2. Introduction
• Cerebral palsy (CP) describes a group of
permanent disorders of the development of
movement and posture, causing activity
limitation, that are attributed to nonprogressive
disturbances that occurred in the developing
fetal or infant brain.
• Three distinctive features:
• Some degree of motor involvement
• Insult to the developing brain
• Non-progressive neurological deficit
DISORDER OF MOVEMENT
AND POSTURE DUE
TO DAMAGE
OF IMMATURE BRAIN.
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• The insult is believed to occur between the time of conception and 2
years.
• Although the neurological deficit is permanent, the orthopedic
aspects are dynamic.
• Children with CP consists of largest group of paediatric patients with
neuromuscular deficits.
• Most common physical disability of childhood.
4. Time of
insult to
brain
• Injury to the developing brain can
occur at any time from gestation
to early childhood.
• Hence, it can be Prenatal,
Perinatal, and Postnatal.
• Contrary to popular belief, fewer
than 10% of injuries that result in
cerebral palsy occur during the
birth process.
5. Time of insult to brain
Prenatal
• MC pattern
• Risk factor:
1. Foetal problems: Genetic disorders
2. Maternal problems: Seizure
disorders, Mental retardation,
previous pregnancy loss.
3. Pregnancy problems:
a) Rh incompatibility
b) Polyhydramnios
c) Placental rupture
d) Drug/alcohol exposure
e) TORCH syndrome
Perinatal AND Postnatal
• Asphyxia/trauma during labor.
• Risk factors:
• Oxytocin augmentation
• Umbillical cord prolapse
• Breech presentation
• LBW baby
• Hypoxic-ischaemic encephalopathy
(HIE), characterized by hypotonia, de
creased movements, and seizures.
• Encephalitis, meningitis (Group
B Streptococcus and Herpes)
• Traumatic brain injury (Child abuse)
8. Geographic Classification
• Monoplegia:
• Rare
• Meningitis
• Hemiplegia:
• Both extremity of the same side.
• UL>LL
• DIPLEGIA:
• MC presentation (50% of the cases).
• All 4 extremities involved.
• LL>UL
• Fine motor sensory abnormality in upper extremity
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• Quadriplegia:
• All extremities involved equally.
• Normal head/neck control.
• Total body:
• Profound cognitive defects along with loss of head/neck control.
• Require full-time assistance.
• Drooling, dysarthria, dysphagia common and complicate care.
• Other types:
• Double Hemiplegia ( bleeding into b/l ventricles, UL>LL)
• Paraplegia ( very rare, both LL equally involved)
10. Physiologic
classification
• Spastic:(increased tone and
exaggerated reflexes)
• MC form (80% of the cases)
• Injury to pyramidal tracts of
immature brain.
• Velocity dependant increase
in muscle tone with
passive stretch.
• Exaggeration of normal
muscle passive
stretch reflex.
• Deposition of type I collagen.
• Joint contractures,
subluxation, and
degeneration common.
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• Other types (Extrapyramidal tracts):
• Athetoid – Dyskinetic, purposeless movements exacerbated by environmental
stimuli.
• Choreiform – Continuous purposeless movements.
• Rigid – Most hypertonic; absence of hyperreflexia, spasticity, clonus;
cogwheel/lead pipe muscle stiffness.
• Ataxic – Very rare; injury to the developing cerebellum.
• Hypotonic – Weakness with low muscle tone, normal DTR.
• Mixed
15. • Clinical examination and history are primary tools.
• Thorough investigation of pregnancy and delivery.
• Delayed motor milestones.
• Primitive reflex patterns of motor activity persist longer than normal,
may be present persistently.
