CEREBRAL PALSY
Thammanoon Srisaarn , MD.
Orthopaedic department
Pramongkutklao hospital
CEREBRAL PALSY
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NON PROGRESSIVE (immature)BRAIN
LESION RESULTS IN MOTOR
IMPAIRMENT(may be other)
 Uncertain
cause
 Nearly drowning, infectious meningitis
 Manifestration progress
CLASSIFICATION
PHYSIOLOGIC (Neuropathic)
 GEOGRAPHIC (Anatomic)
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PHYSIOLOGIC(NEUROPATHIC)
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SPASTICITY(PYRAMIDAL SYSTEM)
ATHETOSIS(EXTRAPYRAMIDAL)
CHOREIFORM
DYSTONIA
HYPOTONIA
ATAXIC (CEREBELLUM)
MIXED
GEOGRAPHIC(ANATOMIC)
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DIPLEGIA
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HEMIPLEGIA
DOUBLE HEMIPLEGIA
PARAPLEGIA
TRIPLEGIA
QUADRIPLEGIA (TETRAPLEGIA)
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TOTAL BODY INVOLVEMENT
MONOPLEGIA
MANIFESTRATION
SPASTIC DIPLEGIA 8- 10 MO.
 SPASTIC HEMIPLEGIA 20-24 MO.
 ATHETOID > 24 MO.
DEPEND ON MYELINATION
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Factors affect walking ability
(diplegia)
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Severity of lower ext. involvement
Seizure
Marked flaccidity
Persistent abnormal primative reflexes
Dislocated hip
Intelligence, mental retardation
Upper ext. involvement
Birth weight
BLECK’S WALKING PROGNOSIS
(after 12 mo.)
1. ASYMMETRIC TONIC NECK REFLEX
2. NECK RIGHTING REFLEX
3. MORO REFLEX
4. SYMMETRIC TONIC NECK REFLEX
5. EXTENSOR THRUST
6. PARACHUTE REACTION
7. FOOT- PLACEMENT REACTION
SCORE > 2 POOR
PROGNOSIS
PROGNOSIS
 GOOD PROGNOSIS FOR WALKING
- HEAD BALANCE BEFORE 9 MO.
- INDEPENDENT SITTING BY 24 MO.
- CRAWLING BY 30 MO.
 POOR PROGNOSIS
- LACK OF HEAD CONTROL BY 20 MO.
(Camposda paz)
PROGNOSIS
 SITTING BEFORE 2 YR USUALLY WALK
INDEPENDENT
 2-4 YR 50% WALK INDEPENDENTLY
 > 4 YR RARELY STAND OR WALK WITHOUT SUPPORT
 NEVER LEARN TO WALK BEFORE 8 YR UNLIKELY TO
WALK (Motor improve plateau 7 yr.)
(Beal )
PROGNOSIS
 2 YR. WITH INDEPENDENT SITTING
- NOT A GOOD PREDICTOR FOR WALKING
ABILITY
 INABILITY TO SIT AFTER 4 YR.
- PREDICTED NONAMBULATION
(Molnar and Gordon)
EVALUATION
HISTORY
 OBSERVATION
 EXAMINATION
 GAIT ANALYSIS
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OBSERVATION
POSTURE
 GAIT
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CROUCH
JUMP
PHYSICAL EXAMINATION
HIP FLEXION DEFORMITY
THOMAS TEST
Modified Thomas test
MODIFIED THOMAS TEST
STAHILI TEST
DUNCAN-ELY TEST
PHYSICAL EXAM.
ADDUCTION DEFROMITY
PHELPS TEST
KNEE EXAMINATION
KNEE FLEXION DEFORMITY
LACK OF FULL EXTENSION ON
INITIAL CONTACT,STANCE
AND INITIAL SWING PHASE
POPLITEAL ANGLE
SLRT
TEST FOR RECTUS TIGHTNESS
KNEE EXTENSION DEFORMITY
PHYSICAL EXAMINATION (SILVERSKIÖLD)
FOOT : EQUINUS DEFORMITY
MOST OFTEN IN HEMIPLEGIA
EQUINOVARUS DEFORMITY
VARUS DEFROMITY
TIBIALIS POSTERIOR  HINDFOOT VARUS
OR
TIBIALIS ANTERIOR  FOREFOOT SUPINATION,
HINDFOOT VARUS (SWING PHASE)
WEAK PERONEUS
PES VALGUS DEFORMITY
Peroneal hyperactivity
TREATMENTS
PRIORITY
 COMMUNICATION
 ADL
 MOBILITY
 WALKING
SURGICAL TREATMENT
SPASTIC TYPE
 AGE 4-8 YEAR IS PROPER
 YOUNGER
HIGH RECURRENCE
 MATURE GAIT
~ 7 YEARS
 SEQUENTIAL V/S ALL AT THE SAME
TIME
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Surgical treatment
Hip flexion deformity
Thomas test 30O
 Modified Thomas test 20O
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Surgical treatment
Hip adduction deformity
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Passive abduction < 30O
both in hip flexion & extension
HIP AT RISK
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Quadriplegia, Nonambulator
Age 2-6 yr.
< 30O abduction in flex or ext.
> 20O flexion contracture
valgus and anteversion
Shallow acetabulum AI > 40
Abnormal migration index
FILM PELVIS EVERY 12 MO. FOR NONAMBULATOR
ACETABULAR INDEX
A
B
C
AB/AC= MIGRATION INDEX (MI)
> 1/3 = subluxation
SURGICAL TREATMENT ON THE
HIP
ADDUCTOR LONGUS TENOTOMY
 ANT. HALF OF ADD. BREVIS
 GRACILLIS
 PSOAS TENOTOMY OR LENGTHENING
preserve iliacus
 RECTUS FEMORIS LENGTHENING
 PROXIMAL HAMSTRINGS RELEASE
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MANAGEMENT OF HIP AT RISK
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AGE < 4 YR. SOFT TISSUE RELEASE(45O Abd in
Ext,60O in Flex.)
AGE 4-8 YR.
MI 25-60%, ABDUCTION <30O ==>RELEASE
MI > 60%, NOT IMPROVE IN 1 YR.==> OR+
CAPSULORRAPHY+
BONY RECONSTRUCTION
AGE > 8 YR
MI
> 40% RELEASE & BONE RECONSTRUCTION
Flynn JM. AAOS 10(3): 2002
Hip subluxation
MI > 30 %
 Soft tissue release for very young
 MI > 50% open reduction + femoral
osteotomy
 AI > 25O pelvic osteotomy
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Management of hip dislocation
Observation
 Open reduction + osteotomy + soft tissue
release
 Resection arthroplasty
 Arthrodesis
 Total hip replacement
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Neck shaft angle < 115O
Anteversion10-20O (30-45O passive IR)
SURGICAL TREATMENT ON THE
KNEE
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SLRT < 60O, PA > 45O
MEDIAL HAMSTRINGS
RELEASE
LATERAL HAMSTRINGS
RELEASE
RECTUS FEMORIS RELEASE
RECTUS FEMORIS TRANSFER
HAMSTRING RELEASE
RECTUS FEMORIS TRANFER