Traumatic Amputation in Childhood: Primary Management
James M. Cary, M.D.
The extent to which optimal function can be provided for the child who is a victim of traumatic limb loss is often determined by the primary management of the injury. In the severely traumatized and contaminated wound, avoidance of further infection and increased vascular compromise is essential. Constructive planning, with consideration of the effects of growth and optimal stump condition through life, may dictate the need for staging in the management of a child's amputation. Surgical experience derived from three major wars in the primary management of traumatic amputations can contribute much to surgery for civilians, including children.
Incidence and Complications
Although trauma is not the most common etiology for childhood amputation, it does present a significant problem in treatment. Only 21 (or 17 percent) of 120 patients currently on the active files of the juvenile amputee clinic at Newington Children's Hospital have trauma listed as the primary cause of their disability. In this group, however, the incidence of complications, and problems with prosthetics fitting and function is disproportionately high4,13. These problems, in most cases, can be attributed to complications, encountered in the primary management, that have precluded construction of an optimal amputation stump.
In the past four years only five children have been transferred to Newington Children's Hospital following primary management of traumatic major limb amputation. Each of these five children, however, had a significant wound complication with actual or potential loss of eventual optimal function. This 100 percent complication incidence prompts a discussion of primary management. Several of these cases may serve to illustrate certain principles of primary care.
Primary Management ofAmputation in Military Surgery
Military surgeons have long recognized that the avoidance of complications, and, in fact, the functional outcome in traumatic amputation as well as other types of extremity trauma are in the hands of the physicians providing definitive primary care9,16. Experience with thousands of cases in several major wars has provided guidelines for this primary management. In time of war these guidelines were not offered as suggestions but as firm directives5,12. For limb amputations these directives for primary surgical treatment can be summarized as follows:
- Ablation will be at the most distal viable level.
- Viable skin will be preserved.
- No wound closure of any type will be attempted.
- Skin traction will be employed.
- The proximal joint will be immobilized in a functional position.
- Plaster will be split to avoid constriction.
This regime is based on five principles of wound management so well established by empirical military experience that they are considered axiomatic:
- Any wound that could be closed at the time of initial debridement can be repaired with equal facility and far greater safety 5 to 9 days later.
- Invasive infection does not occur in a completely debrided open wound with viable tissue.
- Increasing vascular embarrassment due to closed-space edema does not occur in a completely debrided, fasciotomized, open wound.
- Inevitable errors in the estimation of tissue viability and wound contamination can be corrected by secondary debridement of residual necrotic tissue at the time of delayed closure.
- In a severely traumatized and potentially contaminated limb wound there is no real justification for immediate closure.
Illustrative Case History
A 13-year-old boy was admitted 23 days after a train-track injury in which he incurred a traumatic amputation of the right hand and wrist, as well as partial amputation of the left hand. Initially, at the referring hospital, amputation had been completed at the levels of the distal radial and ulnar metaphyses, with primary closure and definitive repair (Fig. 1 ). On admission to this institution full-thickness necrosis of the dorsal skin flap over a 6 x 4 cm area was evident. The stump was tender and edematous, with redness and inflammation at the viable margins. Culture of the wound margin grew staphylococcus aureus (Fig. 2 ).
On admission continuous warm moist compresses were instituted. The edges of the eschar were loosened to permit drainage. On the third hospital day redness and inflammation had subsided at the wound margins. The patient was taken to the operating room where a complete debridement of necrotic skin and underlying soft tissue was performed (Fig. 3 ). The edges of viable skin were undermined and loosened, and skin traction was instituted (Fig. 4 , Fig. 5 , and Fig. 6 ). On the seventh postoperative day the wound was inspected, again in the operating room, and a loosely sutured, delayed primary closure was carried out, and good drainage instituted. Traction had provided cover for this closure without need for further shortening of the stump (Fig. 7 ). Healing was uneventful (Fig. 8 ). The patient was fitted with a standard forearm prosthesis six weeks after admission, and he quickly became adept in its use (Fig. 9 ). The forearm length preserved allowed him to transmit 50 deg. of pronation-supination excursion to the terminal device.
