Amputations in children


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Amputations in children

  1. 1. Amputations in Children
  2. 2.  “Amputare”: latin - cutting around Removal of diseased, protruding functioning unit of body In Children : concerns Growing Irresponsible dependant
  3. 3.  Adult: Occupation and cosmesis Children: Recreation and durability
  4. 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. 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. 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. 7.  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
  8. 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. 9. Causes Congenital 60% Acquired. 40% Traumatic Infections Neoplastic Burns Frost bite Kawasaki‟s disease ……….
  10. 10. CONGENITAL Upper /Lower limb Upper/middle/lower third Complete/partial Longitudinal/ transverse deficiency.
  11. 11.  constriction band syndrome (Streeters Dysplasia)- amniotic bands - complete / nearly complete antenatal amputation. Proximal focal femoral deficiency Tibia/Fibular Hemimelia
  12. 12. 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.
  13. 13. Timing of Amputation the earlier the amputation, the better the childs neurologic plasticity adapts to the alteration.
  14. 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. 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. 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. 17. Infection Purpura Fulminans- Thromboembolic condition – Meningococcal septicemia H.Influenza Toxic Shock Syndrome
  18. 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. 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. 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. 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. 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. 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. 24.  Below-Knee Amputation Terminal overgrowth - multiple revisions. Varus angulation - tibial osteotomy. The thin, conical stump makes rotational control difficult.
  25. 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. 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. 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. 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. 29. COMPLICATIONS Terminal overgrowth Adventitious bursae Bone spurs Extensive stump scarring Neuroma phantom limb phenomenon .
  30. 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. 31. Ertl Procedure
  32. 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. 33.  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.
  34. 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. 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. 36. k You  .