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Amputations in Children

Bramantya Karna

The surgery for and management of amputation in


children is very different from the adult
The majority of amputations in adults are performed
for complication of peripheral vascular disease, while
the most common cause of amputation in children is
congenital limb deficiency, followed by trauma,
infections, and neoplasm

There are a number of ways in which the juvenile


amputee differs from the adult
The limb continues to grow
There is appositional bone growth, especially of
through-bone amputations
The functional demands on the residual limb and
prosthesis are very different for the playful, active
child than those for the more sedentary adult

The psychological factors of incorporating the


amputation and prosthesis into body image are
critical
The incidence of multiple limb amputations is much
more frequent in the child, with their resulting
complexity of decision-making
The juvenile amputee very rarely experiences phantom
limb pain

Principles of amputations in children include


1) Preserve all length possible
2) Preserve growth plates
3) Use disarticulations when possible
4) Preserve the knee joint when possible
5) Stabilize the proximal limb

Amputations in children are devided into two general


categories, congenital and acquired
Acquired amputations in children are caused by trauma
or disease, with trauma being responsible for limb loss
approximately twice as often as disease
The most common cause in older children are vehicular
accidents, gunshots wounds, and power tool injuries;
in young children, accidents with the power tools such
as lawnmowers and others household accidents are the
most common causes

More than 90% of acquired amputations, only one limb


Involve, and its the lower limb involved in 60%
Incidence of acquired limb loss, males outnumber
Females 3 : 2
And amputations performed for disease, malignant tumors
account for more than half, with vascular formations and
sundry other diseases being responsible

Most of the technique of amputation described for adults


are also useful for children
The factors : general body growth and stump growth are
quite significant
Following amputation, the growth factors may prove dis
advantageous loss of stump length, most marked in
above-knee amputations

As in adults, the cardinal consideration : is to conserve


all limb length possible.However in children, a
disarticulation should be performed rather than amputation
through the shaft of a long bone at a more proximal level
Disarticulation :
preserve the physis distally, and therefore growth of the
stumps continues at normal rate
prevents terminal overgrowth of the bone
provides sturdy end-bearing stump and long lever-arm
to enhance prosthetic

Complication
Terminal overgrowth of sectioned longbone is
caused by the apposition of new bone and isnot
related to growth of the physis at the proximal
end of the bone (8-12% require stump revision)
Most often in the humerus and fibula
Less often in the tibia, femur, radius and ulna

Epiphysiodeses have been carried out in attemps


to prevent terminal overgrowth but have never
been successful and are contraindicated
The most effective treatment is surgical ressection
of the excess bone and capping the ressected bone
end with a bonegraft as advocated by Marquardt
and Correll

Other complication :
o
o
o
o
o

Bursa formation
Bony spurs
Stump scarring
Neuromas
Phantom limb

Because of growth factors and increased body


metabolism, children often tolerate procedures
on amputation stumps not tolerated by adults
use of more forceful skin traction
the application of extensive skingrafts
the closure of skinflaps under moderate tension
Complications after surgery tend to be less severe
in children
Painful phantom sensations do not develop
Neuromas are rerely troublesome enough to require
surgery

Painful phantom sensations do not develop


Neuromas are rerely troublesome enough to require
surgery
Extensive scars usually tolerated well
One or more spurs usually develop on the end of the
bone, but in contrast to terminal overgrowth almost
never require resection
Psychological problem after amputation are rare in
children until the teens are reached

Children use prostheses extremely well and their


proficiency increases as they age and mature
observed closely for :
prosthetic repair
frequent changes in the socket
fitting with new prostheses