Atlas Of Amputations And Limb Deficiencies Pdf Free Download
Avice Michonski
In each particular patient case, the surgeon faces many decisions and has considerable latitude exercising personal judgement. Weighing and measuring all options requires thoughtful and thorough consideration. The initial and most basic decision is the choice between amputation versus attempt to salvage. Once amputation has been decided upon as the course of action, preoperatively the surgeon must determine the most distal level of amputation still compatible with wound healing and subsequent satisfactory prosthetic fitting. Selecting this level requires detailed clinical evaluation combined with laboratory and radiographic studies. Except for those few levels that will be specifically discussed in later chapters, in most amputations the surgeon will select the most distal level consistent with successful removal of the diseased state. The surgeon must bear in mind the degree to which the remainder of the appendage can provide a well-healed, non-tender physiologic residual limb. Conservation of residual limb length is a basic principle of modern amputation surgery.
Along with fasciocutaneous flaps and free flap techniques, skin grafts are a viable option in modern amputation surgeries and prosthetic fittings. It is possible for split-thickness skin grafts to hold under the forces applied by a prosthesis, but grafts will be most successful when not adherent to bone. Application of the graft over a cushioned, mobile muscle bed is ideal. However, without the fine layer of subcutaneous fat to absorb shear, grafts are not as durable as normal skin. Fortunately, liners made of elastomeric materials have improved prosthetic success for individuals with scar and skin graftings. This is of particular help for burn victims, as amputations in burned limbs often require skin grafts. The grafted skin and burn tissue will become more pressure tolerant over time if the shear and skin stretch are moderated by careful prosthetic fit and the introduction to the prosthesis is gradual. The amount of time wearing the prosthesis, the amount of force applied and activity levels must be carefully controlled and slowly calibrated forward. Over a period of many months the badly burned limb with amputation and free graft coverage may develop a tolerance that can provide optimum function. Such patients can often use prosthetic devices successfully and thereby avoid amputation at a higher level.
The forces traveling between prosthesis, residual limb and the remaining body are in large part transmitted through the retained bone in the amputated limb. Diaphyseal bone should be sectioned at the length consistent with reconstructive soft tissue closure. Managing the edges of severed bone is essential to pain-free healing, and the sharp cortical bone edges and irregularities should be carefully contoured and rounded. In each amputation case, bone transection and shaping should take into account the available prosthetic devices for that particular level of amputation. Preoperatively, the surgeon must be sufficiently familiar with the most frequent bone related problems at each level in order to minimize future woes. For example, in transtibial amputations, anterior beveling to remove the distal corner of the tibia is one method of proactive management. Removing the distal plantar corner of the calcaneous in a hindfoot amputation is another example of a preemptive strike against future complications.
Limb loss is, however, especially devastating whenever it happens to a child. Sometimes, limb loss in children results from birth defects, cancer or severe infections. In other cases, a traumatic injury from a lawn mower or traffic accident is the reason. Limb loss deeply affects the child and his or her brothers and sisters. It is especially difficult for the parents. Everyone becomes involved in issues concerning surgery, recovery and rehabilitation. The goal of this three-part series is to provide insights about congenital limb deficiencies and acquired amputations in childhood that will be helpful to parents, children and pediatric healthcare professionals.