!PRE%CONFERENCE!SESSION!3!

!ORTHOPAEDIC+MANAGEMENT+OF+THE+UPPER+

EXTREMITY+!

WEDNESDAY,!October!21st,!1%5PM!!

Course!Co%Ordinators!!

Andrea!Bauer,!MD!Benjamin!Shore,!MD!

Carley!Vuillermin,!MBBS!!

Course!Faculty!!

Jon!Davids,!MD!Loren!Davidson,!MD!

Douglas!Hutchinson,!MD!Michelle!James,!MD!Freeman!Miller,!MD!Laura!Peace,!OTR/L!Allan!Peljiovich,!MD!Ann!Van!Heest,!MD!

Lisa!Wagner,!DHS!OTR/L!

AACPDM&CP&Upper&Extremity&Pre1Course&Wednesday&October&21,&115&pm&

Loren&Davidson&Botulinum)Dosing)Chart)Adducted/)Internally)Rotated)Shoulder)

Botox%Dosing%%

Pectoralis& 2U/Kg& Palpate&ant.&axillary&fold&b/t&thumb&and&fingers,&inject&muscle&over&rib&to&prevent&pneumo&

Lat.&Dorsi& 2U/Kg& Palpate&post.&axillary&fold&b/t&thumb&and&fingers,&inject&muscle&over&rib&to&prevent&pneumo&

Teres&Major& 2U/Kg& Inject&muscle&at&top&of&post.&axillary&fold&Subscap.& 112U/Kg& Lateral&approach:&inject&b/t&post.&axillary&and&brachial&pulse&Flexed)Elbow) & &Brachiorad.& 112U/Kg& Midbelly&of&muscle&is&at&level&of&insertion&of&biceps&tendon&Biceps& 2U/Kg& Midbelly&of&muscle&(injection&increases&FA&pronation)&Brachialis& 2U/Kg& Lateral&approach:&four&finger&beadths&above&lateral&epicondyle&Pronated)Forearm) &Pron.&Quad.& 0.511U/Kg& Dorsal&approach:&b/t&radius&and&ulnar&(1/4&dist.&from&ulnar&styloid&to&insertion&of&

biceps&tendon)&Pron.&Teres& 112U/Kg& Midbelly&of&muscle:&3&fingers&breadths&distal&to&biceps&tendon/1&finger&breadth&

medial&Flexed)Wrist) & &Flex.&Carpi&Rad.& 112U/Kg& Midbelly&of&muscle:&4&fingers&breadths&distal&elbow&crease.&1&finger&breadth&

medial&to&distal&biceps&tendon&Flex.&Carpi&Uln.& 112U/Kg& Midbelly&of&muscle:&1/3&distance&from&medial&epicondyle&to&the&wrist.&Palm.&Longus& & Midbelly&of&muscle:&&4&fingers&breadths&below&biceps&tendon&and&1&finger&

breadth&medial&to&midline&of&forearm&Extended)Wrist) & &Ext.&Carpi&Rad.&L.& 112U/Kg& Midbelly&of&muscle:&1/3&distance&from&lateral&epicondyle&to&the&radial&styloid&

(over&radius)&Ext.&Carpi&Rad.&B.& 112U/Kg& Midbelly&of&muscle:&1/4&distance&from&lateral&epicondyle&to&the&radial&styloid&

(over&radius)&Ext.&Carpi&Uln.& 112U/Kg& Midbelly&of&muscle:&1/2&distance&from&lateral&epicondyle&to&the&wrist&(over&ulna)&Clenched)Fist) & &Flex.&Dig.&Sup.& 112U/Kg& Midbelly&of&muscle:&midpoint&b/t&biceps&tendon&to&wrist.&Mainly&over&proximal&

and&middle&ulna&and&interosseous&membrane&Flex.&Dig.&Prof.& 112U/Kg& Midbelly&of&muscle:&midpoint&b/t&biceps&tendon&to&wrist.&Mainly&over&ulna&and&

interosseous&membrane.&&& & (Medial&approach&just&above&ulna&and&below&FCU&will&avoid&ulnar&nerve)&Thumb)in)palm) & &Flex.&Poll.&Long.& 0.511U/Kg& Midbelly&of&muscle:&1/3&distance&from&wrist&to&biceps&tendon&over&the&radius&Flex.&Poll.&Brev.& 0.511U/Kg& Midbelly&of&muscle:&midpoint&and&medial&border&of&the&1st&metacarpal&Add.&Pollicis& 0.511U/Kg& Midbelly&over&the&middle&of&the&second&metacarpal&bone&First&Dors.&Inter.& 0.511U/Kg& Midbelly&of&muscle:&midpoint&of&radial&border&of&the&2nd&metacarpal&bone&Extended)Digits) & &Ext.&indicis&prop.& 0.511U/Kg& Midbelly&of&muscle:&1&finger&breadth&above&ulnar&styloid&on&the&radial&side&of&

ulna&Ext.&dig.&Comm.& 0.511U/Kg& Midbelly&of&muscle:&midpoint&of&the&lateral&epicondyle&and&the&wrist&over&the&

radius&Reference:&Odderson,&Ib&R.,&Botulinum&Toxin&Injection&Guide.Demos&publishing,&New&York,&NY.,&2008&)

