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.

7.
 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

8.
 Disarticulation : Adv
Epiphyseal growth preserved
Terminal overgrowth (so revisions) avoided
Residual limb tolerant of distal weight bearing
 Prosthesis needs frequent repairs and change

9.
Causes
 Congenital 60%
 Acquired. 40%
Traumatic
Infections
Neoplastic
Burns
Frost bite
Kawasaki‟s disease ……….

10.
CONGENITAL
 Upper /Lower limb
 Upper/middle/lower third
 Complete/partial
 Longitudinal/ transverse deficiency.

11.
 constriction band syndrome (Streeter's
Dysplasia)- amniotic bands - complete / nearly
complete antenatal amputation.
 Proximal focal femoral deficiency
 Tibia/Fibular Hemimelia

12.
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.

13.
Timing of Amputation
 the earlier the amputation, the better the child's
neurologic plasticity adapts to the alteration.

14.
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

15.
 consider at a more proximal level
 Avoid multiple procedures
 degloving injury - extensive use of split skin graft
tissue expanders or
microvascular free tissue transfer.

16.
 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.

17.
Infection
 Purpura Fulminans- Thromboembolic condition –
Meningococcal septicemia
 H.Influenza
 Toxic Shock Syndrome

18.
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.

19.
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.

20.
 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.

21.
 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.

22.
 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.

23.
 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.

24.
 Below-Knee Amputation
 Terminal overgrowth - multiple revisions.
 Varus angulation - tibial osteotomy.
 The thin, conical stump makes rotational control
difficult.

25.
 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.

26.
 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.

27.
 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.

28.
 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.

29.
COMPLICATIONS
 Terminal overgrowth
 Adventitious bursae
 Bone spurs
 Extensive stump scarring
 Neuroma
 phantom limb phenomenon .

30.
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.

31.
Ertl Procedure

32.
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.

33.
 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.

34.
 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.

35.
 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.

36.
k You
 .