“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.
Better wound healing- use available skin flaps. The split-thickness skin graft can hypertrophy - increased elasticity of the childs skin + excellent blood supply Less phantom sensations Psychological problems less until teenage Training with prosthesis easier
Elective Amputations for CongenitalDeficiencies longitudinal absence of the fibula (complete) - Symes 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 - Symes amputation and knee fusion.
Timing of Amputation the earlier the amputation, the better the childs 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.
BURN AMPUTATIONSthermal 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.
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.
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.
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 childs 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.