Surgical reconstruction is indicated if it can improve function (and possibly yield cosmetic benefit) without subjecting the patient to many operations. Surgery should be undertaken as early as possible. The goal is to obtain a good grasp-and-release mechanism, preserve good sensation, and facilitate positioning of the hand for optimal function. A very young patient should have frequent postoperative evaluations, especially during the growth period, to avoid recurrence of the deformity due to imbalance or unequal growth.

During surgery, small skin nubbins or rudimentary digits at the distal portions of the limb should be preserved, because even a small nubbin can provide excellent sensation. Amputation should be considered only if there is neurovascular insufficiency, loss of skin cover, or infection and never if there is good skin cover with sensation. Before undertaking any surgical procedure, whether an amputation or a reconstruction, the surgeon must carefully evaluate the patient’s existing and potential use of the limb. For successful rehabilitation, reconstructive surgery must be individualized.

Rehabilitation in Lower Limb Defects. Children with a lower limb defect should be fitted with a prosthesis at 12 or 15 months of age, the normal age for walking. Very often, a complicated, nonstandard prosthesis must be designed for these patients. Occasionally, if function cannot be achieved with reconstructive surgery, it may be achieved with a properly performed amputation—a good example is the removal of a severely malformed foot to obtain proper fit of a prosthesis. With the prosthesis, the child will look almost normal and be almost normally active.

In the growing child, the amputation should always be through a joint, not across a long bone. Amputation through the diaphysis can result in bone overgrowth. Often, after an apparently successful amputation, the growing bone perforates distally through the stump and the ensuing infection and further overgrowth necessitate multiple surgical procedures. During a joint disarticulation, the growth plate must be preserved to ensure future growth of the stump.

Prostheses. Use of prostheses is successful in children as young as 21 months of age. They can master a voluntary opening hook and eventually become more adept at using a prosthesis than adult amputees. Artificial limbs are used as long as they are tolerated by the patient, do not cause pain, and are in good working order. Children are readily accepted by playmates once the curiosity about the prosthesis is satisfied.

Children who wear upper limb prostheses are able to dress themselves and put on and take off their artificial limbs without difficulty. The terminal hook device is a very versatile tool, and most patients prefer it to a cosmetic hand. In adolescence, a functioning cosmetic hand may be substituted.

Parents of children with limb defects should keep well informed about rehabilitation programs that include physical therapy, surgery, and prostheses.