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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
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.
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.
Multi
disciplinary
approach
• Speech
• Hearing
• Vision
• Intellect
• movement
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.
DIAGNOSTIC MATRIX
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?
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
ASSESSMENT
Tailored to assess for:
I. Topographical type
II. Type of movement disorder
III.Presence Infantile reflexes
IV.Structural changes
TOPOGRAPHICAL TYPE
• Monoplegia
• Hemiplegia
• Paraplegia
• Diplegia
• Triplegia
• Quadriplegia
• Total body involvement
TYPES OF MOVEMENT DISORDERS
Athetoid: 10%
Ataxic: 5%
MIXED: 12%
HYPOTONIC: 1%
Spastic: 65%
Manageable
 Dynamic
 Static
Motor performance of spastic Diplegic
children
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.
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
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
gross
Grasp
fine
- Release
- Stereognosis
- R.O.M. of joint
- Fixed deformities
- Muscle power
UPPER LIMB: Assessment
LOWER LIMB ASSESSMENT
Dynamic
Contractures
Fixed
• R.O.M.
• Muscle Power
• Muscle acting on more than
one joint
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
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.
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
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]
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.
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
Rodda et al. JBJS. 2004
Type 1 – Diplegia True equinus
• Hip extension
• Knee extension
• Ankle equinus
Pic Courtesy: Sharaf Ibrahim, Malaysia
Type 2 – Diplegia Jump gait
Jump Gait with
• Bilateral hip
Flexion
• Knee flexion
• Ankle Equinus.
Type 4 – Diplegia Crouch gait
Crouch gait with
• Bilateral hip Flexion
• Knee flexion
• Ankle dorsiflexion.
Apparent Equinus
[Dynamic Equinus]
• Hip flexion
• Knee flexion
• Ankle neutral..
plantigrade
Pic Courtesy: Prof. Sharaf Ibrahim, Malaysia
CLINICAL TESTS
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
Gracilis spasticity – Phelp’s Test
• Passive abduction with knee in extension.
• Improved hip abduction with knee flexion indicates
Gracilis / medial hamstring tightness. Why?
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
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
Achilles Stretch Test
Silverskiold test- Gastroc. vs Soleus
“Spastic Gastrocnemius contracture”
Correction of ankle
equinus with
Knee flexion indicates
Predominantly
gastrocnemius
Contracture. Why?
Thomas Test for Hip Flexors
• Easy & simple, well
known
• Thomas test steps
• Problem : depends on
how much is the other
hip flexed
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.
Staheli’s Hip Flexors Stretch test
• More accurate for
FFD hip
• Prone position
• Pelvis over table edge
Thomas test
Staheli’s
Ely Duncan Test
• Pelvis rise on
knee flexion.
• Significance ?
Rotational Malalignment
• Foot propagation angle
• Femoral rotation
Internal / External
Rotation
• Fem Ant version
• Tibial rotation
Foot – Thigh Angle
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.
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
ADDITIONAL CLINICAL ASSESSMENT
• Plaster cast: BK to assess Ankle contracture
AK to assess Knee contracture
• Myoneural block: Botox injections
• Examination under anesthesia: Per operative
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
NED University Gait Laboratory:
Video-graphic Gait Analysis (VGA)
Gait Lab test being performed on patients during CP workshop on
19 March 2011
PEDOGRAM:
Cavovarus & Planovalgus
EMG:
Indicating spastic, normal & Weak Muscles
Gait Laboratory: VGA
Modified Ashworth Scale
Muscle Tone
Medical Research Council Grading
Muscle Power
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 ?
What are the findings?
Which test being performed?
Any mistake in performing test?
What are the findings
Which test is being performed
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
Case 2 Aws: 9 yr old, H/O Liquor aspiration Birth
Asphyxia. Delayed milestones.
Walked independently for few years, then
deteriorate with abnormal Gait.
9 yr old, Male, H/O birth asphyxia,
Delayed milestones.
What are the Findings
Which type of walker he is?
Which type of Gait?
Which tests are being performed
What R Findings
What is wrong in performing
these tests ?
9 yr old, Male,
H/O birth
asphyxia,
Delayed
milestones.
Walked
independently
for six years,
deteriorated in
last 3 years
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.
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.
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
12 year Ayn.
Fractional Lengthening Hamstring
Position Incision
Semitendinosus lengthening
Semitendinosus tendon
distal attachment transection
Semitendinous attachment to proximaly
transected Gracilis tendon
Fractional Lengthening Hamstring
Semimembranous muscle sheath
V-transection
Post-lengthening Position
Achilles TL
FHL lenghtened + Tibio Talar
capsulotomy
TibP lengthening
Posterior Lenghtening
Ala Carte’ approach
Tibialis Anterior Transfer to 3rd
Cuneiform
TibA transfer
Tibialis Anterior Transfer
Attached with Button Sutured with periostium dorsally
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
• Silverskiold test neg
Rt -30
Lt -10
• Equinus rigid
• FHL, FDP tight
• Plantar fascia tight
• Achilles Tendon tight
• Knee and Hip =
unremarkable
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
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
My Contacts:
dranisbhatti@gmail.com

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Prof. Anisuddin Bhatti Cerebral Palsy case Orthopaedic Examination lecture on zoom 23.8.20 potf

  • 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.
  • 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
  • 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
  • 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
  • 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

Editor's Notes

  1. Sitting posture … Supported Equinus Walking Gait …. Jump, Knee recurvatum & Rocker bottom
  2. Hamstring Tightness, POP Angle 90-90 & Silverskiold test … Plantigrade (Negative) Hip FFC Thomas test … Negative
  3. Hip Rotation Equal Int & Ext Rot & bilat 250 ,450 Rectus Strech Test Negative