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CHAPTER 30
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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
