Cerebral palsy

1. Cerebral palsy

2. Definition
 Non-Progressive, neuromuscular disorder due to injury to immature brain
 Upper motor neuron disease with mixture of muscle spasticity and weakness
 Imbalance muscle forces > dynamic deformity > contracture > subluxation >
dislocation

3. Risk factors
 Prenatal
 Maternal infection ( TORCHES)
 Alcohol
 Drugs ( cocaine. Heroin, marijuana)
 Kernicterus due to Rhesus incompatibility
 Perinatal
 Anoxic events (cord tangled, placenta abruptio)
 Prematurity
 Bronchopulmonary dysplasia, congenital heart disease
 Sepsis
 Postnatal
 Meningitis
 Hypoxic episode (eg. Near-drowning, cardiopulmonary arrest)
 Head trauma

4. Classifications
• Physiologic
• Geographical/ anatomical
• Functional

5. Physiologic : the type of movement disorder
 Spasticity :
• Result damage to pyramidal system , particular motor cortex
• Disinhibit of pathologic reflex arcs lead to increase of tone
• The tone depend on velocity  if muscle stretched rapidly , tone increase .
 Hypotonia:
• Precedes spastic or ataxic 2-3 years
 Dystonia :
 Tone not related to velocity
 Tone do not decrease
 Tone in spasticity describe as clasp knife , in dystonia describe as lead pipe

6.  Athetosis :
 Damage of basal
 Abnormal writhing , involuntary movement .
 Become more exaggerated if try to control it
 Ataxic
 Inability to coordinate muscle movement
 Result unbalance and wide base and clumsy gait
 Mixed : usually mixed spastic and ataxic

7. Anatomic :which part is effected
 Quadriplegia : total body involvement
 Diplegia : legs more than arms but usually still ambulatory
 Hemiplegic : arm and leg on one side of the body usually with spasticity , will be able to
walk .
 Monoplegic : involve one sigle limb
 Total body involvement : quadriplegic + no neck control+swallowing affect + drooling
saliva

8. Function

10. History taking
 Risk factors :
o Abnormal birth history
o Prematurity
o Neonatal nursery
 Delayed developmental milestones
 Eg. head control: 3-6 months,
 Sitting : 6-9 months
 Crawling : by 9 months
 Cruising : 10-12 months
 Walking : 12-18 months
 Early handedness (normal 2-3yo)
 May suggest spastic hemiparesis

11. Physical examination
 LOOK :
 Type of cp (quadriplegic , diplegic , hemiplegic )

12. Progressive musculoskeletal pathology of CP

13. Gait Disorder
True equinus
Pathology: spasticity of gastrosoleus that gradually becomes fixed
resulting in a contracture and equinus gait

14.  Jump gait
Pathology: ankle equinus + co-contraction of the hamstrings and rectus femoris
resulting in incomplete knee and hip extension

15.  Crouched gait
 Due to hamstring contractions
 combination of hip flexion, knee flexion, and excessive ankle dorsiflexion
 Common in diplegic CP
 consequence of isolated lengthening the Achilles in a jump gait pattern

16. o UL attitude
 Shoulder IR and adducted
 Elbow flexion
 Wrist flexion
 Thumb in palm

17.  Lower limb attitude
Scissor attitude
Wind swept appearance
Knee contracted
Equinovarus (hemiplegic) or
equinovalgus(diplegic) foot

18.  Primitive reflex persist
 Persist 2 or more

19. Muscle tone
 Patient should be relax when exam range of motion
 Tardieu test :
 To differentiate spasticity or contracture
 Difference btw R1 & R2
 > 20° spasticity
 < 20° contracture

21. Move and special tests
 Spine
 Scoliosis – flexible or structure
 Adam forward test

22.  Hip
 Tomas test (contracted iliopsoas )
 Staheli test
 Abduction (hip and knee in 90 degree flexion
 Rotational profile : increase femoral
rotation
 Subluxation or dislocation : galleazi test
increase IR,

23.  Knee
• Hamstring tightness - Popliteal angle
• Check R1 & R2 of hamstring muscles
• Ely test (prone)

24.  Ankle and foot
 Silverskiold test
 Determine gastrocnemius or soleus contracture
 Reflex : hypertonic , hyperreflexia , clonus
 Equinus true /pseudo

25. Investigation
 Ultrasound
 Ventricular enlargement
 MRI
 Periventricular leukomalacia
 Periventricular haemorrhage
 Focal infarct
 Gait analysis
 Electromyography
 Radiography

26. Prognosis
 Prognosis for ambulation is poor when:
 Unable to sit by 2yo,
 ≥ 2 infantile reflexes persist beyond 12-15 months,
 Lack of head control by 20 months
 If the child unable to walk by 7yo, most likely the child will never walk

27. Treatment

28. Aim
 Preserve or improve the patient function (siting
or mobility )

30. Hip

31. Goals of treatment
 Aim for > 30° hip abduction for:
 Perineal hygience
 Prevent dislocation
 Prevent hip subluxation and dislocation
 Young child
 Reduce spasticity
 Reduce the dislocation and prevent redislocation in painless hip
 Older child
 Concentrically reduction
 Restore muscle balance
 Bony work ( correction of coxa valga, femoral anteversion & acetabulum dysplasia)

32.  If the hip is painful, chronic dislocated with erosion of femoral articular
cartilage
 Aim to relieve pain
 Do not attempt to reduce the hip

