The Child With An Acquired Amputation

George T. Aitken, M.D.


Recently the postamputation management of children has become an area of new and special interest to physicians and surgeons. As a result, prosthetic fitting and training procedures for children with amputations have improved, and some surgical lessons have been learned. Currently, child amputees are divided into two major groups-those with acquired amputations and those with congenital limb deficiencies. This report is an attempt to summarize current practices in the care of acquired amputations in children.

For the purpose of this discussion, a juvenile amputee is defined as a skeletally immature patient with an acquired upper- or lower-limb amputation. It is believed that valid reasons exist for separating the juvenile from the adult. If one considers a child as a dynamic, growing organism, dependent upon others in the areas of financial, social, disciplinary, and educational activities, and as an individual whose responsible activities are reflections of the disciplines imposed by his family, it becomes evident that he is different from the adult, who is assumed to be responsible financially, socially, and educationally (Fig. 1 ). It is important that all medical and paramedical personnel involved in the care and training of the child amputee should recognize these differences and that they should be emphasized continuously.

The management concepts for acquired amputations presented in this report are based on an experience with 718 children having 782 amputated limbs. The series consisted of 521 males and 197 females (a 3:1 ratio) and there were 322 upper-limb and 460 lower-limb amputations.

Causes of Acquired Amputations

The acquired amputations of these 718 children were reviewed within two major etiological categories: posttrauma and disease. The posttraumatic factors were broken down into seven arbitrary groups; the disease entities producing amputations were broken down into three arbitrary groups (see Table 1 ).

Careful consideration of these figures indicates that preventive medicine might be applied advantageously to reduce the incidence in some of the trauma categories.

Acquired amputations in children are primarily unimembral. In this series of 718 patients, 664 amputations, or 92.5 percent, involved only one limb. Only 6 percent of the cases had two limbs involved, and less than 1 percent had three or more limbs involved (Fig. 2 ).

Amputation Surgery

Amputation surgery in children differs from amputation surgery in adults. In children, one is amputating on an immature, growing patient, whereas in the adult one is doing surgery on a mature individual. In the child an effort must be made to fashion a stump that will not only be adequate for the present but will also be adequate at maturity. In the adult, one is fashioning a stump for a patient who has reached maturity. The specific surgical techniques are no different in children than they are in adults, except as modification in size of instruments, sutures, and drains must be made. Because children's tissues have that undefinable something (possibly called "youth"), healing is prompter and, where necessary, closure under tension can be performed with more possibility of success than in the adult. The use of skin grafts for preserving length is recommended (Fig. 3 and 4 ) .

The surgeon doing amputations on children must be aware of the percentile contribution of long bone epiphyses to longitudinal growth (Fig. 5 , Fig. 6A and Fig. 6B ). There are no sites of election in children. The surgical dictum is "save all length possible." Disarticulations should be done where possible in preference to supraepiphyseal amputations.

Overgrowth

The major postsurgical complication of amputations in children is bony overgrowth (Fig. 7 and 8 ). It has appeared in 11.7 percent of our patients with acquired amputations-in the humerus, fibula, tibia, and femur, in that order of frequency. The treatment for this condition is revision of the stump with removal of the bony overgrowth.

This condition is an appositional, terminal bone production phenomenon that is seen only in people with open epiphyses. Implantation of metal markers has demonstrated conclusively that it is not the result of the growth contribution of the next proximal epiphysis (Fig. 9 A/B ). Thus epiphysiodesis of the next proximal epiphysis is unnecessary and does not prevent overgrowth.

Team Approach

The efficacy of the team approach to the postsurgical management of the juvenile amputee has been well demonstrated in our experience. The team is minimally composed of a physician, an occupational therapist, a physical therapist, and a prosthetist, who ideally should meet in an organized clinical situation. Ancillary medical or paramedical personnel-nurses, medical social workers, secretarial help, psychologists, and available consultants from all specialties of medicine and surgery-are desirable.

Intake information can be obtained from the family prior to the clinic visit and be made available to the clinic team. It is desirable, however, that the family attend at least the first clinic meeting with the patient. Unless the family becomes convinced of the desirability of a prosthesis, the results of fitting and training will be less than ideal. Since the child functions under the discipline of his family, the family must desire prosthetic application and be willing to insist upon training, wearing to tolerance, and practice until functional regain is established.