1

Surgery of the Upper Extremity in Children with Hemiplegic Cerebral Palsy: Use of the Shriners Hospitals for Children

Upper Extremity Evaluation (SHUEE)

Jon R. Davids, MD Assistant Chief of Orthopaedics

Medical Director, Motion Analysis Laboratory Shriners Hospitals for Children Sacramento, California, USA

I Rationale A. Identify all functional deficits B. Single, simultaneous Surgical Intervention 1. Multiple surgical procedures 2. Single period of immobilization 3. Single rehabilitation II Methods A. Shriners Hospital Upper Extremity Evaluation (SHUEE)(1) 1. Spontaneous Functional Analysis (SFA) a. Degree of neurological impairment b. Lower SFA → less functional improvement anticipated 2. Dynamic Positional Analysis (DPA) a. Alignment during functional tasks 1. Elbow, forearm wrist, fingers, thumb b. Surgical interventions directed towards dynamic segmental malalignments 3. Grasp and Release Analysis (GRA) a. Relationship between finger function and wrist alignment b. Thumb alignment and stability

2

III Indications Indications for upper extremity surgical procedures.

Procedure Physical Examination

Radiographic Examination

SHUEE SFA DPA GRA

FCU to ECRB Transfer

Passive wrist extension to

neutral

-

Poor Active Assist

or better

Wrist segment:

volar flexion/ulnar

deviation

-

Wrist Arthrodesis

-

AP Hand: Less that 1

year of growth

remaining

Poor active assist

or worse

Wrist segment:

volar flexion/ulnar

deviation

-

Thumb MCP Arthrodesis

Thumb MCP hyperextension

instability

AP Hand: skeletal age 10 or greater

-

Thumb segment:

closed or in palm

-

Thumb MCP Sesamoid Capsulodesis

Thumb MCP hyperextension

instability

AP Hand: skeletal age less than 10

-

Thumb segment:

closed or in palm

-

Thumb Web Release

Limited thumb passive palmar

extension/abduction

-

-

Thumb segment:

closed or in palm

-

EPL Rerouting Ability to selective active

EPL

-

-

Thumb segment:

closed or in palm

-

PT Lengthening Passive forearm supination to

neutral

-

Poor Active Assist

or better

Forearm segment:

pronation or worse

-

FDS/FDP/FPL Fractional Lengthening

Limited passive finger PIPJ/DIPJ and thumb IPJ

extension

-

Poor active assist

or worse

Finger segment: flexion

Limited release with

wrist in neutral

or extension

Biceps/Bracialis Lengthening

Passive elbow extension to 30

degrees or worse

-

-

Elbow segment: flexion or

worse

-

3

SFA = spontaneous functional analysis; DPA = dynamic positional analysis; GRA = grasp and release analysis; FCU = flexor carpi ulnaris; ECRB = extensor carpi radialis brevis; MCP = metacarpophalangeal joint; EPL = extensor pollicis longus; PT = pronator teres; FDS = flexor digitorum superficialis; FDP = flexor digitorum profundus; FPL = flexor pollicis longus; PIPJ = proximal interphalangeal joint; DIPJ = distal interphalangeal joint; IPJ = interphalangeal joint; AP = anteroposterior; “-” = not applicable IV Preferred Techniques A. FCU to ECRB Transfer(2-8) B. Wrist Arthrodesis (9-11) C. Thumb MCP Arthrodesis (12-15) D. Thumb MCP Sesamoid Capsulodesis (12, 16, 17) E. Thumb Web Release (12-15, 18-20) F. EPL Rerouting (12, 14, 21) G. PT Lengthening (22-25) H. FDS / FDP / FPL Fractional Lengthening (2, 6, 26-29) I. Biceps / Brachialis Lengthening (10, 27, 30-32) V Outcomes A. Smitherman et al,“Functional Outcomes Following Single Event Multilevel Surgery of the Upper Extremity for Children with Hemiplegic Cerebral Palsy” J Bone Joint Surg, in press 2010 1. Retrospective case-control series, level III evidence 2. Case Cohort: 40 children with hemiplegic CP, pre- post- SEMLS 3. Control Cohort: 26 children with hemiplegic CP, no upper extremity surgery 4. Pre-, post-, follow up SHUEE analyses

SHUEE = Shriners Hospital upper Extremity Evaluation, SFA = spontaneous functional analysis, DPA = dynamic positional analysis, GRA = grasp / release analysis 5. Results: SEMLS Cohort a. Improved spontaneous use and dynamic positional alignment following SEMLS

Initial and follow-up SHUEE scores.

Group

Initial SHUEE Follow-up SHUEE Difference SFA

(p value)

Difference DPA

(p value)

Difference GRA

(p value) SFA DPA GRA SFA DPA GRA Non-

operative

21.5 (±11.0)

38.7 (±13.9)

4.1 (±0.5)

21.7 (±8.7)

38.0 (±11.9)

4.4 (±0.4)

0.2 (p=0.89)

0.7 (p=0.98)

0.3 (p=0.36)

Operative

19.2 (±10.0)

37.1 (±10.7)

3.2 (±0.4)

23.2 (±10.2)

54.7 (±10.8)

3.3 (±0.4)

4.0 (p<0.0001)

17.6 (p<0.0001)

0.1(p=0.75)

Non-operative

versus Operative

p=0.374 p=0.734 p=0.16 --- --- --- (p=0.01) (p<0.0001) (p=0.56)

