Prof. Bhatti, Anis deliver on line lecture to Orthopaedic community & trainees, on CP Orthopaedic assessment, and case discussion. It is acknowledged to take few pics borrowed from Prof. Sharaf Ibraheem of Malaysia and from Google along with some text as well.

1. CEREBRAL PALSY
Reconstructive Orthopaedic Surgery
ClinicalAssessment &
Decision making
Prof. ANISUDDIN BHATTI
Dr. Ziauddin University Hospital, Clifton, Karachi
Lecture on Zoom.us, POTF 23.8.2020

2. Cerebral Palsy
• CP an Umbrella term, encompassing a group
of Non-Progressive, non-contagious motor
conditions that cause physical disability in
human development, chiefly in the various
areas of body movement.
1. Cerebral Palsy." (National Center on Birth Defects and Developmental Disabilities,
October 3, 2002) –www,cdc.goc
2. Cerebral Palsy at Dorland Dictionary.
3. Beukelman, David R.; Mirenda, Pat (1999). Augmentative and Alternative
Communication: Management of severe communication disorders in children and
adults (2nd ed.). Baltimore: Paul H Brookes Publishing Co. pp. 246–249. ISBN
1557663335.

3. CP RECONSTRUCTIVE SURGERY
Rx GOALS: The Orthopaedic surgeons have to play an important
role in management of CP child to make him / her able to
overcome his disabilities by improving his residual locomotive
abilities.
Factors:
1. Age Grouping.
2. Clinical pattern.
3. Prognosis of Walking: Ability to walk
independently
4. Structural changes.
5. Cosmetic improvement in gait.

4. Multi
disciplinary
approach
• Speech
• Hearing
• Vision
• Intellect
• movement

5. Diagnostic Matrix - Algorithm
CP Presentation: highly variable
• Ranging from those with mild neurological deficit
to those with severe involvement.
• The diagnostic matrix is an important pillar in
decision making.
• Diagnostic Matrix includes a detailed history, gait
analysis, physical examination of lower limbs,
examination of upper extremities and spine, and
additional tests for appropriate clinical
evaluation.

6. DIAGNOSTIC MATRIX

7. Precise History: Cause & Pathology
• Was there evidence of marked and prolonged
intra partum asphyxia?
• Did newborn exhibit signs of moderate or
severe hypoxic ischemic encephalopathy?
• Is neurological condition one that intra-
partum asphyxia explains?
• Has clinical evaluation been extensive enough
to exclude other conditions? Like a Progressive
Neuro-defecit … Demyelination syndrome?

8. Objectives of
Clinical Assessment
1. Identify the problem
2. Clinical analysis
3. Plan effective management
“Clinical assessment is the most important tool & no substitute
to that ”. Z.K. Kazi
“Dedicated, repeated clinical assessment is mandatory, before
embarking to a have a knife in hand”. Suleman A. Khan

9. ASSESSMENT
Tailored to assess for:
I. Topographical type
II. Type of movement disorder
III.Presence Infantile reflexes
IV.Structural changes

10. TOPOGRAPHICAL TYPE
• Monoplegia
• Hemiplegia
• Paraplegia
• Diplegia
• Triplegia
• Quadriplegia
• Total body involvement

11. TYPES OF MOVEMENT DISORDERS
Athetoid: 10%
Ataxic: 5%
MIXED: 12%
HYPOTONIC: 1%
Spastic: 65%
Manageable
 Dynamic
 Static

12. Motor performance of spastic Diplegic
children

13. Paine Criteria to
PREDICT WALKING ABILITY
1. Independent sitting – 2 years will able to walk.
2. Sitting by 2-4 years - 50% chances to walk
3. Not sitting by 4 years - Rarely stand / walk.

