Orthopaedic Considerations in Cerebral Palsy
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Transcript of Orthopaedic Considerations in Cerebral Palsy
Orthopaedic Considerations in Cerebral Palsy
Stewart Morrison
Western Health Friday Presentation
20th January 2012
Definition + Aetiology“a disorder of movement and posture due to a defect or lesion in the developing brain”
Not a diagnosis, but a heterogenous collection of clinical syndromes
Cerebral lesion is static, musculoskeletal pathology is progressive
Prenatal placenta insufficiency, toxins, genetic factors, TORCH
Perinatal premature delivery, hypoxia, infection, kernicterus, haemolytic disease
Postnatal infection, trauma
ClassificationType of Motor Disorder
Spastic pyramidal system (motor cortex)
Athetoid extrapyramidal (basal ganglia)
Ataxis cerebellum + brainstem
Rigid basal ganglia + motor cortex
+ Mixed
Limbs Involved
Monoplegia one limb (rare)
Hemiplegia one side
Diplegia lower limbs, assymetrically
Triplegia three limbs (rare)
Quadriplegia four limbs
DemographicsTwo per 1000 live births
50% have normal intelligence, 25% able to self-support as adult
Incidence remains static +/- increasing
Clinical Features IDependent on:
I.Severity of neurological lesion
II.Location of neurological lesion
III.Age of child
✚Absence of normal reflexes (blinking, sucking)
✚Persistence of abnormal reflexes (Moro’s reflex)
✚Delayed motor milestones (head control 3 months, sitting 6 months, walking 12 months)
✚Gait disturbance
✚Epilepsy, speech and hearing difficulties, visual defects, feeding difficulties, drooling, learning, behavioural problems
Clinical Features IIPosturing sitting (hypotonic slump)
standing (crouchposture, spastic posture, pelvic obliquity, loss of lumb. Lordosis)
Gait athetoid or ataxic movement
Neuromuscular UMN or spastic paresis
resistance to passive movement
Babinski +ve
Deformities Equinus
FFD Knee
Pathology I
Skeletal muscle growth depends on regular stretching of relaxed muscle, under physiological loading
In CP:✚Muscle does not relax (spasticity)✚Reduced activity (weakness + balance)
Pathology II
I. Dynamic Contractures correctable deformity
II. Muscle Contractures fixed deformity
III. Secondary Bone Changes e.g. medial femoral torsion, lateral tibial torsion
Management ConceptsLimitations
✚Treating the sequelae of a neurological lesion, not the lesion itself
✚Many of the operations were developed for the management of polio myelitis
Stage I Physiotherapy, Orthotics, Botulinum Toxin, Selective Posterior Rhizotomy
Stage II Timing critical and controversial
Unpredictable results
Staged vs. single procedures
Stage III Correctional osteotomies for torsional + joint deformities
Tendon Transfer: Principles✚ Correct joint contractures ✚ muscle of adequate strength✚ muscle of adequate excursion ✚ one tendon for one function ✚ an expendable donor ✚ a straight line of pull ✚ Position and time transfers so that they lie in tissue of optimal condition
Lower Extremity IAge of surgery critical✚Gait evolves into adult pattern by age seven years✚Gait deterioration during adolescence is quite common
Preoperative evaluation✚Multiple joint evaluation required
✚ Eg. TA correction in presence of tight hamstrings will result in persistent crouch at knee and calcaneus gait
✚Gait Analysis critical✚ Swing-phase foot clearance, foot progression angle
Lower Extremity IIHemiplegia
Group I mild foot-drop gait leaf-spring AFO
Group II equinus gait stretching casts, botulinum toxin, AFO, lengthening
Group III Knee, medial hamstrings, gastroc recession, medial hamstring lengthening,
quadricepts involvement distal rectus femoris transfer
Group IV Hip flexion, medial torsion lengthening psoas, external rotation osteotomy, and above
Spastic Diplegia Most achieve good function
Hip flexors, adductors, medial rotators, calf most affected
Secondary bone torsional problems
Lower Extremity IIILengthening Achilles Tendon overused
“a little equinus is better than calcaneus”
? Silveskiod Test (Gastroc vs. Soleus)
Gastrocnemius Recession
Z Lengthening or Percutaneous Techniques
Varus Deformity of the Foot Tib Post usually resonsible (stance and swing)
Tib Ant (swing only)
Lengthening vs. transfer
Valgus Deformity Lengthening, Fusion, Osteotomies
Lower Extremity IVKnee Flexion Contracture “crouch”
Surgical lengthening of medial hamstrings
consideration of NV bundle in severe contracture
Stiff-Knee Gait may occur if rectus femoris co-spasticity
Rectus Femoris transfer indicated
Hip Flexion Contractures often secondary to knee/ankle issues
Thomas or Staheli tests
Psoas lengthening
Lower Extremity V
Hip Subluxation
Rotational Osteotomies
Hip Reconstructive Surgery
(spastic quadriplegia)
Upper Extremity
Evaluation✚Sensation✚Electromyography
Principles✚Define goals✚Restore✚Rebalance
Upper Extremity
Shoulder✚Internal rotation, adduction common Botulinium type A
Supscapularis, Pec Major lengthening
External rotational osteotomy
Elbow✚Static and dynamic flexion contractures flexor release dependent on NV bundle
Wrist/Digits✚Wrist flexion +/- pronation, ulnar deviation lengthening and transfer procedures
Thank youBARCZYNSKI, A., PASIERBEK, M., GAZDZIK, T. S. & KLOSA, Z. 2002. Management of foot deformity in cerebral palsy. Ortop Traumatol Rehabil, 4, 21-6.
GRAHAM, H. K. 2005. Classifying cerebral palsy. J Pediatr Orthop, 25, 127-8.
KAROL, L. A. 2004. Surgical management of the lower extremity in ambulatory children with cerebral palsy. J Am Acad Orthop Surg, 12, 196-203.
GRAHAM, H. K. 2003. Musculoskeletal Aspects of Cerebral Palsy. Journ. Bone & Joint Surgery (British). 85-B, 2:157
SAEED, W. R. 2003. Cerebral Palsy of the Upper Extremity: A Surgical Perspective. Current Orthopaedics. 17:105-116