4

References 1. Davids JR, Peace LC, Wagner LV, Gidewall MA, Blackhurst DW, Roberson WM. Validation of the Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) for children with hemiplegic cerebral palsy. J Bone Joint Surg Am 2006;88:326-33. 2. Beach WR, Strecker WB, Coe J, Manske PR, Schoenecker PL, Dailey L. Use of the Green transfer in treatment of patients with spastic cerebral palsy: 17-year experience. J Pediatr Orthop 1991;11:731-6. 3. Green WT. Flexor carpi ulnaris transplant and its use in cerebral palsy. J Bone Joint Surg Am 1962;44A:1343-52. 4. Hoffer MM, Lehman M, Mitani M. Long-term follow-up on tendon transfers to the extensors of the wrist and fingers in patients with cerebral palsy. J Hand Surg [Am] 1986;11:836-40. 5. Thometz JG, Tachdjian M. Long-term follow-up of the flexor carpi ulnaris transfer in spastic hemiplegic children. J Pediatr Orthop 1988;8:407-12. 6. Tonkin M, Gschwind C. Surgery for cerebral palsy: Part 2. Flexion deformity of the wrist and fingers. J Hand Surg [Br] 1992;17:396-400. 7. Wenner SM, Johnson KA. Transfer of the flexor carpi ulnaris to the radial wrist extensors in cerebral palsy. J Hand Surg [Am] 1988;13:231-3. 8. Wolf TM, Clinkscales CM, Hamlin C. Flexor carpi ulnaris tendon transfers in cerebral palsy. J Hand Surg [Br] 1998;23:340-3. 9. Van Heest AE, Strothman D. Wrist arthrodesis in cerebral palsy. J Hand Surg Am 2009;34:1216-24. 10. Samilson RL, Green WL. Long-term results of upper limb surgery in cerebral palsy. Reconstr Surg Traumatol 1972;13:43-50. 11. Alexander RD, Davids JR, Peace LC, Gidewall MA. Wrist arthrodesis in children with cerebral palsy. J Pediatr Orthop 2000;20:490-5. 12. Davids JR, Sabesan VJ, Ortmann F, et al. Surgical management of thumb deformity in children with hemiplegic-type cerebral palsy. J Pediatr Orthop 2009;29:504-10. 13. Goldner JL, Koman LA, Gelberman R, Levin S, Goldner RD. Arthrodesis of the metacarpophalangeal joint of the thumb in children and adults. Adjunctive treatment of thumb-in-palm deformity in cerebral palsy. Clin Orthop 1990:75-89. 14. Tonkin M, Freitas A, Koman A, Leclercq C, Van Heest A. The surgical management of thumb deformity in cerebral palsy. J Hand Surg Eur Vol 2008;33:77-80. 15. House JH, Gwathmey FW, Fidler MO. A dynamic approach to the thumb-in palm deformity in cerebral palsy. J Bone Joint Surg Am 1981;63:216-25. 16. Tonkin MA, Beard AJ, Kemp SJ, Eakins DF. Sesamoid arthrodesis for hyperextension of the thumb metacarpophalangeal joint. J Hand Surg [Am] 1995;20:334-8. 17. Filler BC, Stark HH, Boyes JH. Capsulodesis of the metacarpophalangeal joint of the thumb in children with cerebral palsy. J Bone Joint Surg Am 1976;58:667-70. 18. Matev IB. Surgical treatment of flexion-adduction contracture of the thumb in cerebral palsy. Acta Orthop Scand 1970;41:439-45. 19. Silver CM, Litchman HM, Simon SD, Motamed M. Surgical correction of spastic thumb-in-palm deformity. Dev Med Child Neurol 1976;18:632-9.

5

20. Smeulders M, Coester A, Kreulen M. Surgical treatment for the thumb-in-palm deformity in patients with cerebral palsy. Cochrane Database of Systematic Reviews 2005:CD004093. 21. Manske PR. Redirection of extensor pollicis longus in the treatment of spastic thumb-in-palm deformity. J Hand Surg [Am] 1985;10:553-60. 22. Gschwind C, Tonkin M. Surgery for cerebral palsy: Part 1. Classification and operative procedures for pronation deformity. J Hand Surg [Br] 1992;17:391-5. 23. Manske PRS, W. R. Pronator teres rerouting for spastic rotational forearm deformities in cerebral palsy. Surgical Rounds for Orthopaedics 1987:39-44. 24. Sakellarides HT, Mital MA, Lenzi WD. Treatment of pronation contractures of the forearm in cerebral palsy by changing the insertion of the pronator radii teres. J Bone Joint Surg Am 1981;63:645-52. 25. Strecker WB, Emanuel JP, Dailey L, Manske PR. Comparison of pronator tenotomy and pronator rerouting in children with spastic cerebral palsy. J Hand Surg [Am] 1988;13:540-3. 26. El-Said NS. Selective release of the flexor origin with transfer of flexor carpi ulnaris in cerebral palsy. J Bone Joint Surg Br 2001;83:259-62. 27. Goldner JL. Surgical reconstruction of the upper extremity in cerebral palsy. Hand Clin 1988;4:223-65. 28. Matsuo T, Lai T, Tayama N. Combined flexor and extensor release for activation of voluntary movement of the fingers in patients with cerebral palsy. Clin Orthop 1990:185-93. 29. Van Heest AE, Ramachandran V, Stout J, Wervey R, Garcia L. Quantitative and qualitative functional evaluation of upper extremity tendon transfers in spastic hemiplegia caused by cerebral palsy. J Pediatr Orthop 2008;28:679-83. 30. Manske PR, Langewisch KR, Strecker WB, Albrecht MM. Anterior elbow release of spastic elbow flexion deformity in children with cerebral palsy. J Pediatr Orthop 2001;21:772-7. 31. Mital MA. Lengthening of the elbow flexors in cerebral palsy. J Bone Joint Surg Am 1979;61:515-22. 32. Purohit AK, Raju BS, Kumar KS, Mallikarjun KD. Selective musculocutaneous fasciculotomy for spastic elbow in cerebral palsy: a preliminary study. Acta Neurochir (Wien) 1998;140:473-8.

