Chapter 34A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
Upper-Limb Deficiencies: Surgical Management
Terry R. Light, M.D.
The birth of a child with an upper-limb deficiency leads to a myriad of confusing parental emotions. Parental concerns and expectations must be dealt with in an honest and forthright fashion by both the physician and the prosthetist caring for the child. Most parents have feelings of guilt and grieve that their infant is not as perfect as they had anticipated through the course of the pregnancy. Many parents feel an intense need to "do something," either surgical or prosthetic, to make their child "normal" and whole. Conflicting advice from well-meaning friends and relatives may create further parental tension and confusion.
Initially, many parents seek a cosmetic prosthesis that will conceal their child's abnormality without regard to its functional impact. The predictable lack of success when a purely aesthetic prosthesis covers sensate skin in the hand should be openly discussed. As parents observe their growing child functioning without a prosthesis, they gradually understand the potential encumbrance of a purely cosmetic prosthesis. Although an aesthetic prosthesis may aid the rehabilitation of the traumatic amputee, it is usually a hindrance to the congenital amputee. If prosthetic wear becomes a source of conflict between parent and child, the child may even express the thought that the prosthesis is to be worn merely to please parents who cannot accept them as they really are-without a prosthesis. If an active prosthesis is to be successfully integrated into the child's life-style, it must provide the child with the ability to either accomplish otherwise impossible activities or to carry out activities more easily or more rapidly. At times, cosmetic restoration, particularly in partial hand and foot loss, may be considered a functional improvement.
The hand allows the child to explore his environment and manipulate objects within that environment. The hand should be able to maneuver in space under volitional control and should be able to reach the body as well as the area in front of the body. The child must be able to aim the hand so that it can precisely approach an object by using visual as well as tactile clues. The object is then grasped by the closing fingers and supporting thumb. The hand must also be capable of releasing the object from its grasp.
The two major types of grasp are precision prehension and power prehension. Precision prehension is used to hold relatively small objects with modest force, while power prehension is used to hold larger objects, often with somewhat greater force. In precision prehension, the object is secured between the distal phalanx of the thumb and the index finger or between the thumb, index, and middle fingers. The fingers are usually extended at the interphalangeal joints while the metacarpophalangeal joints are partially flexed. The object itself usually does not contact the palm.
The three most common forms of precision grasp or pinch are palmar pinch, lateral pinch, and tip pinch. In palmar pinch the flat palmar pads of the thumb and fingers secure opposite sides of the object being grasped. In lateral pinch the palmar surface of the thumb's distal phalanx is brought against the radial border of the index finger. Since this posture is often employed to grasp and twist a key, this pattern is also known as key pinch. Tip pinch provides contact with the distal end of the distal phalanx of the thumb with the distal phalanx of the index or of the index and middle fingers. Tip pinch is used to pick up a small coin from a table top.
Power prehension involves the ulnar digits (most often ring and little fingers), while the radial digits (index and middle fingers) are primarily used in precision prehension. Power grasp usually results in contact of the object against three surfaces: the palmar aspects of the flexing fingers, the palm of the hand, and the thumb metacarpal or proximal phalanx. Although the distal phalanx of the thumb may wrap around the object, the majority of the thumb power is contributed by the stabilizing effect of the adductor pollicis, which resists the pressure transmitted from the fingers through the object.
The hand also has an important role in nonprehensile activities. These activities usually involve the transmission of force through the terminal portion of the limb to another object. Nonprehensile activities include typing or button pushing. Other nonprehensile activities include the punch thrown by a boxer or pushing open a swinging door.
As one considers the treatment of an anomalous hand, it is well to contrast the effectiveness of surgical reconstructions with or without prosthetic management as opposed to doing neither. Nonprehensile activities are usually unaffected by surgical reconstruction. If a hand lacks a thumb (e.g., radial aplasia) and digital motion is good, side-to-side pinch will allow the child to perform most precision activities with reasonable facility. Without the buttressing effect of a thumb, however, power activities cannot be readily accomplished. Compensation may be achieved by flexing the fingers and wrist and securing a large object against the distal portion of the forearm. When the thumb is absent, shifting the index finger to the thumb position by polli-cization will improve power grasp as well as facilitate precision activity.
