Amputations in ChildrenBramantya Karna

The surgery for and management of amputation inchildren is very different from the adult

The majority of amputations in adults are performedfor complication of peripheral vascular disease, whilethe most common cause of amputation in children iscongenital 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 growThere is appositional bone growth, especially of through-bone amputationsThe 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 criticalThe incidence of multiple limb amputations is much more frequent in the child, with their resulting complexity of decision-makingThe juvenile amputee very rarely experiences phantom limb pain

Principles of amputations in children include1) Preserve all length possible2) Preserve growth plates3) Use disarticulations when possible4) Preserve the knee joint when possible5) 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 lossapproximately twice as often as diseaseThe 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 limbInvolve, and it’s the lower limb involved in 60% Incidence of acquired limb loss, males outnumberFemales 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 adultsare also useful for childrenThe factors : general body growth and stump growth arequite significant

Following amputation, the growth factors may prove disadvantageous loss of stump length, most marked inabove-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 amputationthrough 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 proximalend of the bone (8-12% require stump revision)

Most often in the humerus and fibulaLess often in the tibia, femur, radius and ulna

Epiphysiodeses have been carried out in attempsto 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 boneend with a bonegraft as advocated by Marquardtand Correll

Other complication :

o Bursa formationo Bony spurso Stump scarringo Neuromaso Phantom limb

Because of growth factors and increased bodymetabolism, 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 childrenPainful phantom sensations do not developNeuromas are rerely troublesome enough to require surgery

Painful phantom sensations do not developNeuromas are rerely troublesome enough to require surgeryExtensive scars usually tolerated wellOne or more spurs usually develop on the end of the bone, but in contrast to terminal overgrowth almostnever require resectionPsychological 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