UPPER LIMB

There are differences in the approach, acceptance, and management of the upper limb amputee versus the lower extremity amputee. Despite significant and ongoing improvements, upper limb prosthetic devices do not yet replace the sensory function of the hand, and are best considered as a mechanical tool (87). The hand is used to explore the environment and to manipulate objects within it. The hand needs to reach the body and precisely approach an object, grasp, and then release it. Acceptance of the prosthesis is variable (88). Frequently, the exposed skin of a residual limb is preferable to an encased limb. Stump sensation may even be enhanced to compensate for the loss of prehensile area (89). In ipsilateral congenital limb deficiencies, issues with organogenesis can occur and may require further evaluation; however, bilateral limb deficiencies may be associated with craniofacial abnormalities (8). Scoliosis occurs frequently in this population, but rarely requires surgical correction (90).

COMMON UPPER LIMB DEFICIENCIES

Digital Deficiencies

Digital deficiencies are common but rarely present in isolation. Removal of additional digits and intervention with Z-plasty procedures produce acceptable results for children with Polydactyly and syndactyly, respectively. Amniotic band syndrome or Streeter's dysplasia commonly presents with digital constriction banding, though the etiology of this condition remains controversial. In addition, other anomalies may be present, ranging from evidence of other banding, to craniofacial clefting (in 78%) or abdominal to one or more lower limb amputations (in 70%), and abdominal wall, spine, or thorax (in 52%) that have occurred in utero (91). Hand impairments can be attended to if they affect the child's ability to perform activities of daily living (ADLs) or don and doff a lower extremity prosthesis (92).

Etiologies such as Moebius syndrome and Poland syndrome (sequence) result in digital deformities associated with a more serious underlying condition. Moebius syndrome often affects the sixth and seventh cranial nerves, which compromises the child's ability to visually follow objects, swallow, and communicate. In addition to hand anomalies, Poland syndrome involves a partial absence of the ipsilateral pectoralis muscle and hypoplastic chest; therefore, a more proximal evaluation of any distal absence of limb is indicated.

Absence of individual digits creates a multitude of surgical and nonsurgical options. These include no intervention, therapy to enhance hand function, pollicization, or toe transfers. Due to the physiologic function of the normal thumb, hand impairments can vary widely, depending upon which digit(s) is/are absent. There is often greater consideration for surgery and function if the thumb is absent. Pollicization to the most radial digit can provide oppositional grasp (93). Through this microsurgery procedure, children can achieve remarkable functional improvement with improved cosmesis (94). Toe transfers can be transplanted from the second or third ray and minimize effects on gait mechanics (95,96).

Partial Hand and Wrist Disarticulation Deficiencies

Partial hand deficiencies are quite common and are often treated as wrist disarticulation level limbs. Very small underdeveloped vestigial digits, sometimes referred to as nubbins, are present in a majority of these cases, as is shortening of the ipsilateral radius and ulna. These vestigial remnants are rarely problematic, nor do they need to be surgically removed. The child can be quite functional with no intervention, and these remnants may enhance tactile input. The major functional drawback of this particular limb length is the inability to perform prehensile tasks with the involved limb, though the adaptability of the child can be remarkable. Plastic surgeons may be consulted for digit- and hand-level deformity.

 
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