When A Child Has An Amputation Secondary To Trauma

I recently received a referral for a five-year old who had a chronic foot ulcer secondary to trauma. At first, I thought the referral was an error. Surely, this must be a 55-year old, 65-year old or some-other-decade-ending-in-five-year old patient with diabetes, peripheral arterial disease or some other comorbidity contributing to delayed wound healing. I was wrong. 

This young patient had a partial foot amputation several months prior in order to address an injury from a lawn mower. He received follow-up and wound care from the original surgeon. Over time, though, the distance to and from the specialty center, and the frequency of required visits became too difficult for the family. The wound began to exhibit signs of non-healing and the family grew increasingly worried. This case got me thinking about how we manage trauma in our pediatric patients, particularly those with amputations and open wounds, and some of the challenges associated with healing and beyond.

According to the Centers for Disease Control and Prevention (CDC), over 11,000 children and adolescents in the United States, age zero to 18 years old, die annually of unintentional and intentional injuries with trauma being the leading cause of death.¹ In addition, injuries and poisoning remain the leading causes of emergency department (ED) visits for children with over 17 million reported emergency department visits in 2017.² 

Despite recent improvements in product design and stricter safety specifications, lawn mower injuries represent a substantial cause of serious morbidity in children. In a recent retrospective analysis, Ren and colleagues found that, from 1990-2014, approximately 212,258 children (less than 18 years of age) in the United States received emergency treatment following a lawn mower-related injury.³ In the study, the most common diagnosis was laceration involving the hand/finger (30.7 percent) with amputations occurring in 4.4 percent of cases. Of note, the lower extremity (18.2 percent) and foot/toe (15.3 percent) were involved less frequently, and children less than five years old were more likely to suffer burns than older children due to contact with the hot mower surface.³

In the lower extremity, the most severe pediatric foot and ankle lawn mower injuries occur with ride-on mowers.⁴ Although lawn mower-related amputations are rare, they result most commonly from back-over injuries. A back-over injury typically occurs when a child runs out to join a family member mowing the lawn on a ride-on mower, but the operator does not see or hear the child approaching from behind. The driver then shifts into reverse without looking behind the mower and backs over the child, resulting in amputation.³

Though major amputations caused by lawn mower-related injury are rare in children, the long-term consequences, including permanent disability, financial burden, post-traumatic stress disorder, anxiety and depression, can be quite devastating. Rusch and coworkers found that among children who suffered traumatic injury, 98 percent experienced symptoms of post-traumatic stress disorder, depression or anxiety within five days of the injury, and 82 percent remained symptomatic one month later.⁵ In addition, the costs of medical care and therapy for a child with an amputation can accumulate rapidly over time with one study estimating the cost of prosthetics from the time of injury to the age of 18 years to range between $73,140 to $116,040 per single lower extremity amputation.⁶

As podiatric physicians and surgeons, we all see our fair share of trauma and wounds, but there is just something different when we see a traumatic wound in a child. I could not help getting a little bit emotional about the child who was referred to me. Would he require more surgery? Would he need more amputations? Would he eventually get fitted for a prosthetic? Would he ever kick a soccer ball with his dad or go ice skating with his mom? These are some of the things I thought about as I was driving home from the office that day. I cannot even imagine how his parents must feel. I must admit that I hugged my kids a little bit longer that night.

Dr. Isaac is the Director of Research with Foot & Ankle Specialists of the Mid-Atlantic (FASMA). He is a Diplomate of the American Board of Foot and Ankle Surgery.

References

1. Centers for Disease Control and Prevention. WISQARS – Web-based injury statistic query and reporting system. Available at:  https://www.cdc.gov/injury/wisqars/ . Accessed November 16, 2020. 

2. Rui P, Kang K. National hospital ambulatory medical care survey: 2017 emergency department summary tables. National Center for Health Statistics. Available from: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf. Accessed November 16, 2020.

3. Ren KS, Chounthirath T, Yang J, Friedenberg L, Smith GA. Children treated for lawn mower-related injuries in US emergency departments, 1990–2014. Am J Emerg Med. 2017;35(6):893-898.

4. Vosburgh CL, Gruel CR, Herndon WA, Sullivan JA. Lawn mower injuries of the pediatric foot and ankle: observations on prevention and management. J Pediatr Orthop. 1995;15(4):504-509.

5. Rusch MD, Grunert BK, Sanger JR, Dzwierzynski WW, Matloub HS. Psychological adjustment in children after traumatic disfiguring injuries: a 12-month follow-up. Plast Reconstr Surg. 2000;106(7):1451-1458.

6. Loder RT, Dikos GD, Taylor DA. Long-term lower extremity prosthetic costs in children with traumatic lawnmower amputations. Arch 

Pediatr Adolesc Med. 2004;158(12):1177-1181.