14. ORDERS OF CLINICAL EXAMINATION
• No recognized sequence
• Modified according to
motor development .
Better to follow a sequence:
1. Posture
2. Gait
3. Lower limb
4. Spine
5. Upper limb

15. POSTURE
Ability to sit & stand:
SITTING Supportive
Unsupportive
STANDING
a. Crouch Flexed Hip / Knee
calcaneal deformity at ankle
b. Jump / Scz Flexed hip, knee and equines ankle
c. Stiff knee: Extended lumbar spine, flexed hip, extended
knee

16. gross
Grasp
fine
- Release
- Stereognosis
- R.O.M. of joint
- Fixed deformities
- Muscle power
UPPER LIMB: Assessment

17. LOWER LIMB ASSESSMENT
Dynamic
Contractures
Fixed
• R.O.M.
• Muscle Power
• Muscle acting on more than
one joint

18. FOLLOW-UP ASSESSMENT:
Periodical till Adulthood
Although upper motor neuron (Brain) lesion is
static, manifestations may be changing with
Age & Weight.
Same deformity at different ages

19. Gait Patterns
• Different Gait patterns observed in CP
depends on the involvement of spasticity or
contracture of different muscles:
• Variations relates to topographical type of CP
• Best seen in contrast between unilateral
spastic CP and bilateral spastic CP.

20. Spastic Hemiplegia Gaits
• In spastic hemiplegia, there is more involvement distally
and therefore true equinus is the basis of common
patterns.
• Winters et al. described four gait patterns in
spastic hemiplegics based on sagittal
kinematics.
• Type 1 hemiplegia gait – Drop foot type
• Type 2 hemiplegia gait – True equinus with or
without recurvatum knee

21. Type II Equinus
hemiplegic gait.
(a): Right-sided
hemiplegia with
ankle equinus in
stance [AP view].
(b): Right-sided
hemiplegia with
ankle equinus in
stance [Lat view]

22. Spastic Hemiplegia Gaits
• Type 3 hemiplegia gait – Stiff knee gait
• Type 4 hemiplegia gait – JUMP / Scissor:
o In sagittal plane, the ankle is in equinus,
knee in flexion, hip in flexion and anterior
pelvic tilt is present.
o In coronal plane, there is hip adduction
and internal rotation.

23. Spastic Diplegia Gaits:
• In spastic Diplegia, there is more proximal
involvement and therefore apparent equinus and
crouch gait are seen commonly.
• There are four common patterns of gait in
spastic Diplegia as described by Rodda et al.
• Type 1 – True equinus
• Type 2 – Jump gait
• Type 3 – Apparent equinus
• Type 4 – Crouch gait

24. Rodda et al. JBJS. 2004

25. Type 1 – Diplegia True equinus
• Hip extension
• Knee extension
• Ankle equinus
Pic Courtesy: Sharaf Ibrahim, Malaysia

26. Type 2 – Diplegia Jump gait
Jump Gait with
• Bilateral hip
Flexion
• Knee flexion
• Ankle Equinus.

27. Type 4 – Diplegia Crouch gait
Crouch gait with
• Bilateral hip Flexion
• Knee flexion
• Ankle dorsiflexion.

28. Apparent Equinus
[Dynamic Equinus]
• Hip flexion
• Knee flexion
• Ankle neutral..
plantigrade
Pic Courtesy: Prof. Sharaf Ibrahim, Malaysia

29. CLINICAL TESTS

30. Adductor Longus Stretch Test
• Hip abduction angle in Knee extension & flexion
When measurements are same: Adductors tight. Why?
• Hip abduction improves on Knee flexion: Gracilis tight
Same angle
Adductors tight
Abduction
improved
Gracilis is tight

31. Gracilis spasticity – Phelp’s Test
• Passive abduction with knee in extension.
• Improved hip abduction with knee flexion indicates
Gracilis / medial hamstring tightness. Why?

32. Popliteal Angle: Normal ranges in Children
• 1-3 yrs mean angle 60 [00-150]
• @ 4 yrs mean angle 170 in girls, 270 in boys [50-450].
• >5 yrs mean angle 260 little change [0-50]
• PoP angle of >500 in above age groups indicate abnormal
hamstring tightness.
Katz, Kalman. University Telaviv Israel. J Ped ortho 1992. 12:229-231

33. Hamstring Stretch Test
• Hip flexed to 900 & knee
extend
• Measure Popliteal angle 900
flexion to 00 extension
• Hamstring Shift: Difference
b/t Rt & Lt measurements
00
900
500
RtLt

34. Achilles Stretch Test
Silverskiold test- Gastroc. vs Soleus
“Spastic Gastrocnemius contracture”
Correction of ankle
equinus with
Knee flexion indicates
Predominantly
gastrocnemius
Contracture. Why?

