1. CEREBRAL PALSY Thammanoon Srisaarn, MD. Orthopaedic department Pramongkutklao hospital

2. CEREBRAL PALSY NON PROGRESSIVE (immature)BRAIN LESION RESULTS IN MOTOR IMPAIRMENT(may be other) Uncertain cause Nearly drowning, infectious meningitis Manifestration progress

3. CLASSIFICATION PHYSIOLOGIC (Neuropathic) GEOGRAPHIC (Anatomic)

4. PHYSIOLOGIC(NEUROPATHIC) SPASTICITY(PYRAMIDAL SYSTEM) ATHETOSIS(EXTRAPYRAMIDAL) CHOREIFORM DYSTONIA HYPOTONIA ATAXIC (CEREBELLUM) MIXED

5. GEOGRAPHIC(ANATOMIC) DIPLEGIA HEMIPLEGIA DOUBLE HEMIPLEGIA PARAPLEGIA TRIPLEGIA QUADRIPLEGIA (TETRAPLEGIA) TOTAL BODY INVOLVEMENT MONOPLEGIA

6. MANIFESTRATION SPASTIC DIPLEGIA 8- 10 MO. SPASTIC HEMIPLEGIA 20-24 MO. ATHETOID > 24 MO. DEPEND ON MYELINATION

7. Factors affect walking ability (diplegia) Severity of lower ext. involvement Seizure Marked flaccidity Persistent abnormal primative reflexes Dislocated hip Intelligence, mental retardation Upper ext. involvement Birth weight

8. BLECK’S WALKING PROGNOSIS (after 12 mo.) 1. ASYMMETRIC TONIC NECK REFLEX 2. NECK RIGHTING REFLEX 3. MORO REFLEX 4. SYMMETRIC TONIC NECK REFLEX 5. EXTENSOR THRUST 6. PARACHUTE REACTION 7. FOOT- PLACEMENT REACTION

9. SCORE > 2 POOR PROGNOS IS

10. PROGNOSIS GOOD PROGNOSIS FOR WALKING - HEAD BALANCE BEFORE 9 MO. - INDEPENDENT SITTING BY 24 MO. - CRAWLING BY 30 MO.  POOR PROGNOSIS - LACK OF HEAD CONTROL BY 20 MO. (Camposda paz)

11. PROGNOSIS SITTING BEFORE 2 YR USUALLY WALK INDEPENDENT 2-4 YR 50% WALK INDEPENDENTLY > 4 YR RARELY STAND OR WALK WITHOUT SUPPORT NEVER LEARN TO WALK BEFORE 8 YR UNLIKELY TO WALK (Motor improve plateau 7 yr.) (Beal )

12. PROGNOSIS 2 YR. WITH INDEPENDENT SITTING - NOT A GOOD PREDICTOR FOR WALKING ABILITY INABILITY TO SIT AFTER 4 YR. - PREDICTED NONAMBULATION (Molnar and Gordon)

13. EVALUATION HISTORY OBSERVATION EXAMINATION GAIT ANALYSIS

14. OBSERVATION POSTURE GAIT CROU CH JUMP

15. THOMAS TEST PHYSICAL EXAMINATION HIP FLEXION DEFORMITY

16. Modified Thomas test MODIFIED THOMAS TEST

17. STAHILI TEST

18. DUNCAN-ELY TEST

19. ADDUCTION DEFROMITY PHYSICAL EXAM. PHELPS TEST

20. POPLITEAL ANGLE SLRT KNEE EXAMINATION LACK OF FULL EXTENSION ON INITIAL CONTACT,STANCE AND INITIAL SWING PHASE KNEE FLEXION DEFORMITY

21. TEST FOR RECTUS TIGHTNESS KNEE EXTENSION DEFORMITY

22. PHYSICAL EXAMINATION (SILVERSKIÖLD) FOOT : EQUINUS DEFORMITY

23. MOST OFTEN IN HEMIPLEGIA EQUINOVARUS DEFORMITY

24. VARUS DEFROMITY TIBIALIS POSTERIOR  HINDFOOT VARUS OR TIBIALIS ANTERIOR  FOREFOOT SUPINATION, HINDFOOT VARUS (SWING PHASE) WEAK PERONEUS

25. PES VALGUS DEFORMITY Peroneal hyperactivity

26. TREATMENTS PRIORITY COMMUNICATION COMMUNICATION ADL ADL MOBILITY MOBILITY WALKING WALKING

27. SURGICAL TREATMENT SPASTIC TYPE AGE 4-8 YEAR IS PROPER YOUNGER HIGH RECURRENCE MATURE GAIT~ 7 YEARS SEQUENTIAL V/S ALL AT THE SAME TIME

28. Surgical treatment Thomas test 30 O Modified Thomas test 20 O Hip flexion deformity

29. Surgical treatment Hip a dduction deformity Passive abduction < 30 O both in hip flexion & extension

30. HIP AT RISK Quadriplegia, Nonambulator Age 2-6 yr. < 30 O abduction in flex or ext. > 20 O flexion contracture valgus and anteversion Shallow acetabulum AI > 40 Abnormal migration index FILM PELVIS EVERY 12 MO. FOR NONAMBULATOR

31. A B C AB/AC= MIGRATION INDEX (MI) ACETABULAR INDEX > 1/3 = subluxation

32. SURGICAL TREATMENT ON THE HIP ADDUCTOR LONGUS TENOTOMY ANT. HALF OF ADD. BREVIS GRACILLIS PSOAS TENOTOMY OR LENGTHENING preserve iliacus RECTUS FEMORIS LENGTHENING PROXIMAL HAMSTRINGS RELEASE

34. MANAGEMENT OF HIP AT RISK AGE < 4 YR. SOFT TISSUE RELEASE(45 O Abd in Ext,60 O in Flex.) AGE 4-8 YR. MI 25-60%, ABDUCTION RELEASE MI > 60%, NOT IMPROVE IN 1 YR.==> OR+ CAPSULORRAPHY+ BONY RECONSTRUCTION AGE > 8 YR MI > 40% RELEASE & BONE RECONSTRUCTION Flynn JM. AAOS 10(3): 2002

35. Hip subluxation MI > 30 % Soft tissue release for very young MI > 50% open reduction + femoral osteotomy AI > 25 O pelvic osteotomy

36. Management of hip dislocation Observation Open reduction + osteotomy + soft tissue release Resection arthroplasty Arthrodesis Total hip replacement

37. Neck shaft angle < 115 O Anteversion10-20 O (30- 45 O passive IR)

38. SURGICAL TREATMENT ON THE KNEE SLRT 45 O MEDIAL HAMSTRINGS RELEASE LATERAL HAMSTRINGS RELEASE RECTUS FEMORIS RELEASE RECTUS FEMORIS TRANSFER

39. HAMSTRING RELEASE

40. RECTUS FEMORIS TRANFER