Orthopaedic evaluation of cerebral palsy

1. Evaluation of Cerebral Palsy
Dr. Jose Austine
Resident, Dept. of Orthopaedic surgery,
Kasturba Medical College, Mangalore
Moderators
Dr. Deepak Pinto
Dr. Sharan Mallya

2.  William John little – First clinical report of CP (1843)
 Sir William Osler – Coined the term “ Cerebral Palsy “
 Sigmund Freud – Complete description of CP
HISTORY
William John Little William Osler Sigmund Freud

3.  Nothing can be done
 Do exercises Go to
therapist
 Do not operate your
child will become worse
 Adductor tenotomy
with obturator
neurectomy

4. •Is it a Disease?
Is it A Diagnosis?
Is it A Description?

5. Cerebral Palsy-Definition
Cerebral Palsy describes a group of
permanent disorders of the development
of movement and posture, causing activity
limitation that are attributed to non
progressive disturbances that occurred in
the developing foetal or infant brain.

6. Cerebral Palsy-Definition
Cerebral palsy is the result of a brain lesion
Spinal cord and muscles are structurally normal
Brain lesion must be fixed and non progressive
All progressive and neurodegenerative disorders
are excluded from the definition
Abnormality of the brain results in motor impairment

7. Etiology
Prenatal :
 Brain Malformation
 Vascular events
 Maternal infection
 Metabolic disorders
 Toxins
 Genetic syndromes
 Pre-eclampsia in term infants
 Antepartum haemorrhage
 Multiple-birth pregnancy
 In utero death of co-twin

8. Perinatal :
 Preterm birth
 Low birthweight
 Intrapartum hypoxia
 Hypoglycemia
 Infection
 Low placental weight, Low Apgar scores, Prolapsed Cord
 Haemorrhage, Traumatic delivery
 Cephalopelvic disproportion, Abnormal foetal presentation
 Maternal shock, Chorioamniotis
 Prolonged second stage of labor, Emergency cesarean
section
Etiology

9. Postnatal :
 Infection, e.g., meningitis, septicemia, Traumatic
brain injury
 Near-drowning
 Stroke
 Neonatal seizures
 Sepsis
 Respiratory disease
 In preterm infants: patent ductus arteriosus,
complicated neonatal course
Etiology

10. Classification-
Physiologic
Pyramidal Extra-pyramidal
Athetoid
Spastic Choreiform
Rigid
Ataxic
Hypotonic

11. “It is important to correctly classify the
movement disorder of a patient with CP
because the results of surgical treatment
are unpredictable for all but purely
spastic patients.”

12. Classification-
Geographic

14. Winter’s Classification of spastic
hemiplegic cerebral palsy in children
GROUP CRITERIA
0 unclassified Not 1, 2, 3 or 4
1 No ankle dorsiflexion above
neutral in swing
2 No ankle dorsiflexion above neutral in
stance or swing and sometimes knee
hyperextension
3 Knee range of motion <45 and
swing range of motion <50
4 Hip range of motion <35

15. More than one helping hand…..

16.  Speech Evaluation
 IQ Assessment
 Psychological Evaluation
 Ophthalmological Evaluation
 Occupational Therapy evaluation
 Neurologist Evaluation
 Orthopaedic assessment
ASSESSMENT OF A CHILD
WITH CP SHOULD INCLUDE

17. Orthopaedic Evaluation
 History
 Physical Examination
 Gait analysis- observational and gait lab
 Histopathology and Imaging

18. History
Birth History Motor Milestones
 Birth weight
 Gestational age at birth
 Complications after birth
 NICU hospitalisation
 Ventilatory support

20. History
Birth History Motor Milestones
Preferential use of limb Related medical conditions
 Birth weight
 Gestational age at birth
 Complications after birth
 NICU hospitalisation
 Ventilatory support
 May indicate spastic hemiparesis
of the other extremity
 Visual abnormalities
 Difficulty swallowing
 Speech development
 Seizures

21. Physical Examination
1. Muscle tone assessment
2.Muscle strength examination
3.Selective motor control
4. Balance, equilibrium responses during sitting, standing and walking
5. Muscle length examination for shortening
6. Muscle length examination for elongation
7. Joint deformities
8. Torsional bone deformities

22. Muscle tone assessment
 Tone: The resistance to passive stretch while a person
is attempting to maintain a relaxed state of muscle
activity.
 Spasticity: Abnormally increased contraction of a
muscle in response to a stretch. Growth of muscles is
impaired. Clasp knife phenomenon seen.
 Rigidity: Involuntary sustained contraction of a muscle
not stretch-dependent. Growth of muscles is not
impaired. Cog wheel or lead pipe.

24. Muscle tone assessment
Evaluate the patient in a quiet and comfortable
surrounding.
Important to evaluate the child on two or more
occasions as a great deal of variation may be seen in
muscle tone.
Dystonia is characterised by change in muscle tone
with change in behaviour or posture.
Orthopaedic surgery should be considered with
extreme caution in presence of dystonia.

25. “OPERATE ONLY WHEN PURE
SPASTICITY, AVOID WHEN
DYSKINESIA OR MIXED PATTERN.”

26. Muscle tone assessment

27. Muscle tone assessment
Tardieu scale
Assesses spasticity by passively moving the joints at two specified
velocities (slow and fast) while the intensity and
duration of the muscle reaction to stretch (X) is rated on a 6-point scale
with the joint angle (Y) recorded at where the muscle reaction is first felt.
In essence, the scale assesses dynamic and static muscle length as well
as joint range of motion.
Helps to determine dynamic spasticity which may be amenable to treatment
with drugs.