At the initial clinic session a careful physical examination of the patient is carried out and a detailed record is made of the length of the stump, position of the scar, presence or absence of tender areas, the mobility of the proximal joints, and the strength of musculature about these joints. At this time the team as a group determines whether prefitting remedial physical or occupational therapy is indicated. The patient is then evaluated, and a prescription is formulated for the limb required. The multidisciplinary evaluation of the patient at the time of prescription writing will result in a more precise prescription and thus reduce delays in fitting and in training, as well as unnecessary expense.

Time of Fitting

Lower-limb amputees may be fitted with a limb as soon as they evidence a standing activity pattern and demonstrate a desire to walk. Upper-limb cases may be fitted at any age, provided the components of the limb are properly related to the child's functional capabilities as determined by his maturation (FIg. 10-13 ). In both upper- and lower-limb cases, definitive prosthetic application should not be attempted until the stump is mature and relatively painless.

Malignancy

The disease most frequently requiring amputation in childhood is malignant tumor. In the past there has been a reluctance on the part of some clinicians to recommend, and some agencies to approve, prosthetic fitting in children who had amputations for malignant tumors.

At our center a series of 115 cases of amputations for proved malignant tumors was reviewed (Fig. 14 ). Of these patients, 87 percent had lower-limb amputations, and 13 percent had upper-limb amputations. Of the 100 lower-limb cases, 63 were above-knee, 25 were hip disarticulations, and five were hindquarter amputations. In the 15 upper-limb cases, six were above-elbow, three were shoulder disarticulations, and four were fore-quarter amputations (Fig. 15 ).

In analyzing these 115 cases, five arbitrary categories of survival following surgery and prosthetic fitting were established. The number of patients surviving for significant postoperative periods certainly indicate the advantage of prosthetic fitting (Fig. 16 ).

We now recommend that a child who has lost a limb for a malignant tumor should be fitted as soon as the stump is healed and comfortable, provided his chest X-ray is negative at that time.

Fabrication and Training

Commercial components are available in a wide variety of sizes for upper- and lower-limb prostheses. Modern prosthetic practices allow the fabrication of prostheses that are comfortable, well-aligned, and properly proportioned in weight and size for children of all ages.

For the upper-limb patient, a plaster cast is taken of the stump. From this a model is made, and on this model a wax check-socket is fabricated. When the accuracy of this check-socket is established, a new model is cast and a plastic laminate double-walled socket is fabricated. In this manner, an accurate fit is obtained and comfort is assured. To this socket are added whatever components are necessary to fulfill the prescription requirements of the limb ordered.

This limb is then fitted to the patient at another clinic meeting. At that time, the components of the prosthesis are checked against the original prescription; the general fit and alignment of the limb and the adequacy of the harness for suspension and power transmission are checked. If the team agrees that these requirements have been met, training is initiated .

During the course of upper-limb training, a detailed checkout of the limb is made, including determination of power input-output ratios (cable system efficiency).

Initially training should be limited to developing mastery of controls. Once this has been accomplished, the functional applications of the upper-limb prosthesis should be introduced and every effort should be made to promote the development of helping (nondominant) hand functions in both activities of daily living and recreational play.

Patients with above-elbow levels who have to master a dual-control system should not be expected to control their terminal device operation, forearm lift, and elbow-locking in a functional manner before 36 to 42 months of age. Patients with below-elbow levels of amputation can be expected to master the control of a voluntary-opening terminal device in a functional manner at between 24 and 30 months of age.

Assistive devices for sports participation are helpful in selected cases. The two most common are a nonstandard prosthetic hand to fit into a baseball glove (Fig. 17-19 ), and upper- and lower-extremity swim fins. However, adapted equipment may be developed for many activities (Fig. 20 and 21 ).

In lower-limb cases, the patel-lar-tendon-bearing socket shape has proved to be as efficacious for children as it has for adults. Suspension of the patellar-tendon-bearing socket may be by a supracondylar cuff (Fig. 22-24 ) or by knee joints and a thigh corset (Fig. 25-26 ). The indications for the application of one or the other of these suspensions will vary with (1) level of amputation, (2) age of the patient, (3) the activities in which he is engaged, and (4) the stability of the knee joint. Fabrication and fitting techniques for this type of limb are identical with those used for the adult prosthesis.

In the above-knee levels in children, quadrilateral sockets with or without total contact have proved desirable. Suction with or without ancillary Silesian bandage suspension is used. Experience has demonstrated that suction suspension may be used for children of all ages. Socket fabrication may be either of wood or laminated plastic.

After the socket is fabricated, it should be attached to an adjustable leg in order to properly align the prosthesis (Fig. 27 ). Use of the adjustable leg facilitates adjustment for anterior and posterior placement of the thigh on the shank, and for varus and valgus at the knee, equalization of length, and rotation of the foot.

