2. “Amputare”: latin - cutting around
Removal of diseased, protruding functioning unit
of body
In Children : concerns
Growing
Irresponsible
dependant
4. Principles
„Conserve as much limb length as possible‟
growth potential, Preserve physis
progressive relative shortening of the residual
limb - if through metaphysis or diaphysis
Stump overgrowth (myodesis to prevent)
5. Terminal overgrowth :
high osteogenic activity of periosteum-stimulated
by weightbearing within the prosthesis-
cartilaginous spike slowly ossifies.
not related to epiphyses growth since it cannot be
prevented by epiphysiodesis
6. Preserve stump shape :-
narrow and conical with growth –
poor rotational control of a prosthesis.
preservation of bony architecture such as a short
segment of proximal fibula or the distal condyles
of the humerus.
8. Better wound healing- use available skin flaps.
The split-thickness skin graft can hypertrophy -
increased elasticity of the child's skin + excellent
blood supply
Less phantom sensations
Psychological problems less until teenage
Training with prosthesis easier
14. Elective Amputations for Congenital
Deficiencies
longitudinal absence of the fibula (complete) -
Syme's amputation.
Longitudinal absence of the tibia (complete) -
knee disarticulation
if the proximal tibia is present, BK function
preserved through fibula transfer into the proximal
tibia + ablation of the foot.
PFFD - Syme's amputation and knee fusion.
15. Timing of Amputation
the earlier the amputation, the better the child's
neurologic plasticity adapts to the alteration.
16. TRAUMATIC
lawn mover or power tool injuries.
motor vehicle accidents,
recreational accidents,
gunshots and
explosion wounds.
Debride Open Wounds
If Warm Ischemic time> 4 hrs for limb and > 10
hrs for digit:- increased failure rate for
reimplantation
17. consider at a more proximal level
Avoid multiple procedures
degloving injury - extensive use of split skin graft
tissue expanders or
microvascular free tissue transfer.
18. Skin traction over a 1- to 2-week period can add
several centimeters of full-thickness
circumferential skin.
a rigid plaster dressing permits rapid mobilization
of the trauma patient, minimizing pain and
reducing the tendency to form contractures.
21. BURN AMPUTATIONS
thermal or electrical
Extensive use of split-thickness skin is often
successful in the child.
Stump breakdown is less of a problem
Attempt to preserve length if at all possible.
Proximal joint stiffness - early and aggressive
rehabilitation.
22. MALIGNANT TUMORS
Success of Chemo in controlling local growth and
improvement in surgical technique – limb salvage
more feasible
Contraindications to limb salvage
-Inability to obtain wide excision margins
-Projected significant limb length inequality
-Extremely active patient
-Inadequate soft tissue coverage
-Displaced pathologic fracture.
23. requires the same technical care as any tumor
procedure,
complete local control of the lesion for cure or
palliation. Adjuvant chemotherapy or radiation
possibility of a short lifespan, psychological
stress to the family and child
these children should receive aggressive,
early rehabilitation
Use interim prostheses early, as
chemotherapy and weight loss may postpone
definitive fitting.
24. UPPER EXTREMITY
Above-Elbow Amputation
Very short above-elbow amputations
Elbow Disarticulation
Below-Elbow Amputation
Wrist Disarticulation
The Krukenberg, or "lobster-claw,"
operation, child with a long transradial (below-
elbow) amputation.
crude pinching mechanism with preserved
sensation by splitting a long transradial stump
into radial and ulnar rays. bilateral upper-limb
amputees, especially in the blind.
26. LOWER EXTREMITY
hemipelvectomy
hip disarticulation
Above-Knee Amputation (loss of the distal
femoral physis.)
Knee Disarticulation - ideal amputation level in
the child
The long stump, preservation of growth,
muscle control, and lack of terminal
overgrowth.
The patella retained.
27. Suture the hamstrings to the cruciate stump and
oversew the quadriceps tendon to them.
tenodesis preserves muscles strength for walking
and prevents their slippage around the distal
bone end.
As maturity approaches, distal femoral
epiphysiodesis to allow slight shortening, which
facilitates prosthetic design using an internal
hinge.
28. Below-Knee Amputation
Terminal overgrowth - multiple revisions.
Varus angulation - tibial osteotomy.
The thin, conical stump makes rotational control
difficult.
29. skin flaps widely variable - rich vascular supply
avoid scars directly over the end of the stump.
Preserve the fibula. The broad shape of the
combined proximal tibia and fibula enhances
rotational prosthetic control.
30. The pediatric Syme amputation
difficult to perform well - posterior heel-pad
migration.
Modern prosthetic technique allows fitting of
bulbous stumps, which often taper with
maturation.
The main use - congenital anomalies, - fibular
hemimelia and PFFD.
31. Boyd Amputation
preserves the posterior os calcis and thus
stabilizes the heel pad.
produces an excellent end-bearing stump without
the problem of terminal overgrowth.
produce a bulbous stump that may improve with
growth.
32. Midfoot amputations at the Lisfranc or Chopart
level are usually traumatic;
Conversion to a higher-level (Boyd or pediatric
Syme) amputation is often required
Distal partial foot amputations, (metatarsal level),
well tolerated and require only a space-filling
prosthetic shoe insert.
34. Terminal overgrowth
distal apposition of bone by the active
periosteum,
not dependent on the physis, and
epiphysiodesis will not arrest it.
never occurs after disarticulation.
most severe before 6 years of age, not seen
after about 12 years of age.
humerus, fibula, and tibia.
capping, osteotomy, and surgical cross-union,
effective treatment seems to be surgical
revision of the pointed distal bone and its
overlying bursa.
37. Emotional issues
less troublesome for the pediatric amputee.
The congenital amputee, accepts the
condition as normal.
Children who lose a limb traumatically
generally rehabilitate quickly when a
prosthesis is fitted.
function and durability, little concern for
appearance or body image.
parental acceptance of congenital or acquired
amputations difficult. Feelings of guilt or
inappropriate fears - specialized counseling.
38. Pediatric Prosthetics
Staging. the child is changing, growing and
dynamic; based upon the child's
developmental readiness.
Age at Fitting.
Upper limb- when independent sitting balance
lower extremity - pulling up to stand 9- 16
months. Independent ambulation - between
15 and 22 months.
The first prosthesis for a toddler with a knee-
disarticulation or AK amputation - non-
articulated or a locked knee .
By age three or four - unlocked knee.
39. Growth. both longitudinally and circumferentially.
Bony alignment changes.
(a newborn - genu varum. straightens out by the
first or second year, moves into genu-valgum by
the third year, then resolves spontaneously
thereafter)
The prosthesis must accommodate growth and
other physiological changes.
40. Prosthesis replaced every 12-24
months when worn out
Examined every 3-6 months
Size
Length
Weight of patient
Developmental/gait changes
Weight bearing surface
Socket liners.
Distal pads.