Outcome(Assessments(–What,(How,(and(Which(Ones?(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((Lisa(V(Wagner(DHS,(OTR/L(

What(areas(should(I(be(addressing?!!!The!ICF!diagrams!a!model!exhibiting!the!dynamic!interactions!between!the!health!conditions!and!the!

environmental!factors.!!Function!is!described!in!the!areas!of!Body!Function/Structure,!Activity!and!Participation.!!Outcome!assessments!need!to!address!these!areas.!!Current!trends!of!instruments!have!included!caregiver!perceptions!of!functional!abilities,!quality!of!life!concerns,!and!the!transitions!from!childhood!to!adulthood.!A!comprehensive!evaluation!approach!must!be!used!in!order!to!completely!identify!and!address!impairments!and!challenges.!!!!!!

There!is!no!specific!tool!that!addresses!the!multidimensional!needs!of!each!individual!or!each!clinician’s!question.!!There!are!a!plethora!of!outcome!assessments!available!for!a!variety!of!domains.!!!

!How(do(I(choose(the(best(assessment?!!!

After!you!have!chosen!a!purpose!for!the!evaluation!and!a!population!to!evaluate;!ask!the!following:!

1. !ContentJ!Does!the!assessment!address!the!question!that!is!being!considered?!Does!the!scoring!algorithm!

provide!the!information!that!is!desired?!

2. MethodologyJ!Has!the!assessment!been!validated!for!the!population?!!Is!it!reliable?!!Does!the!assessment!have!

the!ability!to!demonstrate!change?!!!

3. Clinical(UtilityJ!Can!the!patients!or!caregivers!complete!the!assessment?!!Does!the!study!staff!have!the!time!to!

administer!the!assessment?!!Is!the!training!required!to!administer!and!score!feasible?!!Is!the!cost!of!the!

assessment!acceptable?!!!

!

Which(ones(are(typically(found(in(the(literature(for(children(with(Cerebral(Palsy?(

! !

!

!

!

!!!!!!!!!!!!!!!!!!!!!Gilmore!R,!Sakzewski,!L,!Boyd,!R,!Upper!limb!activity!measures!for!5J16JyearJold!children!with!congenital!hemiplegia:!a!systematic!review.!Dev!Med!Child!Neur.!2010;!52:!413J421.!Harvey!A,!Robin! J,!Morris!ME,!Graham!HK,!Baker!R.!A!systematic! review!of!measures!of!activity! limitation! for!children!with!cerebral!palsy.! .!Dev!Med!Child!Neur.!2008;50:190J198.!Wagner,!L,!Davids,!J,!!Assessment!tools!and!classification!systems!used!for!the!upper!extremity!in!children!with!cerebral!palsy.!Clin!Orthop!Relat!Res:!2011;!470!(5),!1257J1271.!!!!World!Health!Organization.!International!Classification!of!Functioning,!Disability,!and!Health.!!Geneva:!World!Health!Organization;!2001.!

Body!Structure/Body!Function!ROM!Modified!Ashworth!Scale!Tardieu!Scale!Grip/Pinch!strength!Stereognosis!Semmes!Weinstein!Questionnaire!of!Pain!Based!on!Spasticity!!!!

Activity!and!Participation!Assisting!Hand!Assessment!Assessment!of!Life!Habits!ABILHANDJkid!Activities!Scale!for!Kids!Box!and!Block!Canadian!Occupational!Performance!Measure!Melbourne!Assessment!of!Unilateral!Upper!

Limb!Function!Pediatric!Evaluation!of!Disability!Inventory!Pediatric!Outcomes!Data!Collection!Instrument!Shriners!Hospitals!Upper!Extremity!Evaluation!Test!of!Gross!Motor!DevelopmentJ!2nd!edition!Quality!of!Upper!Extremity!Skills!Test!WEEFIM!!!

!

Caregiver!Response/Quality!of!Life!Pediatric!Quality!of!Life!Inventory!Caregiver!Priorities!&!Child!Health!Index!!of!Life!with!Disabilities!Cerebral!Palsy!Quality!of!Life!Questionnaire!for!Children!Child!Health!Questionnaire!!!!

Quality!of!LifeJ!Peds!QLJParent/Child!percepfon!they!can't!keep!up!

Body!Funcfon/StructureJ!grip/pinch!strengthJ!decreased!

strength!

Acfvity/!ParfcipafonJ!

AHAJ!decreased!scores!!

