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Management of the Upper Limb in Children with Cerebral Palsy
Prof P McArthur FRCS(Plast) PhDConsultant in Congenital Hand and Upper Limb SurgeryDepartment of Plastic SurgeryRoyal Liverpool Children's HospitalAlder HeyLiverpool
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 groupsPL
FCRPT
The Multidisciplinary Team
The Family and Child
Hospital Physiotherapist
Hospital Occupational Therapists
Consultant Paediatric Neurologist
Consultant Upper Limb Surgeon
Consultant Lower Limb Surgeon
Community Physiotherapists
Community Occupational Therapists
Specialist Children's Hospital
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 TreatmentsMean 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?