The monodactylous hand consisting of only a thumb is capable of nonprehensile activities such as holding a shoe lace in place but is incapable of either power or precision grasp. Construction of an ulnar-buttressing digit by either distraction lengthening, toe-phalanx transfer, or free-toe-transfer may allow the hand to achieve meaningful prehension. This may also be achieved by a prosthesis that provides a passive buttress.
The infant is unaffected by his abnormality. As the baby begins to explore its environment, it learns to use its unique physical capabilities to best advantage. The young child's goal is to reach the cookie, grasp it, and bring it to its mouth. If this is most easily accomplished by one hand, the closest or most efficient hand will be employed. If the object is large or if single-hand prehension is not possible, then both hands will act together. The object may be secured against the chest. When upper-limb prehension is severely compromised, a child may develop the capacity for foot prehension.
The child's growing awareness of his abnormality is usually the result of comments from playmates, siblings, or well-meaning adults. The child usually does not become self-conscious until about the age of 6 or 7 years. At this age peer pressure may cause the child with a unilateral abnormality to conceal the hand in a pocket or may lead the child to reject an otherwise successful prosthesis.
Other points of psychological stress occur during adolescence as dating begins and concerns arise over attractiveness to the opposite sex. Feelings may be further complicated by impending marriage and the prospect of offspring with similar abnormalities. Access to knowledgeable genetic counseling is essential, particularly at that time.
Aesthetic considerations are important when weighing different therapeutic alternatives in the management of congenital hand abnormalities. The hand and the face are the unclothed areas of skin most often exposed to scrutiny. When anomalous parts have an abnormal appearance and function is not compromised by their deletion, they should be removed. In this case, conversion of a malformed part to an amputation may result in an aesthetic improvement.
On occasion, the removal of a functionless part may facilitate the fitting of a prosthesis. While approximately half of lower-limb congenital amputees require surgical revision prior to prosthetic fitting, only about 10% of congenital anomalous upper limbs fit for prostheses require surgical revision. Consultation between the surgeon and prosthetist allows the surgeon to understand which anomalies will obstruct prosthetic donning and wear. Portions of the affected limb that are useful for prehension without a prosthesis should never be amputated. It is possible to fit a prosthesis around a short phocomelic limb. This will allow the child to also develop functional capabilities out of the prosthesis. In some instances, the prosthesis may allow digits to function while the prosthesis is worn.
It is usually preferable to begin surgical reconstruction of the anomolous hand prior to or about the first birthday. Anesthesia can usually be safely accomplished by 6 months of age. For children under 18 months of age, it is possible to operate on both hands during the same surgical anesthetic. As the child ages, their frustration when both hands are immobilized increases. In addition, early bilateral surgery may spare the child an additional anesthetic.
Some procedures such as toe phalanx transfer must be carried out early for revascularization and subsequent growth. Children undergoing digit-shifting procedures such as pollicization may benefit from early integration of the pollicized digit into evolving patterns of grasp.
In some instances, it is wise to delay surgery until children are older because of systemic considerations. In children with TAR syndrome (thrombocytopenia with absent radius), in whom low platelet counts at birth gradually increase with age, it is usually wise to wait until the child's platelet count has increased to at least 60,000/mm before considering elective surgical reconstruction. In such cases, centralization of the wrist may sometimes be delayed until the child is 3 or 4 years of age.
It is best to make major decisions regarding the reconstruction or deletion of digits when children are young. It is inappropriate to place the burden for deciding whether a digit is to be deleted or pollicized upon an adolescent. The parental temptation to wait until the child is older to let them make up their own minds should be avoided since this places unrealistic pressure on the adolescent.
SHORT TRANSRADIAL AMPUTATION
This common level of terminal deficiency is effectively treated prosthetically. Surgical reconstruction is rarely indicated. Initial prosthetic management begins with a passive hand. The sophistication of the prosthesis is increased as the child matures.
The Krukenberg procedure has been suggested as a reconstructive alternative for children with congenital absence of the hand, particularly with profound contralateral abnormalities, associated blindness, or a lack of access to prosthetic care. The radius and ulna are separated from one another by the Krukenberg procedure. This creates a prehensile limb that will also allow prosthetic fitting. Because the cosmetic disadvantage of this procedure is substantial, it is rarely appropriate for the unilateral case (see Chapter 36A).
