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CHAPTER 30
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The Child with a Limb Deficiency
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.
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
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.
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.
