Weinstein Lovell and Winters Pediatric Orthopaedics 7e

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CHAPTER 30  |  The Child with a Limb Deficiency

Syme Amputation (Figs. 30-9 to 30-14)

FIGURE 30-9. Syme Amputation . The dorsal part of the inci- sion begins at the tip of the lateral malleolus, crosses over the dorsum of the foot near the dorsiflexion crease of the ankle, and ends about 1 cm below the tip of the medial malleolus. In children with complete absence of the fibula, this landmark can be estimated by palpation of the anatomy, as well as visually. The volar part of the incision connects the ends of the dorsal incision crossing the plantar aspect of the foot at the distal end of the heel pad. In young children who have not been walking, the heel pad is often difficult to identify, and care should be taken to bring the incision far enough distally to retain suffi- cient tissue.

FIGURE 30-10.  The next step is to complete the plantar incision. Because nothing distal to this point will be saved, this incision can be carried directly down to the bone, identifying and cauteriz- ing the bleeding vessels later when the tourniquet is released. The tendons and nerves can be pulled distally and sectioned so that they retract proxi- mally and the vessel can be ligated or cauterized. Completing this part of the incision simplifies the most difficult and important part of the operation, which is to divide the medial and lateral ligament structures without injuring the posterior tibial ves- sel and its branches that supply the heel pad.