LIMB DEFICIENCIES AND

AMPUTATIONS
MUHAMMAD UZAIR KHAN
10th semester
Ipmr-kmu

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The child with an amputation
 Is defined as a person with an amputation who is skeletally immature because the epiphyses of long
bones are still open.
 Amputations can be classified as congenital(60%) or acquired(40%).
Congenital limb deficiencies:
 Classifications: international society for prosthetics and orthotics ISPO classification is most
widely accepted based on anatomic and radiologic bases restricted to skeletal deficiencies.
 Transverse or longitudinal deficiencies.
 In transverse deficiencies the limb has developed to particular level beyond which no skeletal
elements exists. Digital buds may be present.
 In longitudinal deficiencies there is a reduction or absence of element or elements within long
axis of limb. Normal skeletal elements may be present distal to affected bones.

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Etiology:
 Limb buds development>4th week
 Differentiation into identifiable limb segments>up to 7th week
 Recognizable embryonic skeleton > by the end of 7th week
 Teratogenic factors must therefore be present at some time btw the 3 rd
and 7th weeks to produce a limb deficiency.
 Causative factors mostly unknow> genetic link and sporadic genetic
mutations.
 Teratogenic factors: thalidomide, contraceptives, irradiations,
disruption of blood supply in subclavian artery (in upper extremity).

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Levels of limb deficiency:
 The clinical presentation of child depends on type level and number of
deficiencies.
 20-30% children>more than one limb affected
 Transverse deficiency mostly unilateral, below-elbow most common in
females 2:1
 Proximal femoral focal deficiency(PFFD): includes hypoplasia of
proximal femur, with involvement of acetabulum, femoral head, patella,
tibia and fibula.
 May be unilateral or bilateral.
 Clinical presentation: shortened thigh flexed, abduct and ext rotated,
severe LLD, with foot often at level of opposite knee.
 Aitken classification: 4 classes A through D with class A exhibiting least
involvement based on radiographic findings.
 Group A require limb lengthening while B and C will require some level of
amputation or revision and prosthetic fitting(Gillespie). 7
Acquired amputations:
 Account for 40% of childhood amputations.
 Can be traumatic(vehicular accidents, power tools, machinery, gunshot wounds) and disease
related( osteosarcoma and Ewing's sarcoma).
 medical management of malignancies: radiation therapy and chemotherapy.
Surgical Options:
Amputation in the management of Traumatic Injuries and Malignant Tumors:
 Factors to be consider before amputation are skeletal immaturity and future growth(preserve physes
to ensure future growth), terminal overgrowth(painful, spike like prominence of new growth of
residual limb) and wound healing.
 Acquired amputations may result in short residual limb e.g. above knee amputation.
 Limb lengthening technique: use to increase length of limb, increases the efficiency of gait and
promote better prosthetic fit.
 For malignant tumors amputation is done 6 to 7 cm above the extent of tumor to allow for removal
of microscopic tumor.
 In malignant tumors of proximal humerus, pelvis and proximal femur, amputation results in severe
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loss of function.
Amputation to revise congenital limb
deficiencies to improve function:
 Mostly indicated for lower extremity deficiencies.
 If limb lengthening is not an option one of the surgical option for PFFD is knee
arthrodesis and foot amputation.
 Syme and Boyd amputations; Syme amputation involve complete removal of foot
including calcaneus while Boyd preserve calcaneus.
 The knee is usually fused to form one long bone for fitting of above knee prosthesis.
 If tibia or fibula absent in longitudinal deficiencies and significant LLD is present with
ankle joint instability the knee disarticulation and fitting with a prosthesis will
provide very functional lower extremity.

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Rotationplasty:
 Is a typical option for child with congenital limb deficiencies e.g. PFFD, as well as
for those with bony tumors of the proximal tibia or distal femur.
 This procedure involve excision of the distal femur and proximal tibia, 180°rotation
of the residual limb and reattachment of proximal femur with distal tibia.
 the ankle then function as a knee joint with ankle plantar flexion use to extend the
knee and dorsiflexion to flex the knee.
 Advantages: of a rotationplasty are the increase in limb length, improved prosthetic
function, improved weight bearing capacity, and elimination of problems of
terminal overgrowth and pain from neuromas or phantom limb sensation.
 Disadvantages are cosmetic and derotation of the foot because of spiral pull of the
muscles.

