1. Orthopaedic Considerations in Cerebral Palsy Stewart Morrison Western Health Friday Presentation 20 th January 2012

2. 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

3. Classification Type of Motor Disorder Spasticpyramidal system (motor cortex) Athetoidextrapyramidal (basal ganglia) Ataxiscerebellum + brainstem Rigidbasal ganglia + motor cortex + Mixed Limbs Involved Monoplegia one limb (rare) Hemiplegiaone side Diplegialower limbs, assymetrically Triplegiathree limbs (rare) Quadriplegiafour limbs

4. Demographics Two per 1000 live births 50% have normal intelligence, 25% able to self-support as adult Incidence remains static +/- increasing

5. 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

6. Clinical Features II Posturingsitting (hypotonic slump) standing (crouchposture, spastic posture, pelvic obliquity, loss of lumb. Lordosis) Gaitathetoid or ataxic movement NeuromuscularUMN or spastic paresis resistance to passive movement Babinski +ve DeformitiesEquinus FFD Knee

7. 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)

8. Pathology II I.Dynamic Contractures correctable deformity II.Muscle Contracturesfixed deformity III.Secondary Bone Changese.g. medial femoral torsion, lateral tibial torsion

9. 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 IPhysiotherapy, Orthotics, Botulinum Toxin, Selective Posterior Rhizotomy Stage IITiming critical and controversial Unpredictable results Staged vs. single procedures Stage IIICorrectional osteotomies for torsional + joint deformities

10. 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

11. 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

12. Lower Extremity II Hemiplegia Group Imild foot-drop gaitleaf-spring AFO Group IIequinus gaitstretching casts, botulinum toxin, AFO, lengthening Group IIIKnee, medial hamstrings,gastroc recession, medial hamstring lengthening, quadricepts involvementdistal rectus femoris transfer Group IVHip flexion, medial torsionlengthening psoas, external rotation osteotomy, and above Spastic Diplegia Most achieve good function Hip flexors, adductors, medial rotators, calf most affected Secondary bone torsional problems

13. Lower Extremity III Lengthening Achilles Tendonoverused “a little equinus is better than calcaneus” ? Silveskiod Test (Gastroc vs. Soleus) Gastrocnemius Recession Z Lengthening or Percutaneous Techniques Varus Deformity of the FootTib Post usually resonsible (stance and swing) Tib Ant (swing only) Lengthening vs. transfer Valgus DeformityLengthening, Fusion, Osteotomies

14. 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 Contracturesoften secondary to knee/ankle issues Thomas or Staheli tests Psoas lengthening

15. Lower Extremity V Hip Subluxation Rotational Osteotomies Hip Reconstructive Surgery (spastic quadriplegia)

17. Upper Extremity Evaluation ✚ Sensation ✚ Electromyography Principles ✚ Define goals ✚ Restore ✚ Rebalance

18. Upper Extremity Shoulder ✚ Internal rotation, adduction commonBotulinium type A Supscapularis, Pec Major lengthening External rotational osteotomy Elbow ✚ Static and dynamic flexion contracturesflexor release dependent on NV bundle Wrist/Digits ✚ Wrist flexion +/- pronation, ulnar deviationlengthening and transfer procedures

19. 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