What We Treat

Children with limb differences are all unique, which means their treatment should be individualized to meet the needs of each child and family. An upper limb difference can be classified as:

  • Failure of formation
  • Abnormal formation
  • Too many bones and fingers
  • Too few bones and fingers

The Limb Deficiency Program offers comprehensive evaluation, state-of-the-art prosthetic and orthotic devices, and therapy to meet the ongoing functional demands of growing, active children with congenital or acquired upper extremity limb differences.

Our program can treat many of the various types of upper limb differences, including:

Transverse deficiencies

  • Above the elbow: This is an arm difference that occurs during development in utero in which a portion of the arm above the elbow does not develop properly. This can occur immediately above where the elbow may be or higher up the arm and it typically involves only one arm. There is no family or genetic link to this condition. Sometimes surgery can be performed to provide better coverage in thin-skinned areas, remove skin “nubbins” or occasionally elongate the bone for prosthetic fitting. Depending on the age and goals of the patient, a prosthesis can be worn.
  • Below the elbow: This is an arm difference that occurs during development in utero in which a portion of the arm below the elbow does not develop properly. This can occur anywhere along the length of the forearm and typically involves only one arm. There is no family or genetic link to this condition. Sometimes surgery can be performed to provide better coverage in thin skinned areas, remove skin “nubbins” or occasionally elongate the bone for a prosthetic fitting. Depending on the age and goals of the patient, a prosthesis can be worn.

Longitudinal deficiencies of the forearm

  • Radial deficiency: There are two bones that make up the forearm. When all or a portion of the radius (the bone on the thumb side of the forearm) is missing, this can be due to a condition called radial longitudinal deficiency. When this condition is present, there may also be a spectrum of problems with the thumb ranging from normally functioning to absent thumb. Sometimes this can occur spontaneously, but it often is associated with syndromes such as thrombocytopenia absent radius (TAR), Holt-Oram, TBX5 deficiency, VACTERL or Fanconi’s syndrome. Surgery is often performed to improve overall alignment of the wrist. If other differences exist, such as the thumb, surgery can be performed in order to help its function or create a finger to work like a thumb.
  • Ulna deficiency: When all or a portion of the ulna (the bone on the small finger side of the forearm) is missing, this can be due to a condition called ulnar longitudinal deficiency. Sometimes small and ring fingers may also not develop. This condition occurs sporadically and surgery may sometimes be performed to improve position of the wrist and forearm.

Deficiencies of the hand

  • Cleft hand: Children may be born with a widened space between their fingers, or have missing middle fingers. This condition is called cleft hand. This is typically a genetic condition but can also occur spontaneously. Some children may function well with grasp and may not need surgery to improve this function. When treated surgically, reconstruction can be performed to narrow the webspace.
  • Cleft hand, atypical symbrachydactyly: This is a condition where the hand may be smaller than normal, and fingers may not fully form and interconnected. The fingers can be variable in length and functional capacity. The thumb is usually spared and typically only one hand is involved. This occurs spontaneously or in association with Poland syndrome. Surgery can be done in some circumstances to help the hand be able to pinch better. Some examples of surgery include deepening the thumb webspace, finger lengthening or a toe-to-finger transfer. Surgery varies from hand to hand. Prostheses may be helpful for certain activities on a patient-specific basis.
  • Syndactyly: This is a condition in which two or more fingers are stuck together, have no webspace and are unable to separate. Often, fingers remain attached by skin only but sometimes the bones, nerves and blood vessels can be involved between two fingers. The cause of this condition can be spontaneous, genetic or occur with other conditions. In most circumstances, surgery can be performed to separate the fingers. There is usually not enough skin to split the fingers, so skin is usually taken from somewhere else to help cover the deficit. Sometimes when bones are involved, separating fingers may compromise the function of the hand.

Deficiencies of the fingers

  • Clinodactyly: This is when just the tip of the finger is curved, typically in the direction pointing toward the thumb. This can occur spontaneously, genetically or in association with Down syndrome. The finger typically functions very well. Surgery may be considered for fingers that overlap when trying to grip.
  • Camptodactyly: This occurs when a finger is unable to be straightened out. It most commonly occurs in the small finger. It is a spontaneous condition, but can be genetic. Management is commonly conservative, with stretching and splinting as directed by therapy. When contracture is severe, surgery is occasionally performed to straighten the finger.
  • Klirner: This is when the tip of the finger has a more curved appearance than other fingers. It is a spontaneous condition, but can also be genetic. These fingers typically function very well. Surgical intervention may be warranted if the shape of the finger impedes function.

Amniotic band

  • Hand and finger amniotic bands: This condition occurs when a baby is born with multiple band-like wrappings around the arms and/or legs. The pattern of injury is variable but can result in amputating fingers, connecting fingers (syndactyly) or nerve dysfunction depending on locations of the bands. The thumb is typically not involved. The cause is not entirely understood and happens sporadically.

Services We Offer

Children are treated in a multidisciplinary program specializing in the diagnosis and treatment of children with upper limb differences.

Our specialists include:

Our services include surgery and specialty prosthetic upper limb devices for children of all ages.