16. Poor prognostic signs
1. Imposable asymmetric tonic neck reflex.
2. Persistent Moro reflex.
3. Strong extensor thrust on vertical suspension.
4. Persistent neck righting reflex.
5. Absence of normal parachute reflex after after 11 months.
17. Decision
making
• David’s 5 steps paradigm for
clinical decision making:
1. Clinical history.
2. Physical examination.
3. Diagnostic imaging.
4. Quantitative gait analysis.
5. Examination under anaesthesia
18. Associated
conditions
• Mental impairment /
Learning disability (40%)
• Seizure disorder (30%)
• Complex movement
disorder (20%)
• Visual and Hearing
impairment.
• Malnutrition ( GERD,
obesity, undernutrition)
• Hydrocephalus (14%)
• Osteopenia with increased
risk of fractures (significant
femoral osteopenia, Z score
< -2, is seen in 80% of the
patients).
19. TREATMENT
• Individualized approach
• Multidisciplinary team approach - Physical, occupational, speech therapy,
orthotics, nutrition, social work, orthopedics, general pediatrics.
• Benificial to delay operative treatment until after significant growth spurt.
• We treat secondary deformities only and not the primary cause – brain
injury.
• Combined non-operative and operative approach benificial.
20. Non
operative
treatment
• By medication, splinting and
bracing, physical therapy.
• Dantrolene:
• Acts on the level of skeletal muscle.
• Affinity for fast twitch ms fibres –
selectively depress abnormal stretch reflex
and tone.
• Used less frequently due to complications
(Profound weakness, hepatotoxicity)
21. • Baclofen:
• Decrease abnormal flexor and extensor activity.
• Mimics the action of GABA.
• Baclofen pumps used now to decrease dosage of the drugs, side effects.
• Intrathecal baclofen delivery with pump placed subcutaneously in the
abdomen.
• Refilling every 2-3 months.
• Complications:
• Catheter or pump infection/malfunction.
• Spinal fluid leak
• Respiratory depression.
• Drug reaction.
• Oversedation.
22. • Botox:
• BTX-A used which selectively weaken
muscles selectively in patients pf CP.
• Block ACh release in the motor end
plate - inhibit muscle contraction.
• Diffuse only 2-3mm in tissues – easier
to achieve desired effects.
• Effect starts from ~ 24 hours and lasts
for 2-6 months.
• Used as an adjuvant to bracing, casting,
physical therapy.
23. • Physical therapy:
• Strengthening of weak muscles.
• Contracture prevention.
• Gait and balance training.
• Bracing:
• Prevent/slow progression of deformity.
• Ankle-foot orthosis, hip abduction
braces, hand and wrist splints, spinal
braces/jackets used.
24. Four basic principles
Although the central nervous system injury, by definition, is non-
progressive, the deformities caused by abnormal muscle forces and
contractures are progressive.
The treatments currently available correct the secondary deformities
only and not the primary problem.
The deformities typically become worse during times of rapid growth.
For some patients, it may be beneficial to delay surgery until after a
significant growth spurt to decrease the risk of recurrence.
Operative or non-operative treatment should be done to minimize
the impact it has on the patient's socialization and education.
25. Operative Treatment
Operative treatment of deformities:
correct static or dynamic deformity
balance muscle power across a joint
reduce spasticity (neurectomy)
stabilize uncontrollable joints
Often, procedures can be combined—an adductor tendon release
can be done at the time of pelvic osteotomy for hip subluxation.
26. Operative treatment
HIP
• Patho anatomy
• subluxation
• strong tone in hip adductor and flexors lead to scissoring and predisposes to hip
subluxation and dislocation
• dislocation
• dislocation is typically posterior and superior (>95%)
• degeneration
• in time, dysplastic and erosive changes in the cartilage of the femoral head can
develop and lead to pain
27. Flexion deformities:
• Crouched gait
• If flexion-internal rotation deformity – W
position.
Adduction deformity
• Scissoring gait.
