Weinstein Lovell and Winters Pediatric Orthopaedics 7e

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CHAPTER 30  |  The Child with a Limb Deficiency

FIGURE 30-40.  (Continued) D,E : Postoperative photographs of the patient demonstrating pincer grasp of a playing card. F,G : Forearm radiographs of the same patient taken in supination and pronation. The patient opposes the tips of the residual limb with pronation. Note the dislocated radial head seen in supination. Occasionally, this can become symptomatic.

proximal radial head subluxation or dislocation can be a prob- lem. Also, a minority of patients lack sufficient pincer power to take full advantage of the procedure’s functional benefits. The authors recommend this procedure in a child with bilateral upper extremity limb deficiency on one side if there is full elbow and forearm motion and the forearm is long enough to have a properly functioning pronator teres insertion (25% of the normal forearm). Family counseling before surgery is essential, which includes showing a video of patients before and after the operation and/or meeting a patient who has had the procedure. Another surgical option for the short transverse fore- arm amputation is residual limb lengthening (56, 210, 211). Bernstein et al. reported that this procedure could convert a child with a short below-elbow amputation that was ­incapable of being fit with a below-elbow prosthesis to a standard below- elbow prosthesis. The procedure is not without complications, including elbow subluxation or contracture, and ­soft-tissue coverage difficulties at the distal residual limb end. The

authors recommend this procedure when the residual limb is incapable of being fit with an appropriate prosthesis for the level of amputation. Terminal Transverse Transcarpal Deficiency.  The congenital transcarpal amputation is the second-most com- mon deficiency of the upper limb and occurs in a characteristic pattern, with varying degrees of preservation of the proximal carpal row. The existing flexion of the carpals on the radius allows for limited grasping function, which along with normal sensation, makes this an assistive hand for which no prosthesis can substitute (Fig. 30-41). Occasionally, children will benefit from a volar opposition post for certain activities. They will usually wear it only for certain tasks, for example, as a guitar pick adapter or to grasp the handle bars on a bicycle. The authors’ experience with such children is that they have much more difficulty with the cosmetic aspect of their deficiency than do those children with transverse amputations