Syndactyly, the joining together of digits, may be categorized as complete or incomplete, with subcategories of simple or complex. When syndactylization extends the entire length of the digit, the condition is termed complete syndactyly. In cases in which the web involves only a portion of the length of the digits, it is termed an incomplete syndactyly. When skeletal and nail elements of the syndactylized digits are separate, the syndactyly is said to be simple. When there is joining of digital skeletal and/or nail elements, the syndactyly is termed complex. Acrosyndactyly refers to syndactyly in which the ends of the fingers are joined, often as a result of congenital constriction band syndrome. Dobyns et al. have further suggested that syndactyly of digits containing angulated phalanges be termed complicated syndactyly.
Surgical release of syndactylized digits is usually indicated to enhance digital independence. Even short digits consisting of only a proximal phalanx may benefit from separation. Index finger radial abduction may be increased and pinch improved when a short index finger is untethered from the middle finger.
Syndactyly release must provide skin coverage of the adjacent lateral surfaces of the released digits and also create a proper web space floor. Because the surface area of two syndactylized digits is far less than the skin surface area of two separated digits, a full-thickness skin graft is necessary to supplement local flaps.
Many skin flap techniques have been advocated for the separation of syndactylized digits.Successful surgical procedures surface both digits with durable skin, create an appropriate web space floor, and accommodate growth of the digit without secondary contracture (Fig 34A-1.,A and B). Effective techniques employ skin flap tissue to create a sloping web space floor of true anatomic proportions, both in width and depth. This flap tissue may be derived either from the dorsum of the hand, from the palmar aspect of the hand, or from a combination of both palmar and dorsal tissue. Dorsal flaps provide the best skin color match when the web space is viewed from the dorsum but may result in a hypertrophic scar traversing the inter-digital commissure. A palmar flap provides a better commissure contour but results in the shifting of pink palmar skin into the web space. Since the web space is usually viewed from the dorsum, the difference in color is particularly noticeable in dark-skinned individuals.
The web space floor normally begins just distal to the metacarpophalangeal joint and slopes to the edge of the palmar commissure approximately one third the length of the proximal phalanx segment. The web palmar commissure is supple enough to allow interdigital abduction of up to 45 degrees.
Skin incisions on the palmar and dorsal surfaces of the syndactylized digits should be planned to avoid longitudinal scars crossing digital flexion creases because these scars tend to contract with growth. Zigzag incisions may be planned to interdigitate skin flaps and defects to effect either full closure of one digit or partial closure of two adjacent digits.
After the web space floor has been closed and digital flaps rotated into place, templates are made of the residual defects. Templates are used to harvest full-thickness skin grafts from the groin crease. Skin grafts are sutured in place. Interdigital dressings are maintained until all wounds have healed.
When multiple digits are syndactylized, it is usually wise to avoid releasing both sides of a digit during the same procedure.
Polydactyly takes many forms. In black children, post-axial (ulnar) Polydactyly is the most common form, while in white children preaxial (radial) Polydactyly is more frequent. Central Polydactyly is less common than either preaxial or postaxial Polydactyly. Polydactylous digits are rarely supernumerary, that is, they rarely represent parts additional to a normal hand. Most often polydactylous digits are abnormal and suggest an abnormal segmentation or separation of digital ray condensations, as though one or more of the five mesenchymal condensations was inappropriately longitudinally split. The challenge of surgery is not simply to remove sufficient tissue but rather to retain tissue sufficient to optimally reconstruct the retained digits.
Simply amputating one of the duplicate digits will usually result in a residual digit that is considerably smaller than its counterpart on the opposite side. This effect can be lessened by soft-tissue coaptation (Fig 34A-2.,A and B). Incisions are planned to facilitate the coapting of soft tissues from both digits to provide optimal soft-tissue bulk. Angular deformity in either phalanx or metacarpal should be corrected by osteotomy. Surgical reconstruction aims to achieve a digit in which the carpometacarpal, metacarpophalangeal and inter-phalangeal joints are parallel. The longitudinal axis of the metacarpal and phalanges should be perpendicular to the three joints. Correction of angulation is usually achieved by a closing wedge osteotomy and secured by Kirschner wires. An opening wedge osteotomy using a segment of excised bone as intercalated graft is occasionally indicated.
Preaxial Polydactyly takes many forms. Wassel has separated these abnormalities into seven categories, six of which involve biphalangeal thumbs (Fig 34A-3.). Type I deformities may present as simply a wide distal phalanx and nail, in which case no treatment is indicated. If two nails are present, two alternative treatments may be considered. The first option is excision of one nail with the underlying bone, while the second involves a central resection of adjacent nail borders and underlying bone, combined with longitudinal phalangeal osteotomies to narrow the distal phalanx. When the latter technique, known as the Bilhout-Cloquet procedure, is attempted, care must be exercised in matching the nail matrix to avoid an unsightly longitudinal nail ridge. Osteotomies should be carried out distal to the physis to avoid growth disturbance.
