Weinstein Lovell and Winters Pediatric Orthopaedics 7e

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CHAPTER 30  |  The Child with a Limb Deficiency

Following surgery, the therapist should supervise and educate the child and parents in edema control to accelerate return to prosthetic use. In addition, range-of-motion and strengthening exercises accelerate, and may even be necessary to regain, the full function of the prosthesis. Users of myoelec- tric prostheses may need readjustment of their electrodes and, for a while, may have difficulty activating the prosthesis. This is because swelling and reshaping of the limb may alter the optimal sites for electrode placement. Short Residual Limb.  In some patients with either con- genital or acquired amputation, the residual limb will be too short for satisfactory or comfortable prosthetic fitting. In such cases, it may be possible to lengthen the residual limb. Watts has written an excellent review of this subject. Favorable results have been reported for both upper and lower extremity residual limb lengthening (55, 56) (Figs. 30-4A–D). Alekberov et al. (57) report on six patients who had successful ­lengthening of 3.4 to 8.4 cm in congenital below-elbow segments. The remain- der of the literature to date consists largely of case reports. The lengthening of residual limbs is fraught with com- plications, and careful consideration needs to be given to the potential benefits versus the possible complications. Deficient soft-tissue coverage is the main limit to adequate lengthen- ing. Tissue expanders generally do not provide the solution. Free tissue flaps may be used when skin coverage is inade- quate. Free flaps often remove sensation from the end of the residual limb, and especially in the upper limb this can affect the function of the limb both with and without the prosthe- sis. Although difficult, it is possible to fabricate a temporary prosthesis for use during the lengthening process for both above- and below-knee prostheses so that the child can con-

tinue weight bearing, at least during the consolidation phase (55) (Fig. 30-5A–C). Phantom Sensation/Pain.  In the middle of the 19th century, the neurologist Silas Weir Mitchell coined the term “phantom limb.” He described sensations as replicas of the lost limb, some being painful and some not. Phantom sensation of the limb is often described by patients as the feeling that they can move the part, tell how the part is positioned, or feel it itching or tingling. Phantom pain, however, is perceived by the patient as just that—painful. It often is the same as the pain before an amputation or may be cramping, shooting, burning, or of any other characterization. It was generally thought that children born without limbs do not have sensations of them; nor do these chil- dren experience the phantom pain or phantom sensation seen in the acquired amputee (58). Recent reports call this commonly accepted truism into question (59, 60). Whatever this pain is, those who care for children with limb deficien- cies will recognize that these children do not have the same problem as the true chronic phantom pain seen in adult amputees. Melzack et al. (60) reported that at least 20% of children with congenital limb deficiency and in 50% of those who underwent amputation before age 6 experienced ­phantom limb. Of those, 20% of the congenitally deficient group described the sensations as painful, whereas 42% of the acquired amputees described them as painful. To explain the phenomenon of phantom limb in a child who has never had a limb, Melzack et al. have proposed that there is a genetically or innately determined neural network that is distributed in the cortex (not focal), which is responsible for the represen-

FIGURE 30-4. A,B : Preoperative clinical photo and AP radiograph of a patient with a transtibial amputation with short residual limb.