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Amputations in
  Children
 “Amputare”: latin - cutting around
 Removal of diseased, protruding functioning unit
 of body

 In Children : concerns
 Growing
 Irresponsible
 dependant
 Adult: Occupation and cosmesis




 Children: Recreation and durability
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)
 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
 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.
Amputations in children
 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
 Disarticulation : Adv
 Epiphyseal growth preserved
 Terminal overgrowth (so revisions) avoided
 Residual limb tolerant of distal weight bearing

 Prosthesis needs frequent repairs and change
Causes
 Congenital 60%
 Acquired. 40%
 Traumatic
 Infections
 Neoplastic
 Burns
 Frost bite
 Kawasaki‟s disease ……….
CONGENITAL
 Upper /Lower limb


 Upper/middle/lower third


 Complete/partial


 Longitudinal/ transverse deficiency.
 constriction band syndrome (Streeter's
 Dysplasia)- amniotic bands - complete / nearly
 complete antenatal amputation.

 Proximal focal femoral deficiency


 Tibia/Fibular Hemimelia
Amputations in children
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.
Timing of Amputation


 the earlier the amputation, the better the child's
 neurologic plasticity adapts to the alteration.
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
 consider at a more proximal level


 Avoid multiple procedures


 degloving injury - extensive use of split skin graft
  tissue expanders or
  microvascular free tissue transfer.
 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.
Infection
 Purpura Fulminans- Thromboembolic condition –
  Meningococcal septicemia
 H.Influenza
 Toxic Shock Syndrome
Amputations in children
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.
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.
 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.
   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.
Amputations in children
 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.
 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.
 Below-Knee Amputation

 Terminal overgrowth - multiple revisions.


 Varus angulation - tibial osteotomy.


 The thin, conical stump makes rotational control
 difficult.
 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.
 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.
 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.
 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.
COMPLICATIONS
 Terminal overgrowth
 Adventitious bursae
 Bone spurs
 Extensive stump scarring
 Neuroma
 phantom limb phenomenon .
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.
Amputations in children
Ertl Procedure
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.
 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.
 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.
 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.
k You

      .

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Amputations in children

  • 1. Amputations in Children
  • 2.  “Amputare”: latin - cutting around  Removal of diseased, protruding functioning unit of body  In Children : concerns  Growing  Irresponsible  dependant
  • 3.  Adult: Occupation and cosmesis  Children: Recreation and durability
  • 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
  • 9.  Disarticulation : Adv Epiphyseal growth preserved Terminal overgrowth (so revisions) avoided Residual limb tolerant of distal weight bearing  Prosthesis needs frequent repairs and change
  • 10. Causes  Congenital 60%  Acquired. 40% Traumatic Infections Neoplastic Burns Frost bite Kawasaki‟s disease ……….
  • 11. CONGENITAL  Upper /Lower limb  Upper/middle/lower third  Complete/partial  Longitudinal/ transverse deficiency.
  • 12.  constriction band syndrome (Streeter's Dysplasia)- amniotic bands - complete / nearly complete antenatal amputation.  Proximal focal femoral deficiency  Tibia/Fibular Hemimelia
  • 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.
  • 19. Infection  Purpura Fulminans- Thromboembolic condition – Meningococcal septicemia  H.Influenza  Toxic Shock Syndrome
  • 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.
  • 33. COMPLICATIONS  Terminal overgrowth  Adventitious bursae  Bone spurs  Extensive stump scarring  Neuroma  phantom limb phenomenon .
  • 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.
  • 41. k You  .