Type II duplications consist of two undersized (in comparison to normal) distal phalanges seated atop a somewhat widened proximal phalangeal distal articular surface. The radialmost digit possesses a collateral ligament along its radial border, while the ulnar digit possesses a collateral ligament along its ulnar border. The two digits abut with adjacent articular facets and are bound together by pericapsular tissue. It is preferable in most instances to excise the more radial digit because it is usually less well developed. The broad distal articular surface of the proximal phalanx may need to be tapered to a size appropriate to the distal phalanx. The collateral ligament that initially secured the radial aspect of the deleted radial digit must be retained to securely stabilize the radial aspect of the new interphalangeal joint. Retained flexor and extensor tendons must be examined to ensure that the course and insertion of residual tendons are centered.
Type III abnormalities are usually dealt with by deleting the radial digit. Type IV abnormalities usually require deletion of the radial digit, narrowing of the metacarpal head, and collateral ligament reconstruction. The intrinsic muscles that originally inserted into the more radial thumb are reinserted into the hood of the residual ulnar thumb component.
Type V abnormalities usually require deletion of the more radial digit and reinsertion of the intrinsic muscle insertion into the residual ulnar digit. Type VI abnormalities may require shifting of the more distal portion of the radial digit onto the more proximal portion of the ulnar digit.
Central Polydactyly often presents in combination with syndactyly. Frequently an anomalous central digit will be bound to the middle or ring fingers without normal metacarpal development. In such instances the skeletal elements of the unsupported digit are excised, and skin flaps are designed to preserve or reconstruct normal web space contour and digital bulk. When formal ray resection is required, web space-preserving incisions should be selected.
Postaxial Polydactyly of the digit joined only by soft tissue may be treated by simple excision. When the most ulnar digit articulates with the metacarpal head in a fashion similar to that in the Wassel type IV thumb duplication, simple digital excision will result in an inadequate residual digit. It may be necessary to narrow the metacarpal head, but it should be recognized that the little-finger metacarpal head, unlike the thumb metacarpal head, contains a physis and that care must be taken to preserve physeal growth. If the hypothenar musculature inserts into the more ulnar little finger, its insertion must be detached from the skeletal elements being resected and reinserted into the retained radial little finger. Similarly, the ulnar collateral ligament of the deleted digit must be retained and reconstructed to stabilize the ulnar aspect of the residual little-finger metacarpophalangeal joint.
The mirror hand is an unusual abnormality in which there is duplication of the postaxial border of the hand with seven or eight digits and two ulnae. Neither the thumb nor the radius is present. Surgery is useful in expanding the arc of elbow flexion and extension but does not gain forearm rotation. Because there is an overabundance of flexor musculature and relative paucity of extensor musculature, wrist flexion release may be necessary. Deletion of two or three digits with pollicization of one of the digits along the "preaxial" border will improve the aesthetic appearance of the hand and modestly improve function.
The radial-deficient upper limb demonstrates a variable extent of radial absence, aplasia, or dysplasia of the soft-tissue and skeletal elements along the radial (preaxial) border of the limb. When the radius is absent or severely dysplastic, the unsupported carpus will rest against the radial border of the ulna and cause the hand to assume a posture at a right angle to the ulna. The thumb is frequently absent or, if present, is dysplastic. The more radial digits are often stiff with limited active flexion. Because the ring and little fingers are the most supple digits, they are frequently used for side-to-side prehension. The tendency to use a pattern of ulnar prehension is usually a consequence of the greater mobility in the ulnar digits and their position as the presenting part of the deviated hand as it is brought in front of the trunk.
Beginning shortly after birth, the hand is splinted in an effort to stretch radial soft tissues. Surgical centralization stabilizes the hand at the end of the forearm by placing the hand and carpus on the end of the ulna(Fig 34A-4.,A-D). Centralization allows the hand to reach out away from the body, more effectively placing the radial digits in front of the body. The excursion of extrinsic digital flexors and extensors may be focused upon digital motion and not frustrated by collapse of the hand and wrist at the ulnocarpal level.
