Management of the Upper Limb
in Children with Cerebral Palsy
Prof P McArthur FRCS(Plast) PhD
Consultant in Congenital Hand and Upper Limb Surgery
Department of Plastic Surgery
Royal Liverpool Children's Hospital
Alder Hey
Liverpool
Introduction
 Why Upper limb?
 Which Botulinum Toxin?
 Why Ultrasound?
Technique
 Sonography guided
injection of Botulinum
toxin
 Multilevel, multisite
 Dose range per child
used 4 to 20 units/Kg
Visualization of muscle groups?
Visualization of muscle groups
PL
FCR
PT
The Multidisciplinary Team
Hospital
Physiotherapist
Specialist Children's
Hospital
Hospital Occupational
Therapists
The Family and
Child
Community
Physiotherapists
Community
Occupational
Therapists
Consultant Paediatric
Neurologist
Consultant Upper Limb
Surgeon
Consultant Lower
Limb Surgeon
Post Injection Management
 Physiotherapy – Stretch
 Physiotherapy – Strengthen Agonists
 Splintage
Why the controversy?
 Very little level 1 evidence
 Variation in post injection regimes
 Inherently heterogeneous patient group
 Difficulty in establishing treatment goals
Our Experience
 41 patients 2004 – 2008
 M:F ratio, 15:26
 Mean age at first injection 11 years (range 3 – 16 yrs)
 9 Bilateral Upper Limb injections
Treatment Patterns
 14/41 Required 2 Treatments
Mean time to reinjection
8 months (range 3-16 months)
 3/41 Required 3 Treatments
Mean time to reinjection
10 months (range 5-15 months)
Outcomes
 More reliable targeting of treatment due to toxin
used and method of disposition
 “Soft” outcome measures:
 Better posture
 Better hygiene

Better function
Functional Ability
 ABILHAND-Kids questionnaire
 21 tasks
 Bimanual ability assessment
 Discriminators of difficulty
 Base line assessment of function
Goal Attainment
 Individualized outcome markers
 Functionally relevant
 Goal Attainment Scaling
Summary
 Ultrasound guided treatment allows precise disposition
of toxin to desired site
 Botox is the preparation of choice
 A multi disciplinary approach is required to maximize
gains
 High level supporting evidence is elusive
 Individual goals for each child should be identified
Surgical Strategies
Indications
 Pain
 Failure of Toxin Therapy
 Established Contractures
 Hygiene / Dressing / Transfer
Indications
FUNCTION
Principles
Lengthen Tendon
vs
Shorten Skeleton
Surgical Options
 Tendon
 Transfer
 Lengthening
 Release
 Tightening
 Skin Procedures
 Bone / Joint
 Osteotomy
 Excision Arthroplasty
 Arthrodesis
Tendon Transfer Principles
 Subtle Joints
 Stable Joints
 Active Excursion
 Healthy Soft Tissue
 One Tendon One Joint
 One Action
 Synergy
Tendon
 Principles and Aims Differ
 Internal Splinting
 Which Procedure?
 Divide / Lengthen / Transfer
 Depends on which Musculotendinous unit
 Requirements
Bone / Joint
 Arthrodesis
 Thumb CMCJ
 Excision Arthroplasty
 Proximal Row Carpectomy + Tendon Surgery
 Osteotomy
Post Op Care
 Casting
 Splinting
 Therapy
Questions?