence of CVI ______ substantially with age. -Family history: History of ________, which renders venous valves incompetent, causing backflow and increased venous pressure, is a risk factor. -Lifestyle: A _________ lifestyle minimizes the pump action of calf muscles on venous return, causing higher venous pressure. CVI occurs more frequently in ________ who are ________. Vocations that involve __________ for long periods predispose individuals to increased venous pressure in ___________ lower extremities. A higher incidence of CVI is observed in ______ who _______.

rises; DVT; sedentary; women; obese; standing; dependent; men; smoke

Traumatic loss of a limb, the ________ most common cause of amputation, occurs most frequently in vehicle or work related accidents. Trauma related amputation occurs most commonly in young adult men but can happen at any age to any man or woman. This type of injury is usually classified or categorized according to severity of tissue damage. The extent of injury to the musculoskeletal system depends on several factors: (3)

second 1. movement of the object that causes injury 2. Direction, magnitude, and speed of the energy vector 3. the particular body tissue involved

A variety of other types of diabetes, previously called '________ ________", are caused by other illnesses or medications. Depending on the primary process involved (i.e., destruction of pancreatic beta cells or development of peripheral insulin resistance), these types of diabetes behave similarly to type 1 or type 2 diabetes.

secondary diabetes

-equal length anterior and posterior flaps are generally used -the nerves are cut at a level to ensure their being well covered by muscles and remote from the incision -if mid-thigh amputation is done without myoplasty, most of hip adductors and extensors lose their insertions -Myoplasty and/or myodesis is now common. Reinserting divided adductors and hamstrings, restoring much of their power and decreasing muscle imbalance. -end of bone is smoothed

transfemoral (TF) - above knee (AK)

Epidemiology of CVI: Approximately 24 million Americans have __________ _______. Approximately 6 million Americans have ______ changes associated with CVI. _______ _______ ________ affect approximately 500,000 people. Peak incidence occurs in women aged ___-____ years and in men aged ____-___ years.

varicose veins; skin; venous stasis ulcers; 40-49; 70-79

Venous hypertension in diseased veins is thought to cause CVI by the following sequence of events: -Increased venous pressure in the _______ impedes flow from the _______. -Low-flow states within the capillaries cause ________ _______. -Trapped leukocytes release proteolytic enzymes and oxygen free radicals that damage _________ ________ ___________. -________ ________, such as fibrinogen, leak into the surrounding tissues. -The resulting ________ decreases oxygen delivery to the tissues, resulting in local ______ hypoxia. -___________ and _______ ______ result.

venules; capillaries; leukocyte trapping; capillary basement membranes; plasma proteins; edema; hypoxia; inflammation; and tissue loss