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Rotationplasty:

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 Limb sparing procedure:
 Limb sparing procedure involve resection of the tumor and reconstruction of the limb to preserve function
without amputation of the limb.
 Reconstruction involve excision without replacement, or replacement with an allograft or endo prosthetic
implant.
 Contraindicated if tumor has invaded the soft tissues, neurovascular supply or intramedullary cavity to a
large extent.
 It may not be beneficial when the child is skeletally immature.
 Bone grafts may be autologous or allografts.
 Osteoarticular allografts stabilized with plates or intramedullary rods until osteosynthesis has occurred.
 Infections, nonunion and fractures are rare with allografts than metallic endo prosthetic implants.
 Athletic participation are limited in child with Osteoarticular allografts.
 The tikhoff-linberg procedure: for tumors involving proximal humerus.
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 Endo-prosthetic devices:

 An extension of joint arthroplasty.

 Implanted in the area of excised bone and can be custom designed.
 Some designs incorporate a telescoping unit that can be expanded to
accommodate growth.
 Expansion of prosthesis involve surgical procedure at periodic interval.
 Some endo-prosthesis can be expanded with the use of an electromagnetic
field.
 Problems include loosening of prosthesis, infection, and mechanical failure of
the device.

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 Limb replantation:
 For children with traumatic amputations.
 Preserve amputated limb.
 Restoring pain free function.
 Distal replantation favors more than proximal.

Physical therapy:
wound care
control of edema
ROM
strengthening
gait training
self care activities

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Upper extremity prosthetics

 Body powered or externally powerd

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 Lower extremity prosthetics:
 Many prosthesis are available which accommodates some growth and can be
replaced as the child grows. Examples are
 SACH foot, dynamic response or energy storing feet.
 Shank of lower extremity prosthesis is either exoskeleton or endoskeleton.
 Single axis constant friction knee function at constant speed.
 Polycentric knee mimics anatomic knee joint to increase stability.
 Knee units with variable friction allow variable walking and running speeds.

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 Physical therapy intervention:
Rehab team:
 Orthopedist,
 Prosthetist
 Physical therapist
 Parents
Goals of physical therapy:
 Facilitate normal sequence of development.
 Prevent or minimize the development of impairments, activity limitations and participation restrictions.
 Preventing joint contractures, weakness with activity limitations and lack of independence in self care
skills.
 Minimizing muscles imbalances.
 Preventing skin breakdown.
 Developing independence with mobility and self-care skills.

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 Infancy and toddler period:
 Initial examination shortly after birth by orthopedist and physical therapist:
 Positioning and ROM and strengthening exercises initially.
 Prevention of flexion and abduction contractures in child with PFFD.
 Increasing functional strength and weight bearing capabilities.
 Posture correction while prone, sitting and standing.
 Provide therapy to encourage weight-shifting activities to improve symmetry.
 Instruction of parents in proper donning of prosthesis, in checking the skin
and in developing a wear schedule.
 Instructing the child to use terminal devices to engage in bimanual play and
reaching activities

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 Preschool and school-age period:
In preschool years rehabilitation should emphasize
 development of self-care skills
 Mobility or gait training
 Acquisition of school skills such as coloring cutting and writing.
 To learn control of different prosthetic devices e.g. a constant-friction knee.
For the child with acquire amputation, physical therapy examination and evaluation focuses on
 sensitivity of residual limb,
 active movement,
 strength,
 bed mobility and
 ambulation
Children undergoing chemotherapy must be monitored for
 developing contractures and
 loss of strength due to extreme illness. 21
 Preschool and school-age period:
Rehabilitation of Child with a limb sparing procedure includes:
 Exercise through active movements
 Progression to strengthening exercises
Gait training at this age will focus on:
 Symmetry
 Normal characteristics of gait such as stride length, step length, velocity and
all skills to participate in games
 Running techniques

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Adolescence and transition to
adulthood:

 The immediate postoperative concerns and physical therapy intervention for

adolescents undergoing an amputation or a limb-sparing procedure are similar
to those described for school-age children.

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