Abstract
The aim of this study is to determine the demographic data for amputations in children in relation of age, sex, level and cause of amputation. Data were collected from the records of amputees who attended the prosthetic clinic at the Royal Rehabilitation Center, King Hussein Medical Centre, Jordan, between 1 January 1995 and 31 December 2005. Demographic data (age, sex, level and cause of amputation) were analyzed. Some120 children with different levels of amputation were included with mean age of 6.2 years. There were 64 (53.3%) males and 56 (46.7%) females. Male to female ratio was 1.15:1. The dominant level of amputation was trans-radial in 10 patients (15.62%) in the upper limb and trans-tibial in 18 patients (28.12%) in the lower limb. The dominant cause of amputation was congenital deficiency in 56 patients (46.67%) followed by trauma in 48 (40%). The results of this study presented greater similarities to others in the literature, congenital limb deficiency being the dominant cause of amputation in children. This study helps in planning the needs for materials and budgets for the treatment of amputee children in Jordan.
Introduction
Children with limb deficiencies have either congenital limb deficiency or acquired limb amputation. The congenital limb deficiency means that there is partial or total absence of the limb (Day 1991). Congenital limb deficiency is classified as being either transverse which is similar to an amputation stump, or longitudinal in which some distal skeletal elements remain (Day 1991; Krebs et al. 1991). Demographic studies have established the preponderance of the congenital limb deficiencies to acquired limb amputations (Krebs and Fishman 1984; Masada et al. 1986; Cummings and Kapp 1992; Vannah et al. 1999). The majority of acquired limb amputations were due to trauma, followed by tumours and other diseases such as infection, vascular disease (Cummings and Kapp 1992; Carnegie 1999; Rijnders et al. 2000; Bryant and Pandian 2001; Yigiter et al. 2005). Traumatic amputations in children were mainly caused by power tools and machines, vehicular accidents, gunshot wounds, and thermal or electrical injuries (Krebs et al. 1991). The aim of this study is to analyze the demographic characteristics of children with limb deficiencies in Jordan and to compare it with the literature.
Material and methods
In this retrospective study, all the records of all amputee patients who attended the prosthetic clinic at the Royal Rehabilitation Centre (RRC), King Hussein Medical Centre (KHMC), Royal Medical Services (RMS), Jordan, between January 1995 and January 2006 were reviewed. The RRC is a referral centre for orthopedic rehabilitation including prosthetics and orthotics, spinal cord injury and neurological rehabilitation. It is the biggest centre for rehabilitation in Jordan but it is not unique; there are other district outpatient clinics for amputee rehabilitation in the country.
A total of 1528 records for all patients with amputation who attended the clinic during the
study period (1995 – 2006) were reviewed. Of them 124 records (8.12%) were found for
patients with ages 16 years and under at the time of amputation or at the first visit to the
clinic for acquired and congenital amputation. The following demographic data from the
patient records were recorded and analyzed: The age of patient at the time of acquired amputation and the age of patient at the
first visit to the clinic for congenital limb loss; The sex of the patient; Major causes of amputation and some sub type according to the data found in the
files; Type, side and level of amputation for every child; and Whether the patient was provided with a prosthesis or not.
Results
Of the 124 records for children, four were omitted due to incomplete data. Of the 120 children, 64 (53.3%) were male and 56 (46.7%) were female with a ratio of 1.15:1. The mean age of the children was 6.2 years; male children being older than the female children 6.7:5.6 years, respectively. The dominant age group of children was the 1 – 4 years followed by the age group of 5 – 8 years. Table I shows the age distribution.
The age group distribution of children with limb deficiency.
The dominant cause of amputation was congenital limb deficiency in 56 (46.7%) patients followed by trauma in 48 (40%) patients, traffic accidents in 20 (6.7%) patients were the dominant in the traumatic causes followed by power tool and machine, accidents 18 (15%) patients. Table II shows the causes of amputations.
Causes of limb deficiency in children.
In unilateral congenital limb deficiencies the upper limbs were more than the lower limb deficiencies. The most common congenital limb deficiency type in children was the transverse type with 41 limb deficiencies followed by the longitudinal type with 29 limb deficiencies. Tables III and IV present the congenital limb deficiencies.
Types of deficiency in unilateral congenital limb deficiencies.
Type of deficiency in the multiple congenital limb deficiencies.
In children with unilateral acquired amputations, the lower limb amputations were involved more than the upper limb amputations with 34 and 26 children, respectively. In unilateral acquired amputation the trans-tibial level was the most common level in the lower limb, (18 cases) and the trans-radial level was the most common in the upper limb (10 cases). Table V shows the levels of acquired limb amputations in children.
Levels of acquired limb amputation in children.
There was more acquired amputation children fitted with prostheses than congenital limb deficient children, 92.2%:80.36%; and children with lower limb amputations were fitted more than children with upper limb amputations. The prosthetic fitting in limb deficient children is presented in Table VI.
