Pediatric Limb Reconstruction Gone Wrong: Risks of Pursuing Treatment Without Thorough Psychological Evaluation

Abstract

A 12+9-year-old female-assigned at birth diagnosed with osteofibrous dysplasia of her right tibia underwent 15cm bone resection, ipsilateral pedicled fibular graft, and frame application without a thorough multidisciplinary preoperative evaluation. During her course of treatment, the patient's mood and ability to participate in her own care (e.g. showering, feeding herself on a regular and consistent basis, completing home exercises) declined precipitously, and she began to endorse symptoms of suicidal ideation and non-suicidal self-injury behavior. Eventually the patient had to be admitted to the team’s pediatric orthopaedic institution and was later transferred to an intensive outpatient mental health program for safety and mood stabilization. Due to multiple absences, the patient was prematurely dismissed from the mental health program and subsequently refused to participate with any sort of mental health intervention. Simultaneously, she struggled to cope with the demands of her external fixation treatment.Broadly, this case highlights the critical importance of thorough psychological assessment prior to consideration of limb lengthening and/or reconstruction. Psychological assessment should first establish the patient’s baseline mental health, identify any extant mental health symptoms, and connect the patient with appropriate intervention as needed. Second, psychological assessment should establish the family’s baseline functioning, including caregiver availability and support as well as emotional and logistical resources available to support treatment. Third, psychological assessment should continue throughout the course of treatment, in order to identify real time possible changes in a patient’s mental health and intervention needs. Key Concepts: (1) Inadequate preoperative assessment of a patient and family being considered for limb lengthening and/or reconstruction may result in significant medical and psychological consequences for the patient during and after treatment. (2) Preoperative psychological assessment should establish a patient’s baseline mental health and identify any pre-existing mental health concerns. (3) Preoperative psychological assessment should establish a family’s baseline functioning, focusing on the cognitive, emotional, and logistical resources available to support treatment demands. (4) Psychological assessment should continue throughout treatment, in order to promptly identify any emotional concerns that arise throughout treatment.

Keywords

• Limb lengthening and reconstruction
• Pediatrics
• Psychology
• Psychological evaluation