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CHAPTER 30
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The Child with a Limb Deficiency
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
FIGURE 30-4.
(continued )
C,D
: Postoperative clinical photo and AP radiograph of the same patient after tibial lengthening.