Prosthetic fitting in children with limb deficiency.
Discussion
In this retrospective epidemiological study, the authors analyzed the demographic characteristics of children with limb deficiency. The majority of the results were similar of the international studies. The children with limb deficiencies presented 8.12% of all the amputees who attended the prosthetic clinic during the study period. This percentage presented greater similarity of Kay and Newman's (1975) national survey. Male children with limb deficiency predominate female children with a ratio of 1.15:1. The average age of children was 6.2 years, with males were slightly older (6.7 years) than females, (5.6 years); these presented similarities with studies from The Netherlands, Turkey and a local previous study (Al-Worikat 1996; Boonstra et al. 2000; Rijnders et al. 2000; Yigiter et al. 2005).
Congenital limb deficiency was the dominant cause of deficiencies in children: It accounted for 46.66% in this study compared with 67% in the Krebs and Fishman (1984) study, 32% in the Yigiter et al. (2005) study, twice the acquired limb deficiency in the Masada et al. study (1986), and 73.3% of lower limb deficiency in the Rijnders et al. (2000) study.
This means that this study's results were mostly within the area of the literature results. It is thought that the low percentage may be explained by the fact that this study presented the children with limb loss who attended the clinic and this excluded many children and foetuses with congenital deficiency of the limb that were counted in other studies. This calls for a new study of congenital limb deficiency at country level. To the authors' knowledge, no published study on congenital limb deficiency, and no specialized national registry for the congenital abnormalities exist in Jordan. It is suggested that a national registry for children with congenital abnormalities including limb deficiencies should be established in Jordan.
Congenital limb deficiencies involving the upper limbs were more than in the lower limb which presented similarities with literatures (Sener et al. 1999; Boonstra et al. 2000; Rijnders et al. 2000; Kuyper et al. 2001).
The transverse type congenital deficiency was the dominant in the upper limb deficiencies. The longitudinal type congenital deficiency was the dominant in the lower limb deficiencies. These presented similarities with The Netherlands studies (Boonstra et al. 2000; Rijnders et al. 2000; Kuyper et al. 2001) but were different to others such as the Turkish studies (Sener et al. 1999; Yigiter et al. 2005).
The authors found 10 children with congenital multiple limb deficiencies, one of them being a girl with total transverse bilateral arm and total bilateral thigh deficiencies, who presented a big burden for her family and the rehabilitation system in the rehabilitation centre.
Trauma was the second highest cause of limb deficiencies followed by tumors. Traffic accidents were the predominant type of trauma followed by machine and power tools accidents which caused amputation in children in the present study and the majority of other studies.
In the acquired limb amputations the lower limbs were involved more than the upper limbs. The most common level of unilateral acquired upper limb amputations was trans-radial followed by partial hand amputations. The partial hand amputation level was the second most common level in this study, while the trans-humeral was the second most common level in the majority of other studies (Bryant and Pandian 2001; Yigiter et al. 2005). This may be explained by the fact that in Jordan many teenagers work in restaurants or in small metal or carpentry workshops and injure their hands in food processing machines or electric saws. This calls for more restricted legislation in Jordan as well as reexamining the legislation on children's employment.
Amongst acquired unilateral lower limb amputations the trans-tibial amputation was the commonest level followed by trans-femoral amputation in this study, which is similar to the majority of other studies (Boonstra et al. 2000; Rijnders et al. 2000; Bryant and Pandian 2001; Yigiter et al. 2005). In the present study there were four children with acquired multiple limb amputation, all with two limb involvement, due to blast explosion and vehicle accidents.
In this study 92.2% of children with acquired limb amputations were fitted with prostheses while 80.4% of children with congenital limb deficiencies were fitted with prostheses. The lower limb deficient children fitted with prostheses were more than the upper limb or multiple limbs deficient children. In many studies, it was reported that all children with limb deficiencies were fitted with prostheses in the congenital or acquired types except the bilateral above the knee, and the hemipelvectomy. However, prostheses were not provided to all the children who would benefit from them (Stewart and Jain 1995; Sener et al. 1999; Boonstra et al. 2000; Yigiter et al. 2005).
The policy in the authors' centre for fitting a limb-deficient child with a prosthesis is to provide him/her with a prosthesis if it is sure that he/she can use it. If the child is unable to use a prosthesis, a wheelchair or other mobility aid can be provided. For that reason the results concerned with fitting a prosthesis were less than the international literature.
Conclusions
The demographic characteristics of children with limb deficiency presented great
similarity of the literature. Congenital limb deficiency was the predominant cause of limb deficiencies; this calls
for establishing a national registry for the new-born children with congenital
malformations including limb deficient children and calls for more descriptive studies
for congenital limb deficiencies in Jordan. The data in this study helps in planning the needs of materials and a budget for the
amputee children in Jordan.