Trauma and Wound Closure
The case described later in this section is discussed in some detail to emphasize the technique employed. This technique, suited to the primary management of a severely traumatized and potentially contaminated amputation, was employed in the secondary management of complicating necrosis and incipient infection in a case subjected prematurely to definitive wound closure as a primary procedure. Fortunately, infection was neither advanced nor invasive, and adequate debridement and skin traction made possible the retrieval of skin cover for delayed primary closure without loss of optimal stump length.
Planning for Optimal Function
In dealing with a child's traumatic amputation a great deal of constructive planning may be required in order to salvage the best possible function. Once amputation is inevitable, this planning for optimal amputee function and prosthetic use should be the obvious next step.
At this point it might be wise for the surgeon to stop and consider his own frame of mind. He has been exercising considerable mental effort in an attempt to find a way to save the injured part, but this effort has failed. Loss of a limb, particularly for a child, has a considerable emotional impact on the surgeon as well as on the patient and family. This factor, in itself, may have the effect of inhibiting a resumption of the mental effort necessary to think constructively about the amputation.
Good amputee function requires an optimal conversion site, pliable skin cover with sensation, uncomplicated healing, freedom from infection, good vascular stump nutrition and, if possible, a well-muscled stump. Early prosthetic fitting and rapid rehabilitation are highly desirable to avoid serious psychological problems.
Staging of treatment may be necessary to provide these objectives safely and with assurance. A lower-limb amputation must bear weight. If the length and level of amputation is dictated by skin available for primary closure, the opportunity for revision to an optimal functional stump may well be lost6,7,10,14. If a compromise with skin tension in closure is accepted, wound breakdown, infection, and a tender adherent scar are almost inevitable.
Two such patients with persistent sinuses overlying necrotic tissues in primarily closed below-knee stumps have required open revisions that have resulted in short, tender, and poorly muscled stumps.
During the Korean War and throughout the Viet Nam conflict, the practice of lower-leg guillotine amputation at optimal bone length was abandoned for open amputation at the most distal viable level. Skin traction was employed and late revision to optimal stump length was performed with myodesis where possible. The improved functional results and the lowered incidence of wound complications have been convincing.
Trauma necessitating amputation in civilian practice is not far different from that of the wounds of war. The incidence of complications in immediate definitive wound closure in civilian traumatic amputation strongly suggests the acceptance of the military experience and recommendations in the treatment of such injuries.
Illustrative Case History
An 11-year-old girl was transferred to this institution 22 days after an injury in which her left forefoot was crushed by a heavy piece of machinery. Debridement and ablation of the forefoot at the Lisfranc level (tarsocuneiform joint) and closure with a dorsal skin flap were performed initially.
On admission to this hospital, a necrotic dorsal skin flap with copious purulent exudate, culturing Klebsiella enterobacter and Bacillus subtilis, was evident. The patient was mildly febrile (100.6 deg. F), and edema, redness, and tenderness present in the tissues about the plantar pad, malleolar area, and lower shin, attested to the presence of invasive infection in the tissues.
On admission free drainage of exudate was promoted by loosening the eschar and by continuous warm moist compresses. The child was taken to the operating room 48 hours after admission, and open debridement of all necrotic tissue was carried out with further resection through cancellous bone just proximal to the Chopart (midtarsal) level, preserving the viable tissues of the heel. It was hoped that a later revision to a Syme's-type ankle disarticulation could be performed. Ampicillin, to which both organisms were reported sensitive, was administered in therapeutic dosage prcoperatively and for 14 days postoperatively.
Although inflammation in the surrounding tissues subsided rapidly, the wound margins and the granulations covering the bony surfaces remained edematous with continued exudation, and the deeper tissues of the heel and ankle remained swollen.
