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 placenta insufficiency, toxins, genetic factors, TORCH

Perinatal premature delivery, hypoxia, infection, kernicterus, haemolytic disease

Postnatal infection, trauma

ClassificationType of Motor Disorder

Spastic pyramidal system (motor cortex)

Athetoid extrapyramidal (basal ganglia)

Ataxis cerebellum + brainstem

Rigid basal ganglia + motor cortex

+ Mixed

Limbs Involved

Monoplegia one limb (rare)

Hemiplegia one side

Diplegia lower limbs, assymetrically

Triplegia three limbs (rare)

Quadriplegia four limbs

DemographicsTwo per 1000 live births

50% have normal intelligence, 25% able to self-support as adult

Incidence remains static +/- increasing

Clinical Features IDependent 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 IIPosturing sitting (hypotonic slump)

standing (crouchposture, spastic posture, pelvic obliquity, loss of lumb. Lordosis)

Gait athetoid or ataxic movement

Neuromuscular UMN or spastic paresis

resistance to passive movement

Babinski +ve

Deformities 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 correctable deformity

II. Muscle Contractures fixed deformity

III. Secondary Bone Changes e.g. medial femoral torsion, lateral tibial torsion

Management ConceptsLimitations

✚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 Physiotherapy, Orthotics, Botulinum Toxin, Selective Posterior Rhizotomy

Stage II Timing critical and controversial

Unpredictable results

Staged vs. single procedures

Stage III 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 IAge 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 IIHemiplegia

Group I mild foot-drop gait leaf-spring AFO

Group II equinus gait stretching casts, botulinum toxin, AFO, lengthening

Group III Knee, medial hamstrings, gastroc recession, medial hamstring lengthening,

quadricepts involvement distal rectus femoris transfer

Group IV Hip flexion, medial torsion lengthening psoas, external rotation osteotomy, and above

Spastic Diplegia Most achieve good function

Hip flexors, adductors, medial rotators, calf most affected

Secondary bone torsional problems

Lower Extremity IIILengthening 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 IVKnee 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 youBARCZYNSKI, 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