AACPDM&CP&Upper&Extremity&Pre1Course&

Wednesday&October&21,&115&pm&

Michelle&James&

Assessment'of'the'Fingers'and'Thumb'

• Listen&to&the&child&and&parent&o Is&the&child&able&to&perform&activities&of&daily&living&at&the&appropriate&age1&and&

developmental)&level?&o Which&tasks&do&they&struggle&with?&o Do&they&use&both&hands&to&put&on&their&socks&or&pull&up&their&pants?&o If&they&see&an&OT&regularly,&what&is&the&therapists’&assessment&of&the&child’s&abilities?&&

&• Observe&the&position&and&use&of&the&child’s&fingers&and&thumb&during&age1appropriate&activities&

o Quick&House&test&(tape&measure,&specimen&jar,&folded&paper&and&marker)&o Thumb&

! Does&it&get&in&the&way?&! Can&the&child&use&it&to&grasp?&! Sometimes&difficult&to&see&on&standard&SHUEE&video&

o Fingers&! Does&the&child&have&more&difficulty&with&grasp,&release,&or&both?&! Do&the&fingers&have&dynamic&or&static&swanneck&deformities?&

o Gather&information&from&other&team&members&&! Pinch,&grip,&ROM,&stereognosis,&SHUEE&

&• Examine&the&child&on&more&than&one&occasion&before&determining&a&surgical&plan&

&

Expert Tip: Elbow flexion contracture – How do you address it?

Ann Van Heest MD, Professor, University of MN Dept of Orthopedic Surgery Gillette Children’s Specialtycare, Shriner’s Hospital for Children Twin Cities

SURGICAL TECHNIQUE

Mital performs biceps-brachialis lengthenings through a curved antecubital approach. The lacertus fibrosus is excised, and Z-lenthening of the biceps tendon and release of the brachialis aponeurosis through multiple transverse incidions in the fascia are performed. Most commonly, a correction of 30 to 40 degrees is obtained. If near–full extension is achieved, then no further release is necessary. Further correction can be obtained by release of the origin of the brachioradialis, and/or partial myotomy of the brachialis. In long-standing contractures of greater than 60 degrees, further elbow extension is blocked by contracture of the neurovascular structures and skin. Excessive tension on the neurovascular elements is unnecessary and can lead to vascular compromise. It is not necessary to release the anterior capsule. If this procedure is performed on nonfunctional limbs, full extension is not necessary and surgery in combination with postoperative serial casting provides adequate correction. A period of 4 weeks of postoperative immobilization, followed by bivalved elbow splinting, is recommended.

RESULTS

Carlson reported on early results of 90 elbows in 86 patients at an average age of 10 years old for patients with contractures of less than 45 degrees, and 14 years old for patients with contractures of greater than 45 degrees. At follow up of 22 months, active extension improved by 17 degrees and elbow flexion with ambulation improved by 57 degrees for the lesser involved group treated with a partial release of the biceps, brachialis, and brachioradialis. At follow up of 18 months, active extension improved by 38 degrees and elbow flexion with ambulation improved by 51 degrees for the more involved group treated with a more extensive release of the biceps, brachialis, and brachioradialis. Carlson reported on 9 year follow up with the same surgical cohort, totally 23 elbows in 23 patients. She showed that improved elbow extension with less elbow flexion during gait persists for the long term. No loss in surgical improvement was noted. Though movement deviations in upper and lower extremities often occur simultaneously in patients with unilateral CP, it is the upper extremity deviations and not the lower extremity deviations that correlate best with lower self-esteem. Even in high functioning individuals with mild CP, self-esteem may be adversely affected by such deviations. Elbow flexion is the main contributor in arm posturing deviations (compared to shoulder flexion, shoulder abduction, and wrist flexion). As such, correction of this particular anomaly could be of benefit for the child’s development of improved self-esteem. REFERENCES

Mital, M. A.: Lengthening of the elbow flexors in cerebral palsy. J. Bone Joint Surg. [Am.] 61:515, 1979.

Carlson, M. G., Hearns, K. A., Inkellis, E., and Leach, M. E.: Early results of surgical intervention for elbow deformity in cerebral palsy based on degree of contracture. J. Hand. Surg [Am] 37A:1665, 2012.

Riad, J, Brostrom, E., Langius-Eklof, A.: Do movement deviations influence self-esteem and sense of coherence in mild unilateral cerebral palsy? J. Pediatr. Orthop. 33:298, 2013.

AACPDM CP Upper Extremity Pre-Course

Wednesday October 21, 1-5 pm

Freeman Miller

Pronator transfer versus release Indication: Limitation in active supination, for most cases the goal should not be full active supination. If the goal is cosmetic then having neutral position is ideal, if it is an assist hand (Hemiplegia) active supination of 10 to 20 degrees is enough. For a primary use hand, quadriplegia, having hand that can supinate to 40 to 50 degrees without loosing active pronation is ideal however usually very hard to achieve. In these hand be very careful not to loose active pronation since this is the area in which they have typically developed functional skills such as driving wheel chairs and using eating utensils. Consider that in in most situations under correction of the pronation deformity will be better accepted by the patient and family and be more functional then overcorrection into a fixed supination position. Release or Transfer: My bias is toward release however transfer is also indicated 1. Full passive supination and limited active supination - this pattern may indicate underlying primary dystonia a=with little or no spasticity - avoid transfer because of over correction risk, often no treatment is best, release is typically OK if there is clearly some spasticity. Do not release either if it is pure movement disorder. 2. Mild to moderate passive fixed contracture (lacking up to 60 degrees of full supination) and active motion in a similar range. Pronator transfer will likely provide more long lasting active supination with low risk of over correction. 3. Severe contracture (no passive supination possible) and no or very limited active supination in any range, Release is more simple then transfer and likely yields the same results. There is no work of over correction this group, and the goals are usually limited to reducing severe pronation instead of a goal of function active supination. Procedure Note: Make sure the whole distal tendon is harvested for either release or transfer because it has a long relatively wide insertion and it is easy to leave a piece on the volar side attached.