It was felt inadvisable to proceed with revision in the face of persistent surface infection. At 14 days, following initial debridement, thin split-thickness skin was applied to the open wound. Subsequent healing was rapid. The patient was discharged with the grafted wound dry, and with resolution of all inflammation, swelling, and drainage, on the 20th day following skin grafting.
She was readmitted six weeks later, when revision to a formal Syme's-type ankle disarticulation was carried out with prompt and uncomplicated wound healing.
Despite the use of a walking plaster cast, instituted three weeks after surgery, definitive prosthetic fitting and use were delayed for three months by persistent edema and tenderness of the heel pad the result, it is felt, of the previous infection. However, after fitting eventual prosthetics usage was satisfactory, and no further complication with the Syme's-type stump ensued.
The Syme's Amputation in Children
In younger children where significant growth remains, any type of diaphyseal amputation leaves much to be desired in terms of ultimate adult function1. Not only is there invariably a small, flabby, poorly muscled stump, but loss of the distal epiphysis results in progressive relative shortening with growth. Overgrowth, stemming from appositional endosteal proliferation not epiphyseal growth-is a frequent complication, often requiring multiple revisions which result in further shortening.
Sometimes diaphyseal amputations cannot be avoided, but in young children, where a major cause of trauma is the power rotary mower, the massive resulting injury is often to the forefoot. The skin over the heel, though traumatized, may be salvageable.
In severe foot injuries in the growing child the Syme's (ankle disarticulation) level is the site of election. The Chopart or Lisfranc levels can be fitted and tolerated in the child, but give a less functional prosthetic result when he grows to adulthood10,16.
In World War II the Syme's amputation was used freely and frequently by the Canadian and British medical corps for adults8 but was not favored by American military surgeons, partly due to the high rate of complication and below-knee revision needed. However, understanding of the amputation has improved and it is now successfully performed throughout the world.
Where possible, the Syme's-type amputation is almost mandatory in young children for optimal function, so that possible complications of the procedure should be considered to see how they may best be avoided in the primary management2. Where the tissues about the heel and plantar heel pad are not traumatized, a primary, loose, well-drained closure might be considered. Where these tissues are traumatized although viable, as is frequently the case in severe foot injuries, it would seem unwise to subject the heel pad to the further trauma of surgical dissection, as in the Canadian military practice of open-flap Syme's amputation. These heel pads, after open-flap treatment, are often scarred, tender, and poorly adapted for end-bearing function after delayed closure.
There is another reason for rejection of the open-flap Syme's technique in young children. The operation is not performed, as in adults, with resection of the cartilage surfaces of the ankle, hut is a true disarticulation that leaves the distal epiphyses of tibia and fibula undisturbed. Open disarticulations are troublesome. Cartilage, deprived of nutrition, undergoes necrosis and desquamation, and the recesses of the joint invite persistent bacterial invasion.
In a severe foot injury in a child where the heel pad is felt to be viable, an open forefoot amputation may be performed. All surface cartilage is debrided to bone. After edema has resolved and nutrition of tissues is established, a delayed formal revision to a Syme's ankle disarticulation can be performed with relative safety. In those cases in which there is persistent wound edema or surface infection, or where restoration of tissue nutrition is delayed, the application, as in the case previously described, of a very thin split-thickness skin graft as temporary wound cover will usually result in a clean, dry, closed wound. This can subsequently be revised with safety.
Above-Knee Amputation in Children
The above-knee amputation at best results in a far greater disability than one performed at the below-knee level. Only with an ideal muscular stump can the above-knee amputee function without marked impairment4,8,10,13.
Illustrative Case History
A 14-year-old boy, rather small and immature for his age, was admitted for further treatment of a traumatic above-knee amputation of the right leg at the junction of the middle and distal thirds of the femur, The initial injuries, one month previously, had been closed but severely traumatized fractures of the right tibia and fibula, and a comminuted spiral fracture of the midshaft of the right femur, Injury to the distal popliteal artery and tibial trifurcation had failed to respond to attempted repair, and circulation to the foot and lower leg was lost. A supracondylar amputation with primary wound closure was performed five days after injury. The femoral fracture was immobilized with skeletal transfixion pins incorporated in plaster.
