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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 child's 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 (Streeter's Dysplasia)- amniotic bands - complete / nearly complete antenatal amputation.  Proximal focal femoral deficiency  Tibia/Fibular Hemimelia
  12. 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. 13. Timing of Amputation  the earlier the amputation, the better the child's 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 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. 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  .