31. Selective Motor Control
• Involves isolating movements on request, appropriate timing
and maximal voluntary contraction
• Muscle selectivity scaled into three grades of control to isolate mo
0- No ability
1- Partial ability
2- Complete ability

32. Muscle strength
 Manual muscle testing
 Hand held dynamometer

33. Posture and Balance
 During sitting, standing and walking
 Can the child sit unsupported without use of hands?
 Can the child get into a sitting position without assistance?
 Is the child’s balance easily disturbed in the sitting position or as the walks?
 Children with CP have deficient equilibrium responses.
 Posterior, anterior and lateral equilibrium responses should be
evaluated.
 Poor balance requires supportive devices.
 Ambulatory status should be assessed using GMFCS

34. Assessment for contracture
Following muscle groups are assessed for muscle shortening:
• Hip flexors
• Hip adductors
• Knee flexors
• Ankle plantar flexors
• Foot invertors and evertors

35. Tests
 Thomas test
 Duncan Ely test
 Staheli’s test
 Phelp’s gracilis test
 Popliteal angle
 Silfverskiold test
 Flexion withdrawal test
 Straight leg raising test
 Evan’s test
 Ober’s test

36. Thomas Test

37. Duncan Ely’s test
 Tests spasticity of rectus femoris
 Prone and each leg is flexed at the knee.
 If the patient has a tight rectus femoris or a hip flexion contracture,
the hip on the same side will flex raising the buttock off the table.

38. Staheli’s prone hip flexion contracture test
 To measure hip flexion contracture
 Patient prone with pelvis over table’s edge and limb hanging free in
flexion
 One hand over PSIS, while the hip under examination is extended
 Point of contracture is when the pelvis begins to tilt posteriorly

39. Phelp’s gracilis test
 To test for gracilis contracture
 Patient prone the examiner passively abducts both thighs as far as
possible, then flexes knees to 90 deg & tries to abduct hips further.
 Test is positive if abduction increases further

40. Popliteal angle and SLRT
 To test for hamstring contracture

43. Silverskiold
test

44. Flexion withdrawal test
(Confusion test)
 Frequently, active dorsiflexion can be obtained only with the
flexor withdrawal reflex
 Test:
 Flex the knee 90 degrees over the table’s edge and the patient
is asked to flex the hips while the examiner resists flexion of the
thigh.
 Automatic dorsiflexion of the ankle occurs in a positive response

45. Ober’s test

46. Muscle length assessment
for elongation

47. Lower limb deformities in children
 Hip
- Flexion and adduction
- Internal rotation
- Subluxation/ disclocation
 Knee
- Flexion
- Recurvatum
-Patella alta
 Ankle
- Equinus
- Varus or valgus
 Foot
- Cavus
- Forefoot adduction
- Hallux Valgus
- Claw toes
 Gait
- Intoeing
- Scissoring

48. Upper limb deformities in children
The Flexed Wrist
The Flexed Elbow
The Pronated
Forearm
The Thumb-in-Palm
Deformity

49. Torsional Bone deformities
Normal anteversion
Excessive
anteversionIntoeing

50. Craig’s test
In prone, knee flexed to 90 deg. With one hand over the greater trochanter, the other
hand internally or externally rotates the leg till the trochanter is felt most prominent.
The angle of version is that subtended between the imaginary vertical to the long axis
of the leg.

51. Tibial Torsion
Thigh-Foot angle
Bi-malleolar axis method

52. Gait analysis- Observation
Observation of gait should be made in the following
three dimensions:
a. Coronal (patient walking away and toward the examiner)—
Trendelenberg gait, pelvic obliquity and equinus should be noted.
b. Sagittal (patient walking back and forth in front of the examiner)
Flexion/extension of hip, knee and ankle should be noted, as
well as step length.
c. Axial (looking vertically downward from above)—Internal and
external rotation of the femur, tibia, or foot should be noted.

56. • A child showing jumping gait pattern with hips, knees, and ankles in flexion.
• The patient needs to hold hands or use a walker, and rarely they can balance
themselves.

57. • Apparent equinus can be differentiated from true equinus by the position of the
ankle and knee in stance period.
• Apparent equinus gait has a relatively neutral ankle with increased knee flexion
whereas true equinus is associated with excess ankle plantar flexion.

58. Crouch gait

60. Scissoring gait

61. Gait analysis- Lab

62. Gross Motor
Function
Classification
System

63. In summary, gait analysis has the following purposes:
1. To clearly document the three dimensional movement of the
lower extremity.
2. To document changes in gait over time as patient grows.
3. To allow pre and post operative comparisons after tendon or
bone surgery
4. To analyse the rotational profile of the patient before surgery
and to help select the correct site and amount of rotational
change.
5. To confirm a surgical plan when needed.

64. HPE and Imaging
1. Periventricular leukomalacia
2. Intraventricular and periventricular
hemorrhage.
Patchy areas of necrosis secondary to
vascular insult in the periventricular white
matter

65. Radiological Evaluation
STAGES OF HIP DEFORMITY
Hip at risk
Hip abduction of <45° with
partial uncovering of the
femoral head on radiographs
Reimers index <33%
Hip subluxation
Reimers index >33%
Disrupted Shenton's line

66. STAGES OF HIP DEFORMITY
Spastic dislocation
Frankly dislocated hip
Reimers index >100%
Windswept hips
Abduction of one hip with
adduction of the contralateral
hip

67. Reimer’s Migration index
 Percent of femoral head with no acetabular coverage
 Most accurate method to identify and monitor hip stability
 < 33% = at risk
 > 33% = subluxated hip

68. THANK YOU