The clinic team-the physician, therapist, and prosthetist-should be present during this preliminary alignment checkout in order that these three disciplines concur in the adequacy of the fit and alignment.

By use of a transfer jig, the alignment obtained with the adjustable leg can be transferred to a standard knee, shank, and footpiece. The finished limb is then delivered to the patient at a subsequent clinic meeting {Fig. 28 ). If the finished limb fits adequately and is properly aligned, gait training is initiated.

It is important that the therapist training lower-limb patients recognize that children do not walk like adults. They must be trained to walk as do children of the same age, and not be required to meet adult standards. Heel strike, midstance, and toe-off, which are characteristic of adult gait, usually do not appear in children until they are at least five years of age.

As the child gains skills in level walking, stair-climbing and ramp-walking are introduced. Later, as skill and agility develop, recreational activities may be introduced. Generally children acquire these skills independently.

When the upper- and lower-limb patient has been fitted with a comfortable, well-aligned limb and has developed adequate fundamental skills, a conference is held among the parents, the patient, and the therapist in charge of training, and a home program is outlined. This home program includes instruction in how to maintain the limb, as well as instructions in how to encourage the patient to acquire increasing functional skills.

Most children with acquired amputations are capable of attending regular schools. They are not "crippled children," in the sense that they need neither special transportation nor special architectural facilities, nor do they need the advantages of special educational techniques.

The curiosity aroused by a child's prosthesis among his colleagues can be satisfied easily by a demonstration of the prosthesis and its functional attributes, supervised by either the teacher or the parents. Such demonstrations often will avoid the "Captain Hook" problem.

Follow-up

Children are growing individuals, and they grow both longitudinally and circumferentially. They are as nondiscriminatory in the care of their prostheses as they are in the care of their toys. This heavy-duty usage produces frequent mechanical breakdowns in their prostheses. Follow-up visits at intervals of three to six months are recommended, at which time the prosthesis may be repaired or replaced. If indications for retraining to produce new skills or eradicate faulty functional patterns are present, then this additional training program may be prescribed.

There are well-established schools of prosthetic education at three universities-the University of California at Los Angeles, New York University, and Northwestern University. These schools have facilities to train physicians, therapists, and prosthetists in the principles and techniques of properly managing acquired amputations. Increasing emphasis is being focused on the problems of the juvenile with an acquired amputation.

Summary

This report has attempted to summarize the principles governing the management of the child with an acquired amputation. These principles are based on experience with 718 children.

The juvenile amputee is different from the adult amputee, and we believe should be treated in a separate environment. It is recommended that their treatment be separated from general orthopedic clinics.

The technique of amputation surgery in children is similar to that in adults, but the levels of amputation are very different. In children, save all limb length possible; do disarticulations rather than supraepiphy-seal amputations wherever possible.

Bony overgrowth is the major postamputation complication in children. In our series, it occurred in approximately 11 percent of the cases. The treatment entails removal of the overgrowth and revision of the stump. Epiphysiodesis of the next proximal epiphysis is not indicated.

Upper-limb cases may be fitted at any age if the components of the limb are properly related to the child's motor development. Lower-limb cases should be fitted when the stump is mature and the patient evidences a willingness to stand and walk.

Modern prosthetic practices permit the fabrication of upper- and lower-limb prostheses for children of all ages. Standard limb components are commercially available in a sufficient variety of sizes to permit fitting at all ages. Children with acquired amputations, either upper or lower limb, should be fitted promptly with properly prescribed limbs. They should be trained in the use of the limb to a level of function that is commensurate with their age. They should be followed at frequent intervals commensurate with the need to make necessary repairs, maintain optimal mechanical efficiency, make corrections for longitudinal and circumferential growth, and lastly, to introduce additional training to correct faulty habits or produce more complex skills.

A child with a well-fitted prosthesis who has been adequately trained has great rehabilitation potential and deserves the best services we are capable of offering.

Acknowledgements

This article was originally prepared as narration for the film "The Child With an Acquired Amputation," which was reviewed in the November 1967 issue of the ICIB. The material has been freshly illustrated for purposes of this publication. The script for the movie on which this article is based was developed with the collaboration of Charles H. Frantz, M.D., and Claude N. Lambert, M.D. Their valuable assistance is gratefully acknowledged.

George T. Aitken, M.D. is the Medical Co-Director of the Area Child Amputee Center Grand Rapids, Michigan