On admission to this institution the stump was edematous, with inflammation about the wound closure. Drainage from the sinus tract with exuberant granulation tissue extended down to the distal bone end. Skin and tissues about the transfixion pins showed redness and scant drainage. A radiograph showed early callus about the femoral fracture. Clinically there was only slight spring, without gross motion, at the fracture site.
Pins were removed. Compresses and stump wrapping were applied with gradual healing of the granulating wound at the distal stump. There was, however, persistent stump edema and pain, followed by reopening of the sinus, continued drainage, and the radiographic finding of a necrotic ring sequestrum involving the distal 1.5 cm of the femur. Eight weeks after admission open revision, with excision of the sinus tract and surrounding granulating tissue, and removal of sequestrum, was performed. Delayed closure of the wound eight days later was followed by firm uncomplicated healing.
The boy was fitted with a total-contact, suction-socket, ahove-knee prosthesis. Recurrent stump edema on attempted use of suction interfered with this application, and revision of the prosthesis to a simple total-contact device without suction was necessary before usage was satisfactory. His present function, though satisfactory, is not optimum, due to the rather short, poorly muscled above-knee stump. This is thought to be residual to the severe trauma and to the complications of wound healing which precluded myodesis and the development of maximal muscular capability for above-knee prosthetics use.
Importance of the Distal Femoral Epiphysis
In the young child the importance of the distal femoral epiphysis cannot be over-emphasized1. Seventy-five to 80 percent of femoral growth comes from the distal growth plate. From six years of age to maturity, for example, the increment in length amounts to 14 cm (5 and 1/2 in.). The presence of the distal epiphysis with tough prepatellar skin cover can provide good end-bearing control for a prosthesis15. Knee disarticulation allows the best myodesis for a muscular above-knee stump. The length can be adjusted for conventional prosthetics fitting by elective epiphysiodesis.
Salvaging an Effective A bove-Knee Stump
The ability to salvage an effective above-knee stump in either the adult or the child with severe proximal lower-leg trauma and popliteal artery damage has, again, been the product of military surgery experience in this instance, in fact, the by-product of a failure. The special vascular research team assigned to emergency treatment of arterial injuries during the Korean War had notable success with femoral injuries, but failures of popliteal and trifurcation repairs, particularly when associated with severe lower-leg trauma, were frequent11. The key to amputation salvage in these cases is the preservation of the geniculate circulation. This circulation can provide nutrition and viability to a very short, open, below-knee amputation if all muscle is removed. This result was established by observation of the demarcation of the necrosis after popliteal-repair failures. This technique of open amputation with skin traction was started late in the Korean War, and became standard in Viet Nam. There is, of course, insufficient soft tissue for an effective below-knee stump, but revision to an ideal above-knee transcondylar level in the adult, or to a knee disarticulation in the younger child is rendered possible.
A Debt to Military Surgery
The mass casualties of wartime, however tragic, have given military surgeons an opportunity to observe objectively and to evaluate the treatment results of statistically significant numbers of severe injuries, which for the civilian surgeon are but an occasional experience. A familiarity with, and a respectful regard for, the principles of treatment evolved from this experience can be of great value in the primary management and constructive planning of treatment for the child with an injury necessitating amputation. The guidelines for primary management set out so clearly by military directives should not be lightly disregarded, for the nature and effect of the trauma resulting in loss of limb in the child in civilian experience are not significantly different from those of the severe war wound. To ignore the principles of wound management in severe trauma is to invite complication, loss of optimal function, and, sometimes, catastrophe3.
Cordial thanks are expressed to the Newington Children's Hospital for providing the photographs used to illustrate this report.
Newington Children's Hospital, Newington, Connecticut
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