Weinstein Lovell and Winters Pediatric Orthopaedics 7e

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CHAPTER 30  |  The Child with a Limb Deficiency

FIGURE 30-42.  This example of a myo- electric prosthesis, called the Otto Bock Electrohand, was made with a clear socket for teaching purposes. The proximal portion of the socket, which fits on the residual limb, contains the electrodes that pick up the signals from the muscles. This fits into the prosthesis, which contains the electrical and mechanical working parts of the hand.

problems beyond the management of each individual limb. Children with bilateral knee disarticulation or transtibial amputations will walk without support, and therefore a uni- lateral upper extremity amputation in association poses no special problem, other than donning and doffing the pros- theses. With bilateral amputations above the knee disarticula- tion level, however, walking without support is problematic; upper extremity function is needed, and a wheelchair may be required for long distances and to conserve energy. One of the most common types of patients seen in the pedi- atric age-group with this problem is the ­quadrimembral ampu- tee resulting from neonatal meningococcemia (Fig. 30-43). In these patients, it is often necessary to cover the residual extremi- ties with split-thickness skin grafts to maintain length. These

grafts, if not adherent to bone, hold up very well in the pros- thesis, and are not a hindrance to fitting. Treatment must be individualized for each patient, while following certain general guidelines. The first is to help the patient maximize function with his or her residual limbs. This is especially true with the upper extremities, in which sensation is so important to func- tion. Although these children will become proficient in the use of bilateral upper extremity ­prostheses, if their residual limbs are long enough, they will usually perform many of their daily activities, especially at home, without their prostheses. A common mistake is to attempt to fit all four extremities of these children with quadrimembral loss at the same time. Doing so may result in actual delay in functional recovery and rejection of the prostheses. In most situations, it is best to first fit the lower extremities and achieve ambulation, then fit the upper extremities. In the child with a congenital quadrimembral deficiency, there will usually come a time when the parents, and perhaps the child, desire prosthetic fitting. As is true for acquired defi- ciency, it is best to avoid fitting all four extremities at once, but rather focus on meeting specific needs. Although experi- ence shows that most of these children will have limited or no use of their prosthetic devices, they and their parents need and are entitled to this experience at least once (Fig. 30-44). Authors Preferred Recommendations.  The authors generally fit patients with upper extremity prosthesis with a passive hand terminal device when sitting balance is achieved. The child is fit with an activated terminal device between 1.5 and 2 years of age. No generalizations as to the type of ter- minal device can be made. As mentioned previously, multiple limb-deficient patients are fit with lower extremity prostheses first, followed by upper extremity prostheses within the first few years of life. The fitting of the child with upper extremity deficiencies is highly patient dependent. Patients with bilateral transverse forearm amputations with residual limbs of sufficient length are offered a unilateral Krukenberg operation at school age. Patients with unilateral transverse forearm deficiency with a short residual limb unable to be fit with an appropriate level prosthesis are offered fore- arm lengthening to improve prosthetic fit and function.

FIGURE 30-43.  Clinical photograph of a patient with meningococ- cemia and quadrimelic limb deficiency. Multiple split-thickness skin grafts were necessary to cover the residual limbs after infection.