Weinstein Lovell and Winters Pediatric Orthopaedics 7e

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CHAPTER 30  |  The Child with a Limb Deficiency

FIGURE 30-4.  (continued ) C,D : Postoperative clinical photo and AP radiograph of the same patient after tibial lengthening.

tation of the limb, even in the absence of normal limb bud ­development. Phantom pain and distal residual limb pain are also com- monly associated with other pains, such as headache, bone, or joint pain (59, 61). The frequency of phantom sensations varies. They are often triggered by a wide variety of stimuli. Feeling nervous or happy, not wearing a prosthesis, being cold, or being ill are frequent triggers. Fortunately, these sensations do not interfere with the child’s usual activity, and most chil- dren say they just try to ignore the sensations (62). There is good evidence in adult patients that preemp- tive analgesia during amputation surgery, or immediately in the postoperative period, can decrease postoperative phantom pain in adults, and it has been suggested that the same is true in children (63). Epidural or spinal anesthesia can decrease postoperative limb pain as compared to general anesthesia (64, 65). Postoperative continuous-infusion intraneural cath- eters have also been used with success (66, 67). For established phantom limb pain, there is no single highly successful treat- ment. Because many of these problems resolve with prosthetic alterations or physical therapy modalities, a multidisciplinary approach has proven to be the best intervention in evaluating and properly treating the phantom limb phenomenon when it becomes a problem. A properly fitting socket, with appropriate suspension and sock thickness, is the best and first treatment of choice (62, 68). A heavy, tight shrinker, either worn inside the pros- thesis or when the prosthesis is off, may provide relief. Physical therapy interventions, including weight-bearing and graduat- ing pressures such as tapping, rubbing, and massage to the residual limb, have been reported to give temporary or per-

manent relief. Rubbing and massaging the uninvolved limb at similar points to those in which they are experiencing the phantom limb sensation may provide relief. Various physical modalities have been utilized in the treatment of phantom sen- sations in children, including transcutaneous electrical nerve stimulation, biofeedback, ultrasound, and the physical agents of heat and cold (69). For the occasional adolescent amputee who has problems with phantom pain following an amputation, gabapentin (Neurontin, Park-Davis) has proven a useful medication for some patients (70).

Congenital Deficiencies of the Lower Extremity Fibular Deficiency

Definition and Classification.  According to the ISO ter- minology, fibular deficiency is a longitudinal deficiency that is either partial or complete. However, this definition does little to accurately portray the spectrum of deficiency that is seen. Numerous classifications specific for fibular deficiency have been proposed (21, 35, 71–73). To be useful, a classifica- tion should guide treatment or aid in prognosis. As treatment changes, it may be reasonable to expect that classifications change. Most classifications are anatomic and are based on the radiographic appearance. Maffulli and Fixsen describe total aplasia of the fibula and a forme fruste of the same condition in which the fibula and tibia are short to varying degrees (74, 75). A more specific classification, which is probably the most widely used today, was proposed by Achterman and Kalamchi