AACPDM&CP&Upper&Extremity&Pre1Course&

Wednesday&October&21,&115&pm&

Michelle&James&

&

Wrist&Tendon&Transfers&(Getting&the&Balance&Right)&

• Review&all&data&pre1operatively&o Previous&exams&

! Active&wrist&ROM&! Can&the&child&open&their&fingers&with&the&wrist&supported&in&neutral&extension?&&

o SHUEE&! Wrist&position&during&activity&

o Dynamic&EMG&! FCU&activity:&continuous&vs.&out&of&phase&vs.&inactive&

o Tone&(spastic&vs.&dystonic&vs.&combination)&&

• FCU&to&ECRB&indications&o FCU&active&out&of&phase&(during&grasp)&o Child&is&able&to&open&fingers&with&wrist&supported&in&neutral&o Child&uses&fingers&better&when&wearing&wrist&splint&(they&don’t&have&to&like&it…)&

&• FCU&to&ECRB&technique&

o Mobilize&FCU&until&≥3&cm&excursion&o Create&a&generous&subcutaneous&tunnel&around&the&ulna&so&that&the&path&of&the&

transferred&tendon&is&not&constrained&by&sharp&turns&or&tight&tissue&o Weave&through&ECRB&proximal&to&the&crossover&of&the&APL/EPB&or,&if&FCU&is&short&

(common),&transect&the&ECRB&proximally&(close&to&the&musculotendinous&junction)&and&weave&or&repair&side1to1side&

o Set&tension&so&the&repair&holds&the&wrist&at&neutral&or&in&slight&(30&degrees&or&less)&extension&

! Set&in&slight&extension&only&if&the&child&can&open&fingers&easily&with&the&wrist&held&in&slight&extension&

o If&performing&a&simultaneous&EPL&re1routing,&repair&FCU&to&ECRB&first&and&route&EPL&superficially&

o Immobilize&for&6&weeks,&then&protect&from&passive&wrist&flexion&>&neutral&for&4&more&weeks&&

&

Wrist Arthrodesis in Children with Cerebral Palsy Jon R Davids, MD

Shriners Hospital for Children Sacramento, CA USA

I. Indications / Patient Selection / Anticipated Outcomes A. GMFCS 1. GMFCS IV, V: Hygiene, Pain Relief, Ease of Care 2. GMFCS III: Function, Hygiene, Pain Relief, Ease of Care a. Assess WC / Walker / Computer use prior to surgery 3. GMFCS II, I: Function, Hygiene, Pain Relief B. SHUEE Assessment Pre- and Post-operative 1. Spontaneous Functional Analysis: Neurological Impairment 2. Dynamical Positional Analysis: Task specific deficits 3. Gasp & Release Analysis: Wrist / Finger / Thumb couple C. Outcomes 1. Hygiene: Improved position 2. Pain Relief: Articular cartilage degeneration / contracture correction 3. Function a. Based on initial degree of impairment b. Accurate assessment / management of Grasp / Release function c. Stabilization effect for more complex movement disorders: Dystonia II. Surgical Technique: Pearls / Pitfalls A. Skeletal shortening is better that soft tissue lengthening 1. Proximal Row Carpectomy a. Preserve distal radio-ulnar articulation / ligaments / stability B. Soft tissue surgery 1. Less is more a. Preferred: Fractional lengthening of extrinsic finger and thumb flexors b. Occasional: Tendon Z lengthening c. Never: Sublimus to Profundus Transfer d. Never: Complete release 2. Finger Swan Neck deformities a. Intrinsic / Extrinsic imbalance unmasked b. Overly aggressive extrinsic lengthening / release C. Alignment 1. Extension: 5° 2. Ulnar Deviation: 5° D. Thumb Reconstruction 1. Almost always required

