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
Perinatal
Postnatal
placenta insufficiency, toxins, genetic factors, TORCH
premature delivery, hypoxia, infection, kernicterus, haemolytic disease
infection, trauma
Classification
Type of Motor Disorder
Limbs Involved
Spastic
Athetoid
Ataxis
Rigid
+ Mixed
Monoplegia
Hemiplegia
Diplegia
Triplegia
Quadriplegia
pyramidal system (motor cortex)
extrapyramidal (basal ganglia)
cerebellum + brainstem
basal ganglia + motor cortex
one limb (rare)
one side
lower limbs, assymetrically
three limbs (rare)
four limbs
Demographics
Two per 1000 live births
50% have normal intelligence, 25% able to self-support as adult
Incidence remains static +/- increasing
Clinical Features I
Dependent 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 II
Posturing
Gait
Neuromuscular
Deformities
sitting (hypotonic slump)
standing (crouchposture, spastic posture, pelvic obliquity, loss of lumb. Lordosis)
athetoid or ataxic movement
UMN or spastic paresis
resistance to passive movement
Babinski +ve
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
II. Muscle Contractures
III. Secondary Bone Changes
correctable deformity
fixed deformity
e.g. medial femoral torsion, lateral tibial torsion
Management Concepts
Limitations
✚ 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
Stage II
Stage III
Physiotherapy, Orthotics, Botulinum Toxin, Selective Posterior Rhizotomy
Timing critical and controversial
Unpredictable results
Staged vs. single procedures
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 I
Age 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 II
Hemiplegia
Group I
Group II
Group III
Group IV
mild foot-drop gait
equinus gait
Knee, medial hamstrings,
quadricepts involvement
Hip flexion, medial torsion
Spastic Diplegia
leaf-spring AFO
stretching casts, botulinum toxin, AFO, lengthening
gastroc recession, medial hamstring lengthening,
distal rectus femoris transfer
lengthening psoas, external rotation osteotomy, and above
Most achieve good function
Hip flexors, adductors, medial rotators, calf most affected
Secondary bone torsional problems
Lower Extremity III
Lengthening 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 IV
Knee 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 you
BARCZYNSKI, 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