CHAPTER 30
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The Child with a Limb Deficiency
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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.
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.
Syme Amputation (Figs. 30-9 to 30-14)