Although centralization does improve function in front of the body, it is not always indicated. If active elbow flexion is lacking, the abnormal radial deviation at the ulnocarpal level provides the child with the ability to bring the hand to the face. Because centralization frustrates this function, it is contraindicated if elbow flexion is lacking.
The normal thumb participates in a wide variety of both precision and power prehensile activities. The hand without a thumb is nonetheless capable of great dexterity. Side-to-side pinch between fingers allows precision activity to be accomplished with relative facility. Normally, when an object is grasped in power prehension, the object is forced against the palm by the flexed fingers and buttressed by the stability of the thumb metacarpal. The ability of the individual without a thumb to hold large objects securely is thus markedly compromised. Large objects can be held securely only by using both hands together or by flexing the wrist and securing the object against the forearm or body. Pollicization shifts the index finger from its normal position to the thumb position along the radial border of the residual hand so that it can participate in power as well as precision activity. This shifted digit, however, is not a normal thumb.
If the index and middle fingers were used for precision pinch prior to surgery, it is likely the pollicized index finger will continue to participate in precision activity against the middle finger. If the predominant pattern of precision prehension was between the middle and ring fingers or between the ring and little fingers, it is likely that this pattern will persist after polli-cization. In such situations the functional advantage of pollicization is realized only with power activity.
Pollicization consists of four major elements, the skin incision, neurovascular dissection, skeletal adjustment, and musculotendinous rebalancing. Skin incisions are designed to create a web space between the shifted digit and the middle finger and to allow digital transposition without the need for skin grafting (Fig 34A-5.). Neurovascular structures are preserved by ligating the proper digital artery to the middle finger and splitting the common digital nerve to the index and middle fingers. Care must be taken to preserve dorsal venous drainage of the digit. By resecting a major portion of the metacarpal, including the physis of the metacarpal head, the resultant digit will be of a length similar to that of a thumb. The metacarpophalangeal joint of the index finger is hyperextended and secured to the residual proximal metacarpal. Musculotendinous balance is achieved by advancing the first dorsal interosseous and first palmar interosseous muscle insertions into the hood and by shortening the extensor extrinsic tendons. Shortening of the flexor tendons is not required. Spontaneous use of the digit is usually noted within a few months and continues to improve as the child ages.
The ulnar-deficient hand is characterized by an absence or hypoplasia of the ulna. Ectrodactyly is usually present and may be manifested in the absence of any of the fingers, including the thumb. Syndactyly is common, particularly between the ring and little fingers, and should be treated in the fashion described earlier in this chapter. The wrist is usually stable and rarely requires surgical intervention. The elbow may be stiff due to radiohumeral synostosis. In some instances, if the hand is positioned behind the body, osteotomy of the radius is indicated to bring it into flexion (Fig 34A-6.). Another problem is the presence of severe flexion contracture of the elbow. Because surgical releases are usually limited by tight neurovascular structures, serial splinting or Ilizarov joint stretching have been employed to improve joint motion.
Confusion exists regarding the appropriate classification of children with a normal-length radius and ulna and absence of the central (index, middle, and/or ring) fingers. The typical cleft hand or split hand is usually bilateral and may be associated with bilateral cleft-foot abnormalities and an autosomal dominant inheritance pattern. Morphologic variation is common. Digital absence, digital fusion, cross bones, syndactyly, and distal Polydactyly may all be evident within affected hands. Because the morphology of this condition may vary considerably from the right to the left side and from one generation to another, cases in which a true cleft is not evident are often overlooked.
Digits frequently diverge from the central cleft with ulnar deviation of the ring and little metacarpals and radial deviation of the middle and index metacarpals. The index metacarpal is often deviated toward the thumb metacarpal, thus creating a narrow first web space. Syndactyly is frequently encountered, particularly between the ring and little finger. Syndactyly should be released as previously described. Metacarpal osteotomies may be necessary to gain parallel alignment of metacarpals at the time of web space closure (Fig 34A-7.,A and B). In many instances, a flap derived from redundant skin in the central cleft may be rotated into the first web space at the time of first-web space release.
Treatment of the hand with short digits (brachydac-tyly) or absent digits (adactyly or ectrodactyly) engenders much debate (Fig 34A-8.). Since these abnormalities are usually unilateral, affected children possess considerable physical capabilities without surgical or prosthetic intervention.