33. Hip Surveillance in CP
 The process of monitoring and identifying the critical early indicators of hip
displacement
 WHY
 can lead to pain, reduced function and reduced quality of life
 CP have an increased likelihood of hip displacement
 early detection of hip displacement
 Early detection - referral for assessment and/or management
 Surveillance is ideally initiated by 2 years of age

34.  Surveillance consists of two components
 clinical examination
 radiographic examination
 Surveillance frequency increases with increasing GMFCS level
 Hip xrays at 2 years In patients with clinical risk factors-difficulty posturing or
pain,limb length discrepancy,increased hip tone or reduced ROM
 If migration index >30%-hip x-rays 6 monthly
 GMFCS >3 hip xrays annually

35.  Reimer index (a/b) x 100%
 a is the distance measured the lateral border of the femoral head to the Perkins
line
 b is the width of the femoral head parallel to Hilgenreiner's line.

36. Spasticity of hip adductors and flexors
• Stretching exercises
• Appropriate posturing
• Myoneural blocks (no contractures)
• Neurectomy of obturator nerve
• May result in abduction deformity

37. Contracture of hip adductors
• Aim to restore muscle balance
• Adductor release
• Release origin of adductor longus / gracilis muscles
• Adductor transfer
• Release origin and transfer to more posteriorly to ischium
• Reduce adductor & increase hip extensor muscle power
• Obturator neurectomy
• In severe and non-ambulant child
• Risk of creating abduction deformity

38. Contracture of hip flexors
• Iliopsoas tenotomy at lesser trochanter
• For non-ambulant
• Fascilitate perineal ca
• Intramuscular iliopsoas recession at the
pelvic brim
• Release psoas & retain iliacus for ambulant

39. coxa valga & femoral anteversion
 Mild cases may resolve once muscle balance is restored
 Severe cases required varus derotation osteotomy (VDRO)

40. Acetabulum dysplasia
• Acetabulum augmentation
• Eg, Shelf, Dega, Pemberton osteotomy, chiari
• Redirectional osteotomy NOT helpful
• Improve coverage of one side result in worsening of coverage
in another region

41. knee

42. Hamstring lengthening
• Intramuscular aponeurotic lengthening of semimembranosus
& beceps femoris
• Z-lengthening of semitendinosis
• Aim popliteal angle 20-30°

43. Bony procedure- guided growth

44. Ankle

45. Equinus
 most common deformity in cerebral palsy
 Pathophysiology
 imbalance of ankle dorsiflexors and plantar flexors
 Due to spasticity/contracture of the gastrosoleus complex

46. Treatment
 Non Operative
 Serial manipulation and casting
 Botox injection into Gastrocnemius
 Articulated or hinged AFO
 Solid AFO
 Operative
 TAL
 Gastrocnemius recession

48. Z white slide

49. Gastrocnemius recession

50. Excessive lengthening
• Result in crouch gait
• Poor push-off in gait cycle

51. foot

52. Hallux Valgus
 most common in diplegics with equinus and planovalgus feet
 associated with equinovalgus and external tibial torsion
 Pathophysiology
 caused by combination of adductor hallucis overactivity and externally applied forces

53.  Treatment
 Non Operative
 Observation
 Operative
 first metatarsophalangeal joint arthrodesis
 proximal phalanx (Akin) osteotomy

54. EquinoPlanoValgus
 common foot deformity seen with cerebral palsy (spastic diplegic and
quadriplegic)
 Pathophysiology
 equinus with pronation deformity
 Due to spastic peroneal muscles, contracted heel cords and ligamentous laxity

55.  Treatment
 Non operative
 Bracing in flexible deformities
 Operative
 Bony and soft tissue procedures
 Soft tissue
 TAL,
 Peroneus brevis lengthening,
 Post tibial tendon advancement
 Bony Procedures
 calcaneal osteotomy
 lateral column lengthening (Evans procedure)
 Grice procedure
 Subtalar arthroereisis

56. EquinoCavoVarus
 more common in spastic hemiplegia
 Pathophysiology
 equinus deformity of the hindfoot
 With supination deformities of the midfoot and forefoot

57.  Treatment
 Soft tissue
 TAL and posterior tibial tendon muscular lengthening
 SPOTT (Split Posterior tibial tendon transfer)
 SPLATT (Split anterior tibialis tendon transfer)
 Bony procedure
 Calcaneal osteotomy
 Arthrodesis

58. Upper Extremity Disorders
 typically seen in in patients with hemiplegia and quadriplegia
 Treatment divided into
 Hygienic
 Functional procedure
 Characteristic deformities include
 Shoulder contracture
 Elbow contracture
 Forearm pronation
 Wrist, thumb and finger

59.  Shoulder contracture
 Indications contracture greater than 30 degree
 Internal rotation at glenohumeral joint
 Treated with shoulder derotational osteotomy and/or subscapularis and pectoralis
lengthening with biceps/brachialis lengthening capsulotomy
 Elbow and forearm pronation contracture
 lacertus fibrosis release, biceps and brachialis lengthening, brachioradialis origin
release
 pronator teres release

60.  Wrist flexion deformity
 wrist is typically flexed and in ulnar deviation
 Treatment
 FCU or FCR lengthening
 FCU to ECRB transfer – poor grasp
 or FCU to EDC transfer – good grasp
 flexor release
 wrist arthrodesis

61. Thank you