28. Operative for hip
Reconstuctive procedures
• proximal femoral osteotomy with soft-tissue release
• indications
• children > 4 years old or Reimers index > 60%
• best to treat all pathology at single stage if the patient has a severely dysplastic CP hip
salvage procedures
• valgus support osteotomy (femoral head resection + valgus subtrochanteric femoral
osteotomy (e.g McHale Technique)
• indication
• salvage technique for symptomatic and chronically dislocated hips in cerebral palsy
29. Operative - soft tissue procedures
Hip adductor and psoas release with abduction bracing
indications
children < 4 years and Reimers index > 40%
Consider for "at risk" hips (see chart above)
any evidence of progressive subluxation if less than 8-year-old
May also be used as a supplement to bone procedures
30. Proximal femoral osteotomy and soft-tissue
release, possible acetabular osteotomy
goals of treatment
hip containment in the severely dysplastic hip with progressive subluxation
single-stage osteotomies may have improved outcome
technique
shortening varus de rotational osteotomy to correct increased valgus and
anteversion
may need pelvic osteotomy to correct acetabular dysplasia; the indications to
combine pelvic osteotomy at the time of femur osteotomy remain
controversial
32. Spinal
deformities
• Scoliosis
• Wheelchair sitting difficult.
• Spastic quadriplegic
• Surgery when curves greater than 45 to 50
degrees, worsening pelvic obliquity.
• More likely to progress than idiopathic
scoliosis.
• Bracing less effective.
33. Treatment
• Small curves with no loss of function – conservative.
• Ambulatory pt – posterior fusion.
• Much higher complication rate than idiopathic scoliosis.
34. Foot and ankle
• Equinovarus, equino valgus, hallux valgus.
• Goal of treatment is to obtain a plantigrade, painless, brace able foot.
• Equino valgus foot:
• Spastic diplegia
• Spastic peroneal muscles, contracted heel cords, ligamentous laxity.
• Peroneus brevis lengthening.
• Calcaneal osteotomy
SPASTICITY..>MUSCLE CONTRUCTUE..>JOINT DEFORMITY
Due to spasticity resistance while movement and altered position during
function.
35. Equinovarus foot:
• Spastic hemiplegia
• Overpull of posteior or anterior tibialis tendon or both.
• Split posterior tibialis transfer.
• Split anterior tibialis transfer.
• Achilis tendon lengthening.
Hallux Valgus:
• Treated by 1st MTP joint fusion
• High rate of complications.
• Proximal phallanx (Akin) osteotomy.
36. Upper extremity
• Divided into those to treat hygiene and those to increase function.
• Functional procedures indicated for patients with voluntary control
and better sensibilities.
• Shoulder contracture:
• Internal rotation contracture of the glenohumeral joint.
• Proximal humerus derotation osteotomy.
• May need subscapularis and pectoralis lengthening + biceps/brachialis
lengthening and capsulotomy.
• Indicated in greater than 30 degree contracture.
37. Elbow contracture:
• Flexion contracture.
• Treated with Biceps and Brachialis lengthening.
• Brachioradialis origin release.
Pronation deformity:
• Treated with pronator teres release.
Wrist flexion deformity:
• Flexion and ulnar deviation contractures.
• May be treated early with flexor carpi ulnaris (FCU) to extensor carpi
radialis brevis (ECRB) tendon transfer or FCU to extensor digitorum
communis (EDC) transfer in functional patients with voluntary control
• Concommitant proximal row carpectomy.
• Wrist arthrodesis in advanced cases.
38. Thumb in palm deformity:
• Flexed thumb prevents grasping and can interfere with hygiene.
• Lengthening of Adductor Pollicis, first dorsal interosseus, flexor
pollicis brevis, flexor pollicis longus.
• Combined with 1st web space z plasty and tendon transfer.
Swan neck deformity:
• Can be corrected with correction of wrist flexion deformity.
• Fractional Z lengthening of tendons.
39. Conclusion
• CP patients require specialized approach much different from
conventional orthopedic training principles.
• Pt should be evaluated as a whole for holistic treatment.
• Botulinum toxin pr other drugs used initially to prevent contracture.
• Limited releases done in late cases to improve function.
• Ortho management should always be combined with dedicated
counselling, physiotherapist, rehab experts, and pediatricians.
