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CHAPTER 30
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The Child with a Limb Deficiency
A
B
C
FIGURE 30-39.
A
: A typical patient with a congenital below-elbow amputation. There is usually enough length to fit a
prosthetic arm and still permit good active elbow motion.
B,C
: Two different children with transverse incomplete forearm
deficiency fitted with a myoelectric-powered hand performing common functions of childhood. Many of the children who use
the prosthesis develop amazing skills in its use.
fitted after, had stopped using their prosthesis. However, of
those who continued to use their prosthesis, there was no dif-
ference in the amount of use between the two groups. The
most common age at which patients discontinued use of their
prosthesis was at 13 years, most commonly because the pros-
thesis was viewed as cosmetically unacceptable and function-
ally superfluous. Sorbye (200) reported that, of the patients
in their clinic who were younger than 24 years, 87% were
using their myoelectric prosthesis, and 65% of these used it
all day and for all activities. Hubbard et al. (201), reporting
on the Toronto experience, found that 70% of the below-
elbow amputees were using their prosthesis, whereas 30% had
rejected it.
With this and other evidence, it is now the usual practice to
recommend fitting around the age of 4 to 6 months with a pas-
sive hand to aid in normal development. This lightweight pros-
thesis helps the child become comfortable with a prosthesis and
acquaints them with the two-handed activities that a normal child
would perform. The hope is that the child will develop the central
cortical pathways necessary for bimanual dexterity.
Depending on the child’s acceptance and use of this pas-
sive prosthesis, a more functional terminal device is fit between
15 and 18 months (31, 202). Today, there are a number of ter-
minal devices available (203). There are two choices to power
the device: battery (myoelectric) and body (cables). Although
there will be many factors to consider in the selection (cost
and funding, clinic philosophy, and parent choice), virtually all
centers today in North America are fitting most children with
myoelectric powered terminal devices (Fig. 30-39). Table 30.4
compares the advantages and disadvantages of myoelectric and
body-powered terminal devices for the child with a congenital
below-elbow amputation.
Surgical Treatment Recommendations.
One surgical
option in the treatment of patients with bilateral transverse
forearm deficiency is the Krukenberg operation. This opera-
tion separates the radius and ulna to create a forearm capable
of pinch and grasp between sensate ends (Fig. 30-40). This
was invented in 1916 to treat World War I upper extrem-
ity traumatic limb deficiency patients, and there are several
favorable reports of function after this surgery for traumatic
amputation in the literature (204–207). The procedure has
also been proposed for patients with congenital transverse
forearm amputation with similar good results (208, 209).
This procedure has been accepted in third-world countries
for both congenital and traumatic bilateral upper extremity
amputations. In the Western world, concerns over the cos-
metic appearance of the arm after surgery have limited its use,
much like the Van Nes rotationplasty. Current surgical indi-
cations are limited to the blind bilateral upper extremity limb
deficiency patient.
The advantages of the Krukenberg procedure are that the
child gains sensory feedback with pincer function between the
distal radius and ulna, which cannot occur with a prosthesis.
Moreover, the operation does not preclude prosthetic fitting.
At the author’s institution, the experience with the Krukenberg
procedure is that patient’s Krukenberg limb becomes the domi-
nant functioning extremity. Patients occasionally will choose to
wear a passive hand cosmetic prosthesis in certain social situ-
ations over their Krukenberg limb. Complications including