Surgical options

Limb lengthening 
Limb lengthening is a treatment for major limb length discrepancies (often greater than two inches). In general, lengthening can be done with either an external fixator, or with an internal fixator.

While your child is undergoing lengthening treatment, the doctor will typically see you on a weekly basis to ensure the limbs are lengthening properly. In addition, physical therapy is very important during the lengthening process, as it can help prevent stiffness once the limb becomes longer.

Limb lengthening is a very specialized surgical skill, and only surgeons who are trained in limb lengthening should perform the operation. If the bone is lengthened too fast, it may not heal, and the surrounding muscles, nerves, and joints may be at risk for permanent damage. If the bone is lengthened too slow, it may heal too quickly, and the bone may not be able to reach its desired length.

There are two types of devices that are used in limb lengthening surgery:

It is important to have a thorough discussion with your surgeon about limb lengthening and which device is best suited for your child’s condition.

Learn more about limb lengthening

Other surgical options:

  • Lengthen or shorten fingers and smaller bones
  • Straighten bones and fingers
  • Amputation
  • Reposition bones and fingers
  • Transfer fingers and toes
  • Targeted muscle innervation
  • Orthotic devices—Custom fit braces and splints

Prosthetic devices

Upper limb prostheses are designed to meet the functional demands and needs of children with limb loss. There is no right or wrong decision when it comes to whether to wear a prosthesis. Understanding the types of prostheses available for the level of limb loss helps the child and family make the decision that is right for them. Options for prostheses include: non-articulating functional prostheses; body-powered prostheses; myoelectric prostheses; and activity-specific prostheses.

  • Non-articulating functional—These prostheses are generally worn to give children equal arm lengths and to help with simple tasks such as propping, support, balance, and trunk and upper arm strengthening as well as the appearance of the arm. Simple grasp may be an option depending on the type of hand made with the prosthesis.
  • Silicone restorations—These prostheses are highly cosmetic, real-life stylized non-articulating functional prostheses. Silicone prostheses require specialized fabrication that takes extra time for the customization.
  • Body-powered—Body-powered prostheses provide grasp and release function that operates a terminal device by a cable and harness. Tension on the cable either opens or closes the terminal device: prosthetic hand; prehensor; or hook.
  • Myoelectric —A myoelectric prosthesis is an active, electrically powered prosthetic device that allows children to open and close a prosthetic hand for grasp and release functions. Small electrodes are built into the socket, which detects signals from the muscles under the electrodes. The signal from the muscle helps control the speed and the degree of opening. This technology helps increase independence while providing a more natural appearance than many conventional prostheses. As children grow, the ability and appearance of the hand becomes more important to them. This technology is well-suited for teens though adulthood. Using specially designed computer software, patients can program grip patterns and select other hand features, in many cases using gesture control —an advanced option that allows the wearer to change hand patterns with a simple gesture. We offer two types of myoelectric prosthesis: one for full-hand deficiency and one for partial-hand deficiency.
  • Microprocessor - For our older patients, advanced innovative prosthetic devices are available that provide independent movement of each finger and stronger, faster grasp and release functions. These include the I-Limb, Michelangelo, BeBionics and various other advanced options. The Children’s Limb Deficiency Program was one of the first providers in Atlanta to offer advanced microprocessor upper extremity prosthetic technology. 
  • Sports, recreation, and activity-specific prostheses— These prostheses are designed to help children perform a specific task or sport. They help children participate in activities that require two hands for grasp and movement.

Targeted muscle reinnervation

Our hand and upper extremity orthopaedic surgical specialists currently offer targeted muscle reinnervation. The Children’s Limb Deficiency Program team is prepared to support the prosthetic and rehabilitation needs of the patients who have had TMR as part of surgical reconstruction.

Our Unique Approach

Whether or not your child is having surgery or being fitted with a custom brace or prosthesis, it is important to establish a close relationship with their physician and members of the care team.

All of our team members are trained and experienced in working with children with limb differences and their families. Our certified orthotists have formal education in biomechanics and material sciences, which is required in designing custom devices. We work closely with patients and their families to make sure they have the training and support they need to be independent and confident, now and into the future.

Children's Physician Group 

Physical Therapists

Prosthetists

Community Providers 

Our program consists of employed doctors, surgeons, physical therapists and orthotists and prosthetists as well as community providers whom we work closely with to help ensure care is delivered seamlessly at our hospitals. 

Community providers who are part of the upper limb difference team include:

​Hand surgery

Limb deficiency services and programs 

Children’s provides additional services and programs for children with limb deficiencies and deformities: 

  • Rehabilitation: The rehabilitation team at Children’s is trained and experienced in working with children who are undergoing limb-lengthening and limb-salvaging procedures.
  • Adaptive Sports Program: Our team partners with sports medicine and rehabilitation to help children and teens find sports they enjoy and can play safely. We can design and assist with the technology needed for adaptive sports.
  • Prosthetic training: Training is provided by therapists trained and experienced in working with children during stages of prosthetic fitting.

Helpful Resources

External resources

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