The$Role$of$Thumb$Arthrodesis$in$Cerebral$Palsy$AACPDM&2015&PreCourse&3&

&Allan%Peljovich,%MD,%MPH%

The%Pediatric%Hand%&%Upper%Extremity%Center%of%Georgia;%Atlanta,%Georgia%

%I.%CP%and%the%Thumb%% A.%Inability%to%control%thumb%motion%impairs%functional%pinch%and%grasp.%% B.%Presentation%of%spasticity%is%somewhat%variable.%% % 1.%House%Classification.%% % % a.%1J%Adduction.%% % % b.%2J%Adduction%and%MCP%flexion.%% % % c.%3J%Adduction%and%MCP%extension.%% % % d.%4J%Adduction%and%MCP/IP%flexion.%%II.%Principles%in%treating%thumb%spasticity%(general)%% A.%Determine%the%real%impact%of%spasticity%on%the%child.%% % 1.%Affect%on%function%and%daily%life%ability.%% % 2.%Affect%on%care%and%hygiene.%% B.%Implement%treatment%based%upon%the%problems%found%during%assessment.%% % 1.%Nonoperative%modalities.%% % % a.%Splinting.%% % % b.%Therapy.%% % % c.%Spasticity%modulation.%% % % % (1).%Injectables.%% % % % % (a).%botulinum%A.%% % % % % (b).%phenol.%% % % % (2).%Oral%medications.%% % 2.%Consider%surgery.%% % % a.%When%nonJoperative%treatment%is%insufficient.%% % % b.%When%nonJoperative%treatment%is%onerous.%%III.%%Surgical%principles%% A.%%If%the%goals%are%for%function…%% % 1.%Improve%ability%to%oppose,%pinch%and%release.%% B.%If%the%goals%are%to%eliminate%problems%with%care%and%hygiene…%% % 2.%Get%the%thumb%out%of%the%palm.%% C.%Steps.%% % 1.%Weaken%the%tight%or%spastic%muscles.%% % 2.%Augment%weak%or%paralyzed%muscles%needed%for%function.%% % % a.%Tendon%transfer.%% % % b.%Tendon%reJrouting.%% % 3.%Stabilize%joints%that%are%unstable%statically%or%dynamically.%% % % a.%There%are%3%intercalated%joints%in%the%thumb%ray.%% % % b.%Capsulorrhaphy.%% % % c.%Arthrodesis.%

% % % % (1).%Primary%reconstruction.%% % % % (2).%Salvage%or%revision%of%a%failed%reconstruction.%% % % % % (a).%Not%all%parents/patients%ready%for%fusion.%%IV.%Specific%Thumb%joints.%% A.%CMC%joint.%% % 1.%Rarely%fused%as%rarely%needed.%% % 2.%Relative%intolerance%to%an%unopposable%stiffer%thumb%ray.%% B.%MCP%joint.%% % 1.%Most%common%thumb%joint%addressed%using%fusion.%% % 2.%Effective%for%hyperflexion%and%hyperextension%deformities.%% % 3.%Effective%when%capsulorrhaphy%has%failed%or%deformity%occurs.%% % 3.%Techniques.%% % % a.%Bony%arthrodesis%versus%chondroJarthrodesis.%% % % b.%SesamoidJmetacarpal%arthrodesis.%% % % % 1.%Specifically%for%hyperextension%deformity.%% C.%IP%joint.%% % 1.%Usually%fused%for%recalcitrant%instability%or%deformity%following%recon.%%References$ $$ $1.% Goldner%J,%Koman%L,%Gelberman%R,%Levin%S,%Goldner%R.%Arthrodesis%of%the%

Metacarpophalangeal%Joint%of%the%Thumb%in%Children%and%Adults.%CORR.%1990;253:75J89.%

2.% House%J,%Gwathmey%F,%Fidler%M.%A%Dynamic%Approach%to%the%ThumbJinJPalm%Deformity%in%Cerebral%Palsy.%J%Bone%Joint%Surg.%1981;63A.%

3.% Kowalski%M,%Manske%P.%Arthrodesis%of%digital%joints%in%children.%J%Hand%Surg%(Am).%1988;13A:874J9.%

4.% Sakellarides%H,%Mital%M,%Matza%R,%Dimakopoulos%P.%Classification%and%Surgical%Treatment%of%the%ThumbJinJPalm%Deformity%in%Cerebral%Palsy%and%Spastic%Paralysis.%J%Hand%Surg%(Am).%1995;20A(3):428J31.%

5.% Smeulders%M,%Coester%A,%Kreulen%M.%Surgical%Treatment%for%the%ThumbJinJpalm%Deformity%in%Patients%with%Cerebral%Palsy%(Review).%Cochrane%Database%of%Systematic%Reviews.%2005(4):1J22.%

6.% Tonkin%M,%Beard%A,%Kemp%S,%Eakins%D.%Arthrodesis%for%Hyperextension%of%the%Thumb%Metacarpophalangeal%Joint.%J%Hand%Surg%(Am).%1995;20A:334J8.%

7.% Tonkin%M,%Hatrick%N,%Eckersley%J,%Couzens%G.%Surgery%for%Cerebral%Palsy%Part%3:%Classification%and%Operative%Procedures%for%Thumb%Deformity.%J%Hand%Surg%(Br).%2001;26B(5):465J70.%

8.% Tonkin%M,%Freitas%A,%Koman%A,%Leclercq%C,%Van%Heest%A.%The%Surgical%Management%of%Thumb%Deformity%in%Cerebral%Palsy.%J%Hand%Surg%(Eur).%2008;33E(1):77J80.%

9.% Van%Heest%A.%Surgical%Technique%for%ThumbJinJpalm%Deformity%in%Cerebral%Palsy.%J%Hand%Surg%(Am).%2011;36A:1526J31.%

%

AACPDM&CP&Upper&Extremity&Pre1Course&Wednesday&October&21,&115&pm&

Douglas&Hutchinson&&Extensor)Pollicis)Longus)Re2routing)&

1) Prerequisites:&&Adducted&thumb(almost&a&given)&and&volitional,&functional&EPL(common&but&not&always)&

2) Concomitant&procedures;&&Adductor&+/1&&FPB&release&depending&on&adducted&thumb&posture&

3) Other&PE&considerations:&&Hyperextension&of&MP&joint?&&If&so&the&procedure&a&bit&different.&&Don’t&want&the&EPL&to&extend&IP&jt&or&MPjt&primarily&but&instead&act&as&an&abducter&first&and&foremost&

4) Surgical&steps:&a) 2&incisions,&1&over&MPjt&extending&to&middle&of&prox&phalanx&and&1&over&

2nd&compartment&at&wrist&to&allow&both&harvest&of&EPL&from&lister’s&and&replacement&under&first&compartment&retinaculum&

b) Release&epl&along&medial&and&lateral&‘retinacula’&at&MP&joint&leaving&‘ridge’&of&soft&tissue&behind&for&repair.&

c) Transect&epl&over&proximal&phalanx&once&distal&to&retinaculum&&d) Bluntly&retract&EPL&into&proximal&wound&and&behind&Lister’s&tubercle&e) ‘Tenolys’&EPL&proximally&under&skin&to&allow&better&alignment&along&

first&compartment&muscles.&f) Use&Bunnell&tendon&passer&from&distal&to&proximal&following&path&of&

EPB&and&trying&to&stay&as&close&to&radial&styloid&as&possible&in&an&effort(not&sure&how&often&this&is&truly&successful!)&to&place&tendon&under&first&compartment&retinaculum.&&If&Passer&is&only&subcutaneous&you&can&tell&and&then&replace&before&passing&EPL.&

g) Pass&EPL&from&proximal&to&distal&and&bring&out&thumb&wound.&h) Check&to&see&that&you&have&approximately&1&cm&more&tendon&now&IF&you&

were&going&to&simply&rerepair&to&end&of&EPL(one&should,&since&there&is&a&more&direct&pull&now,&have&extra&tendon&you&will&cut&off&and&therefore&its&OK&to&hold&end&of&tendon&with&any&clamp&you&wish).&

i) Hold&thumb&in&Abduction(radial,&not&palmar)&and&wrist&in&neutral&or&some&dorsiflexion(20&degrees&at&most)&while&sewing&tendon&back&down&to&‘retinacula’&starting&proximal&to&MPjt.&(I&use&410&Mersilene&usually&since&it&is&a&white&nonabsorbable).&&Tight&tension&of&EPL&in&cases&where&volitional&function&is&more&in&doubt&so&it&can&at&least&act&passively&as&a&tenodesis.&

j) If&there&is&MPjt&hyperextension&tendencies(not&uncommon&at&all)&sew&EPL&tendon&directly&into&capsule/periosteum&at&proximal&edge&of&joint&so&its&primary&force&will&act&to&abduct&the&first&metacarpal.&&

k) ‘Tenodese&the&rest&of&tendon&into&distal&stump,&end&to&end&tensioning&so&IP&joint&straight&and&not&hyperextended.&

l) I&rarely&pin&MPjt&but&need&to&be&careful&of&casted&position&if&you&don’t&to&avoid&hyperextension.&

m) Throw&away&the&extra&cm&of&EPL&n) Close,&with&absorbable&stitch&of&choice(running&monocryl&for&me)&and&

then&immobilize.&

&&&&&5)&Post&Op&Treatment&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

&a) My&preference,&depending&on&what&else&was&done&concomitantly(Green,&

pronater&release,&FDS/FPL&fractional&lengthening,etc)&is&a&‘Tape&Cast’&with&plaster&splint&holding&position&of&thumb&and&tape&up&to&elbow&directly&on&forearm&skin&&&covered&with&Coban&in&younger&kids&who&can&slowly&get&out&of&regular&casts&or&a&bivalve&cast&in&older&‘responsible’&types&with&over&wrapping&several&days&later.&

b) Immobilize&for&416&weeks(depending&on&convenience&of&patient&and&surgeon!)&and&then&go&to&3&months&of&hand1therapy1made&thumb&spica&splint.&&

c) &I&usually&splint&first&month&‘Fulltime’&where&its&only&off&for&showers,&then&second&month&‘Parttime’&where&they&remove&and&use&their&hand&quietly&around&parent&but&on&when&at&Day&care,&etc&as&well&as&at&night&and&third&month&‘Nighttime’&only.&

d) Actual&therapy&rarely&needed&other&than&splint&adjustments&as&passive&motion&not&wanted&and&they&really&don’t&need&to&‘relearn&it’.&

POST-OP PEARLS By Peace Patience -Knowing what protocol is -Knowing parents/patients -Knowing muscle is small Evaluate -Pre and Post Op -Outcome tool repeated -Video pre/post Activate -Transfer with: -Place/hold -Short/long arc -Mid/end range -With/without gravity -Resistance at 12 weeks -No compensation -Active/assistive range Rapport -With child -With caregiver -With surgeon Life Skills/Style -Why did they have surgery? -Will they have therapy for a lifetime? -Will they do Home Exercise Program?

Greenville Pediatric Specialty Care

Orthopaedics

Laura Peace, OTR/L Occupational Therapist Rehab Services 950 West Faris Road Greenville, SC 29605 Main: 864.271.3444 Direct: 864.240.6277 Fax: 864.240.2143 E-mail: lpeace@shrinenet.org www.shrinershospitals.org