35. Thomas Test for Hip Flexors
• Easy & simple, well
known
• Thomas test steps
• Problem : depends on
how much is the other
hip flexed

36. Modified Thomas Test for Hip Flexors
• With fixed knee flexion,
Thomas test should be
performed with knee
outside at table edge to
prevent false positive
results.

37. Staheli’s Hip Flexors Stretch test
• More accurate for
FFD hip
• Prone position
• Pelvis over table edge
Thomas test
Staheli’s

38. Ely Duncan Test
• Pelvis rise on
knee flexion.
• Significance ?

39. Rotational Malalignment
• Foot propagation angle
• Femoral rotation
Internal / External
Rotation
• Fem Ant version
• Tibial rotation
Foot – Thigh Angle

40. Craig Test: FAV
Trochanteric Prominence Test
• Prone position and knee at
90° flexion.
• Angle between the vertical
line and long axis of the leg
at the greatest prominence
of the greater trochanter
palpated laterally
measures the amount of
FAV.
In recent studies, it has been found that trochanteric prominence test in combination
with hip internal rotation, X-rays is a better predictor of FAV and neck-shaft angle as
compared with computed tomography.

41. Tibial torsion mal-alignment
Thigh foot Angle
• Prone position, knee in
90° flexion, and neutral
ankle and hind foot
position,
• Angle between the
thigh axis and foot axis
(axis between the 2nd and
3rd metatarsals) gives
Tibial torsional
measurement

42. ADDITIONAL CLINICAL ASSESSMENT
• Plaster cast: BK to assess Ankle contracture
AK to assess Knee contracture
• Myoneural block: Botox injections
• Examination under anesthesia: Per operative

43. Advanced tests:
Repeated examination &
A. Careful Analysis of the Gait
i. Video Assisted Observational Gait
Analysis.. VAOGA
ii. Gait laboratory: Video-graphic Gait
Analysis.. VGA
B. Posture and
C. Recognition of potential Skeletal
changes lead to better judgment
to correct or prevent structural
changes reasonably early i.e
before 15 (13) years. (Molnar-
Gordon)
Gait
Laboratory,
Plays an
important role
in accurate
Judgment
VAOGA:
Video Assisted
Observational
Gait Analysis

44. NED University Gait Laboratory:
Video-graphic Gait Analysis (VGA)
Gait Lab test being performed on patients during CP workshop on
19 March 2011

45. PEDOGRAM:
Cavovarus & Planovalgus
EMG:
Indicating spastic, normal & Weak Muscles
Gait Laboratory: VGA

46. Modified Ashworth Scale
Muscle Tone

47. Medical Research Council Grading
Muscle Power

48. Case 1 Jr Ab: Age 9 yrs. Premature birth (28 wK), H/o Liquor
aspiration Birth Asphyxia.
milestones achieved normal Except abnormal gait.
• What are the
Findings ?
• Which type of
Sitting & Gait ?

49. What are the findings?
Which test being performed?
Any mistake in performing test?

50. What are the findings
Which test is being performed

51. 9 years old, male, premature
birth 28 weeks of gestation;
milestones achieved normally;
Presenting complain : Tip toe
walking bilaterally &
unable to squat
Alyn Duncan sign Negative
Pop Angle 30 degrees bilaterally
External & internal rotation
normal
Silverskoild test negative -30-150
Developing Rocker Bottom &
Recurvatum Knee
What is Ur
decision for
Reconstructive
Surgery
&
Why

52. Case 2 Aws: 9 yr old, H/O Liquor aspiration Birth
Asphyxia. Delayed milestones.
Walked independently for few years, then
deteriorate with abnormal Gait.

53. 9 yr old, Male, H/O birth asphyxia,
Delayed milestones.
What are the Findings
Which type of walker he is?
Which type of Gait?