When digital soft-tissue sleeves are substantially longer than the enclosed skeletal elements, the skeleton may be lengthened by a nonvascularized toe phalanx transfer. The proximal phalanx of the third or fourth toe is "harvested" with its proximal volar plate and collateral ligaments. The toe phalanx is then secured in the finger sleeve by Kirschner wires and by suturing the volar plate and collateral ligaments to the intact proximal skeleton. Rudimentary flexor and extensor tendons may be defined and sutured to the palmar and dorsal aspects of the transferred phalanx. Although these transferred phalanges are more likely to continue to grow after transfer if the procedure is carried out between 6 to 12 months of age, the procedure may still be beneficial in older children. Toe phalanx transfer is particularly helpful when the thumb lacks phalanges or when the thumb is present along with metacarpals but the fingers lack phalangeal elements to pinch against.
Free-tissue microvascular transfer of the second toe or of the second and third toes together has been employed to augment hands without digits or digital soft-tissue sleeves. Vascularized toe transfers continue to grow until skeletal maturity and yield a digital length approaching the predicted length of the toe. The digit will retain the form of a toe and at best will have the range of motion of a toe. In most instances of adactyly, the proximal musculature is poorly defined with restricted excursion. When these musculotendinous units are sutured to a free-toe transfer, the resultant digital motion is often quite limited. It is rarely worthwhile to attempt to achieve prehension in an adactylous hand by transfer of two separate digits. When a well-controlled thumb is present without other digits, there may be benefit in transferring a toe to the hand to provide counterpressure to the thumb and thus achieve prehension.
In some cases of brachydactyly, resection of the index or of the index and middle metacarpals may enhance prehension through "phalangization," a procedure in which prehension is shifted proximally to facilitate grasp between the thumb, ring, and little metacarpals.
CONGENITAL CONSTRICTION BAND SYNDROME
Congenital constriction band syndrome has many manifestations (Fig 34A-9.). These include band indentation, distal edema, acrosyndactyly, and/or amputation of distal parts.
Bands that encircle a limb or digit may result in distal edema. Surgical treatment requires excision of the indented skin and of any deep fascial constricting tissue. The skin is closed after Z-plasty flap transposition.
Syndactyly release is described in the preceding section on syndactyly. Although a sinus with a web space floor is often present, this web space floor is situated too distally and will require formal release to bring the web space to the appropriate proximal level. Syndactyly usually is the result of a failure of normal interdig-ital web space resorption during embryonic development. When syndactyly occurs in association with congenital constriction band syndrome, however, a sinus is usually evident proximal to the area in which the skin is joined. This form of syndactyly is termed ac-rosyndactyly or fenestrated syndactyly. In developmental syndactyly, adjacent digits are joined side to side in a fashion similar to the intrauterine embryonic paddle form. In acrosyndactyly, however, noncontiguous digits may be joined. The index finger might be joined to the ring finger, while the middle finger is forced palmar or dorsal to the distally webbed digits.
When amputation occurs as a result of congenital constriction band syndrome, the amputation may occur at the joint, metaphyseal, or diaphyseal level. Diaphyseal amputations usually occur through hand or foot phalanges or through the tibia. The resultant tapered ends may require revision in adolescence or adulthood because of the propensity of these amputations to appo-sitional overgrowth.
Although lower-limb amputation through the tibia occurs occasionally, amputation through the arm or forearm is rare as a result of congenital constriction band syndrome. Deep indentation from band constriction at the humeral level may result in an insensate paralyzed hand of no functional value and subject to repeated infection. In some instances these hands may be amputated electively. Prosthetic fitting of such limbs may be complicated by the insensitivity of the residual forearm.
When thumb length is insufficient for prehension due to congenital constriction band amputation, second-toe or hallux transfer may provide effective augmentation of the thumb (Fig 34A-10.,A and B). Because the blood vessels, nerves, and musculotendinous structures proximal to the level of the amputation are normal, satisfactory ultimate neural, vascular, and motor function may be anticipated. The transferred toe will continue to grow as the child's hand grows.
Children with upper-limb deficiencies may benefit from surgical reconstruction. The surgeon should consider both functional and aesthetic impact. In most instances, prosthetic fitting does not require surgical modification of the upper limb, that is, prostheses should be fabricated to fit the limb as it is. In other words, function of the residual limb out of the prosthesis should not be compromised in an attempt to simplify prosthetic fitting since children may spend considerable periods of their day without their prosthesis.
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Chapter 34A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles