Orthopedic management of cerebral palsy patients; either of upper or lower limbs

1. Dr Samir Zahed
Professor of Orthopedic Surgery,
Benha University, Egypt

2. ‫ال‬َ‫ق‬ َ‫ين‬ِ‫ذ‬َّ‫ل‬‫ا‬ َّ‫ن‬ِ‫إ‬َّ‫اَلل‬ ‫ا‬َ‫ن‬ُّ‫ب‬َ‫ر‬ ‫وا‬َّ‫م‬‫ث‬
َ‫خ‬ َ‫َل‬َ‫ف‬ ‫وا‬‫ام‬َ‫ق‬َ‫ت‬ْ‫س‬‫ا‬ْ‫ي‬َ‫ل‬َ‫ع‬ ٌ‫ف‬ ْ‫و‬ْ‫م‬ِ‫ه‬
‫و‬‫ن‬َ‫ز‬ْ‫ح‬َ‫ي‬ ْ‫م‬‫ه‬ َ‫َل‬َ‫و‬َ‫ن‬(13)
‫األحقاف‬

3. Outline
 Grounds
 Cerebral Palsy Upper Limb
 Cerebral Palsy Lower Limb

4. Grounds

5. Cerebral palsy, Grounds
 Definition
 Types
 Impact on musculoskeletal
system
 Delayed motor development
 Impaired gross, fine motor &
cognitive functions
 Orthopedic management
 Goals; correct muscle imbalance,
correct deformities, stabilize joints
 Team;
 neuro physician,
 PH
 orthotics,
 orthopedic surgeon

6. Cerebral Palsy Upper Limb

7.  P/A ROM for the shoulder,
elbow, forearm, wrist and
fingers;
 Muscle strength of upper
limb motors especially
pinch & grip;
 Patterns of deformity;
 Sensibility;
 Stereogenesis;
 Functional activities of
pinch, grasp, and release
(dexterity or skill)
Cerebral Palsy Upper Limb
Assessment
= Two-point discrim.
(>15–20 mm)
= The severity of motor
impairment has been
shown to correlate with
sensory deficits.
= The greater the sensory
deficit the more likely
there will be some
neglect and disuse.
The typical arm has
elbow flexion, wrist
flexion, and forearm
pronation (?? Shoulder
add. IR)

8. Cerebral Palsy Upper Limb
Assessment
Jebson upper extremity functional
patterns.
Type 0: No active function in the entire upper
extremity
Type 1 Proximal function, none to minimal distal
function (uses hand as a paperweight/
posting device)
Type 2: Mass grasp, poor active control and
strength, poor fine motor control
Type 3: Fair active grasp/release (able to place
object with fair accuracy), poor thumb
opposition
Type 4: Good active grasp/release, fair thumb
opposition (key pinch only)
Type 5: Normal to near-normal function, good
thumb opposition, able to perform
sophisticated fine motor tasks (e.g., buttoning
clothes)
Functional activities

9. Cerebral Palsy Upper Limb
Conservative Treatment
 Stretching
◦ (P- ROM)
◦ Self ROM
 Strengthening
◦ (A- ROM)
◦ Resistive exercise
 Fine motor activities
 Hand splinting
◦ Night wristing splint
◦ Wrist/Thumb Support
◦ Thumb Loop Splint & C Bar splint
to abduct the thumb
 Encourage arm / hand use
during everyday activities as
hand writing & shoe tying
Treatment

10. Operative Treatment
 Shoulder add. & IR
 Elbow Flexion
 Forearm Pronation
◦ I- Correction is achieved
secondary to procedures
for other deformities
 Common flexor origin slide
 FCU to ECRB EDC or BR
◦ II- Correction is achieved
through procedures
weakening pronation &/or
augmenting supination
 Pronator release, rerouting or
transfer to wrist or finger
extensors
 BR rerouting
◦ Combinations
◦ Classification and
treatment options by
Gschwind and Tonkin
Pronation deformity classification and
treatment options by Gschwind and Tonkin
TreatmentType
Surgery is unnecessaryType 1.
Active supination
beyond neutral
Pronator quadratus release.
Flexor aponeurotic release
Type 2.
Active supination to
less than, or to neutral
position
Pronator teres transfer
(Brachioradialis re-routing)
Type 3.
No active supination,
free passive supination
Pronator quadratus and
flexor aponeurotic release
(Pronator teres myotomy
/lengthening +
Brachioradialis re-routing)
Type 4.
No active supination,
tight passive supination
= Flexion contracture of elbow may limit
reach activities of hand.
= Cosmetic disability and impair self-
image
= Operative treatment is seldom indicated
unless extension loss exceeds 30.
= Elbow deformities between 30 and 60,
soft tissue procedures (including excision
of the lacertus fibrosus, Z-lengthening of
the biceps, and fractional lengthening of
the brachialis aponeurosis)
= For deformities exceeding 60, a flexor-
pronator origin slide accompanied with
anterior elbow capsulotomy may also be
required.
= Rerouting or lengthening of the pronator
teres (PT) muscle may prevent increased
pronation deformity after anterior elbow
Cerebral Palsy Upper Limb
Treatment
= Adduction and internal rotation
shoulder deformity is common
= Surgical treatment is rarely
indicated,
= Pectoralis major and
subscapularis muscles should
be lengthened to correct
shoulder adduction and
internal rotation deformity;
= Capsular release may also be
performed.
= Transfer of the latissimus dorsi
and teres major may augment
active external rotation of the
arm

11. Operative Treatment
 Wrist Flexion
I. Wrist and Finger Flexor
Tightness and its management
 Lengthening of the wrist flexor tendons
 Release of finger flexor tendons
 Flexor/Pronator slide:
II. Extension Loss of the Wrist and
its management
 Zancolli 1: FCU lengthening
 Zancolli 2a: FCU & FCR lengthening
 Zancolli 2b: FCR lengthening + transfer
to augment wrist extensors
 Zancolli 3: FCR lengthening + PT to
ECRB + FCU to EDC
III. Static contracture > 45˚
 Soft tissue release + fusion +/- PRC
Cerebral Palsy Upper Limb
Treatment
= Wrist deformity may develop
due to flexor tendon tightness,
inadequate wrist extensors,
contracture of the wrist volar
capsule or combination of these
factors.
i) Fractional Tendon Lengthening
ii) Tendon Z-lengthening
iii) Superficialis-to-profundus
procedure (STP)
= STP weaken flexors the most
but fractional lengthening the
least, Z lengthening is in
between
= Zancolli1: have full finger
extension with ˂20º wrist flexion
= Zancolli 2: active finger
extension can be provided only
with wrist flexion ˃20º.
- 2a; weak wrist extension when
fingers are in flexion.
- 2b; no wrist extension at all
when fingers are in flexion.
= Zancolli 3: do not have active
finger extension, severe
= The transfers mostly used for wrist
extension are: FCU→ECRB,
ECU→ECRB, PT→ECRB, BR→ECRB
and FDS→ECRB.
= If a more radial deviation of the
wrist is required, these transfers
should be made to the ECRL tendon.
= Additionally, the FCU→ECRB
transfer performed to maintain wrist
extension actively adds to the
forearm supination

12. Operative Treatment
Cerebral Palsy Upper Limb
Treatment
Wrist Flexion Treatment
Algorithm

13. Operative Treatment
 Hand thumb in palm
◦ Treatment of adductor and
flexor muscle spasticity
 Adductor / Flexor PB Release
 Releasing 1st dorsal interosseous
muscle
 FPL tendon lengthening
◦ Supporting the abductor
and extensor tendons
 Tendon transfers
 Shortening APL and EPB tendons
via plication
 EPL Re-Routing
 FPL Abductorplasty
 Releasing the first web skin
Cerebral Palsy Upper Limb
Treatment
With the aim of maintaining
the thumb extension and
taking the thumb out of the
palm, transferring BR, PL,
ECRB, FCR, FCU and
FDS tendons were
recommended by several
authors
Thumb in Palm Summary

14. Surgery
of the
Upper
Extremity
in
Cerebral
Palsy
Koman et al
Orthop Clin
N Am 2010
X
X
?
?
?
?
Operative interventions of upper extremity in CP
Cerebral Palsy Upper Limb

15. Cerebral Palsy Lower
Limb

16. Case 1
- 5YM
- GMFCS 4
- Bilateral hip
scissoring, knee
flexion, ankle
equinus
- Bilateral hip
adductor flexor
tenotomy,
Hamstring release
CP Lower Limbs
 Presentation

17. Case 2
- 3.5YM
- GMFCS 3
- Bilateral hip flex
adduc, knee
flexion, ankle
equinus
- Bilateral hip
adductor flexor
tenotomy.
Hamstring release,
gastroc recession
 Presentation
CP Lower Limbs

18. Case 3
- Naser Al Nauwiser
- 12Y boy
- GMFCS 5
- Deterioration of the
sitting abilities
- Pain in the left
buttock
- Difficult nursing due
to closed perineum
- Adductor tenotomy
+ VDO + pelvic
osteotomy
 Presentation
CP Lower Limbs

19. Assessment
◦ GMFCS
 To discriminate/describe,
To prognosticate, To
evaluate change over
time
 GMFCS ER, Arabic
version, GMFM 66 &88
◦ Spine & upper limb
◦ Lower limb examination
 Hip (adducion, flexion,
med rotation)
 Knee (flexion deformity,
tight rectus, high patella)
 Ankle & foot (euinus,
hindfoot varus /valgus,
forefoot varus inversion/
eversion)
 Rotational profile
◦ X ray hips &knees
‫يمشي‬‫قصور‬ ‫أي‬ ‫بال‬) I ) ‫ِّلمستوى‬‫ا‬‫األول‬
‫يمشي‬‫قصور‬ ‫وجود‬ ‫مع‬) II ) ‫ِّلمستوى‬‫ا‬‫الثاني‬
‫يمشي‬‫باليد‬ ‫تمسك‬ ‫تنقل‬ ‫أداة‬ ‫باستخدام‬) III ) ‫ِّلمستوى‬‫ا‬
‫الثالث‬
‫يعتمد‬‫وجود‬ ‫مع‬ ‫التنقل‬ ‫نفسه‬ ‫على‬ IV ) ‫ِّلمستوى‬‫ا‬‫الرابع‬
‫قصور‬‫تنقل‬ ‫جهاز‬ ‫استخدام‬ ‫احتمال‬ ،
‫آلي‬)
‫النقل‬‫آخر‬ ‫شخص‬ ‫بواسطة‬(‫بواسطة‬ V ) ‫ِّلمستوى‬‫ا‬
‫الخامس‬
‫يدوي‬ ‫متحرك‬ ‫كرسي‬‫مثال‬)
GMFCS – E & R
Gross Motor Function Classification
System
Expanded and Revised
Total forefoot varus weightbearing compensation
CP Lower Limbs

20. Treatment Alternatives
◦ PT/Splints(AFO, dynamic
AFO, GR AFO)
◦ Medications (baclofen)
 Oral 0.75-2 mg/kg
 intrathecal pumb
◦ Botox, phenol, alcohol
injection
◦ Surgery
 Impact of surgery on
GMFCS
 Depends on levels of
deformity
 Level I: dynamic
 Level II: static with no skeletal
changes
 Level III: static with skeletal
changes (bone deformity or
joint dislocation)
Levels of deformity and treatment options
Level of
Deformity
Pharmacologic/
Neurosurgery
Muscle &
Tendon
Surgeries
Bony Surgeries
I. Dynamic soft
tissue
imbalance, no
skeletal
deformities
_ Botulinum toxin
Injection
_ Selective dorsal
rhizotomy
_ Intrathecal baclofen
_ Partial/complete
tendon transfers
_ Not appropriate
II. Fixed soft tissue
imbalance, no
skeletal
deformities
_ Not appropriate as
isolated intervention
_ Serial stretch casting
_ Lengthening
(multiple possible
techniques)
_ Not appropriate
III. Fixed soft tissue
imbalance, with
skeletal
_ Not appropriate as
isolated intervention
_ Appropriate in
conjunction with
skeletal surgery
_ Reshaping
Osteotomies
_ Arthrodesis
CP Lower Limbs