54. Which tests are being performed
What R Findings
What is wrong in performing
these tests ?

55. 9 yr old, Male,
H/O birth
asphyxia,
Delayed
milestones.
Walked
independently
for six years,
deteriorated in
last 3 years

56. A 9-year old boy presented with history of birth asphyxia,
delayed milestones. He is an independent walker with a gait as
in attached Picture.
Q1- What type of Problem and Gait is This & why?
Q2- Name seven different clinical examination test to evaluate his problem.
Q3- Which clinical test for what, why and what that test indicate to do.
Key
1- CP Diplegia. Jump Gait
2- Clinical test to perfom
a. Sikverskiold for Gastronemius contracture alone or both: Gastro & Solius.
Positive indicate Gastro release. Negative indicate TAL.
b. POP angle to for Hamstring Contracture. Angle <90 degree indication of
Hamstring recession.
c. Combined Abduction for adductors. < 60 degree needs Myotomy.
d. Phelp test for Gracilis contracture. Positive to lengthen.
e. Alyn duncan: Rectus strech test. Positive for release tendon.
f. Rotational deformity to check Anteversion. To correct coxa valga anteversa.
g. Foot Thigh angle to chek Tibial Torsion. To correct tibial torsion.

57. Case 3: 12 years old male. Ayn ab
• History of uncomplicated pregnancy, preterm delivery,
• Positive history of Birth asphyxia,
• delayed developmental milestones;
• cognitive functions intact.
• Started walking at age of 3 ½ years, then never been able
to walk without support.
• No previous surgeries; no other diseases;
• Physiotherapy … short time period then stopped.
• Now, presents with complain of both lower limb deformity
& unable to walk.
• Bilateral Hip Subluxation.

58. 12 year Ayn.
Combined abduction 500 POP 900 - 900
Internal Rotation Increases on supported walking &
develop Scissor, Jump Gait with Hyperactive TibP & TibA
What is
Ur
decision
for
Recon
Surgery

59. 12 year Ayn.

60. Fractional Lengthening Hamstring
Position Incision

61. Semitendinosus lengthening
Semitendinosus tendon
distal attachment transection
Semitendinous attachment to proximaly
transected Gracilis tendon

62. Fractional Lengthening Hamstring
Semimembranous muscle sheath
V-transection
Post-lengthening Position

63. Achilles TL
FHL lenghtened + Tibio Talar
capsulotomy
TibP lengthening
Posterior Lenghtening
Ala Carte’ approach

64. Tibialis Anterior Transfer to 3rd
Cuneiform
TibA transfer

65. Tibialis Anterior Transfer
Attached with Button Sutured with periostium dorsally

66. Case 4: 2 ½ y old, male
• Preterm birth,
uncomplicated pregnancy,
C-section delivery; history
of Birth asphyxia &
incubator utilized after
birth for about 1 week.
Normal developmental
milestones achieved.
• Presents with Gait
deformity that is
progressively increasing

67. • Silverskiold test neg
Rt -30
Lt -10
• Equinus rigid
• FHL, FDP tight
• Plantar fascia tight
• Achilles Tendon tight
• Knee and Hip =
unremarkable

68. Procedures performed
Left leg:
1. Tendon Achilles Z-lengthening
2. Flexor Hallucis Longus
lengthening
3. Flexor Digitorum lengthening
4. Tibialis Posterior lengthening
5. Tibio-talar-calcaneal
Capsulotomy/arthrotomy
6. Plantar Fascia release
Right leg:
1. Gastrocnemius muscle
sheath recession.
Gastrocnemius muscle sheath
resection
Long leg cast applied

69. Bibliographic Reference:
1. Orthopaedic Management of
Cerebral Palsy. Eugene E Bleck. 1979. WB Saunders.
2. Orthopaedic Management of Cerebral Palsy. 2nd
Ed. Helen W Horstmann & Eugene Bleck. 2007.
Blackwell Publication.
3. Cerebral Palsy. Freeman Miller. 2005. Springer
• 4. Multiple literature from google.com
• Videos prepared with Dr. Sadam Mazar Baloch &
• Dr. Nida Hameed at Dr. Ziuaddin University,
Karachi

70. My Contacts:
dranisbhatti@gmail.com