21. Surgical Management
◦ Hip
 Adductor tenotomy
 Psoas tendon recession
 Hip sublux/ dislocation
 Adductor release
 Varus STO
 Pelvic osteotomy
 Excessive medial torsion
 Femoral derotation
 Hip abductor contracture
 Abductor release
 Painful hip
 Proximal femoral resection
CP Lower Limbs

22. Surgical Management
◦ Knee
 Flexion deformity
 Hamstring release
 Posterior knee capsulotomy
??
 Anterior 8 plate
 Supracondylar osteotomy +
patellar tendon advancement
 Tight rectus
 Rectus femoris transfer
 Patella alta
 Patellar tendon advancement
 Management of the Knee in
Spastic Diplegia: Young et al
CP Lower Limbs

23. Surgical Management
◦ Foot
 Level of deformity(I,II,III)
 Components of deformity
(ankle,hind,mid,forefoot)
 Tib ant split transfer (dynamic
forefoot supination in swing)
 Tib post recession/split transfer
(equinovarus foot in stance)
 Gastrocnemius recession
 Calcaneus med/lat sliding
osteotomy in rigid hindfoot
 Subtalar fusion (5-7y
planovalgus) foot/triple fusion
(severe cases 10y). Subtalar
arthroersis is contraindicated
 Lateral column lengthening
 Medial column lengthening
 MTP fusion in halux valgus
 Combinations of surgeries is the
rule
CP Lower Limbs
1
2
3

24. Quiz 1
A six-year-old male child has
cerebral palsy and limited
ambulatory function.
Physical exam is notable for mild
spasticity in all four extremities,
with the lower extremities
demonstrating more involvement
than the upper extremities.
Cognitive function is mildly delayed
for chronologic age.
Which of the following terms best
describes this patient's cerebral
palsy?
1- Hemiplegia
2- Diplegia
3- Paraplegia
4- Monoplegia
5- Total body
Physiology:
-Spastic: increased muscle tone and
hyperreflexia with slow restricted movements
secondary to simultaneous contracture of
agonists and antagonists. This is the most
common form.
- Athetosis: constant succession of slow,
writhing involuntary motions
- Ataxia: Inability to coordinate muscles for
voluntary movement. Characterized by wide-
based gait.
- Mixed: combination of spastic and athetosis
with total body involvement.
Anatomy:
- Hemiplegia: Affecting both limbs on one side,
arm usually worse than leg.
- Diplegia: Affecting right and left side equally.
Minimal spasticity may be present in upper
limbs, but lower limb spasticity
predominates. IQ may be near normal.
- Paraplegia: Affecting both legs, sparing of
arms.
- Quadriplegia: Both legs and both arms.
Associated with low IQ and higher mortality.
- Monoplegia: Affecting only one limb.

25. Quiz 2
The parents of a wheelchair-bound 8-year-old
boy with cerebral palsy present with difficulty
during diaper changes and with hygiene
care.
His physical exam demonstrates 5° of hip
abduction on the left hip and 15° on the right.
An AP pelvis radiograph is shown in figure .
What is the most appropriate treatment?
1- Bilateral botox injections and physical
therapy
2- Nighttime Pavlik harness
3- Bilateral abductor release and valgus
femoral osteotomies
4- Bilateral adductor release, varus femoral
osteotomies and acetabuloplasties
5- Observation with repeat radiograph in 6
months

26. Quiz 3
A 15-year-old, non-ambulatory patient with cerebral palsy
who is unable to maintain an upright head position against
gravity, has pain while sitting in his wheelchair.
An AP pelvis radiograph is shown in FigureA and attempted
frogleg lateral view in Figure B.
A preoperative CT scan (Figure C) demonstrates significant
femoral head flattening.
What is the most accurate Gross Motor Function
Classification System level, and what is the most
appropriate surgical intervention?
1- GMFCS V: Open reduction with varus derotational
osteotomy, femoral shortening, psoas release, and pelvic
osteotomy
2- GMFCS I: Hip adductor and psoas release plus abduction
bracing
3- GMFCS V: Open reduction with varus derotational
osteotomy
4- GMFCS V: Proximal femoral resection
5- GMFCS I: Open reduction with femoral varus derotational
and pelvic osteotomy

27. Dr Samir Zahed
Benha University, Egypt
March 2017