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ChairpersonDr. R. S. Jatti Presenter Dr. Srinath
Gupta
Cerebral Palsy
Brain Development Brain grossly differentiates into cerebrum
and cerebellum during 1st Trimester of embryonic life
Neurons begin to develop in 2nd trimester By end of 2nd trimester all neurons are
formed and any damage occurring now is irreversible
Synaptic connections occur in 3rd trimester
First described in 1862, by William John Little, an orthopedic surgeon who observed that children with tone and developmental abnormalities often had prolonged labor, prematurity or breech delivery
Cerebral Palsy was known as Little’s Disease for decades.
The term cerebral Palsy originated with William Osler and Sigmund Freud
Static Encephalopathy has been used interchangeably with cerebral palsy
Trivia
Overview Definition Incidence Etiology Classification Management Lower Limb Deformities
Definition Static, non progressive disorder of CNS
secondary to an insult to immature brain, resulting in varying degrees of motor milestone delay and dysfunction
CP is a disorder of tone, posture or movement
It results in paralysis, weakness, in coordination or abnormal movement
Incidence 2.4-2.7 for every 1000 live births
EtiologyPrenatal:
◦Infection: TORCH Complex, HIV◦Cerebral malformation◦Obstetrical complication: pre-eclampsia,
eclampsia, abruptio placentae, placenta previa, placental infarction
◦Maternal diseases◦Abuse of drugs
Contd…Perinatal:
◦Prematurity◦Low birth weight◦Complicated delivery◦Asphyxia◦Cerebral trauma◦Hyperbilirubinemia◦Blood incompatibilities◦Infections: Herpes simplex, meningitis◦Severe hypoglycemia
Contd…Post natal :
◦ Infections : Meningitis, encephalitis◦ Head injury◦ Cerebral anoxia◦ Aspiration◦ Asphyxia◦ Seizures◦ Near drowning◦ Cardiac arrest◦ Cerebrovascular accidents◦ Sickle cell anaemia◦ Vascular malformations
Classification Because of the wide variability in presentation and
types of cerebral palsy, there is no universally accepted classification scheme.
Monoplegia Hemiplegia Paraplegia Diplegia Quadriplegia Double Hemiplegia Total body
Classification based on Geographical Distribution
Physiological classification Spastic Athetoid Choreiform Rigid Ataxic Hypotonic Mixed
Spastic:◦ Most common type◦ Associated with injury to pyramidal tracts in immature brain
Athetoid:◦ Associated with injury to extrapyramidal tracts◦ Dyskinetic purposeless movements◦ Dystonia or hypotonia can occur with athetoid cerebral palsy
Choreiform:◦ Continual purposeless movements of wrists,fingers,toes and
ankles
Contd…
Rigid:◦ Most hypertonic form◦ Cogwheel or leadpipe rigidity
Ataxic:◦ Very rare◦ Injury to developing cerebellum◦ Disturbance of coordinated movement viz. walking◦ Characterized by weakness, in-coordination, a wide
based gait, and trouble with fine and rapid movements.
Hypotonic:◦ Passing stage in spastic or ataxic cerebral palsy
Mixed:◦ Signs of pyramidal and extrapyramidal deficits
Contd…
Spastic Diplegia•Bilateral spasticity of legs•1st noticed when infant begins to crawl-tends to drag the legs behind more ( commando crawl)•Severe spasticity –application of diaper is difficult due to excess adduction of hips•Brisk reflexes, ankle clonus•Scissoring posture of lower extremity when suspended by axilla
•Walking tiptoes, disuse atropy ,impaired growth of lower extremity•Intellectual development normal•Minimal seizures •CT/MRI-periventricular leukomalacia of white matter mainly lower limb fibres•All spastic types characterized by toe walking, a crouched gait, and flexed knee, scissoring
Spastic Hemiplegia•Arms often more involved than leg-difficulty in hand manipulation is obvious by 1 yr•Delayed walking -18-24 months•Equinovarus deformity of foot, walks on tip toes because of increased tone•Affected upper limb has dystonic posture when child runs
•Deep tendon reflexes increased, ankle clonus, Babinski sign +•1/3rd have seizure disorder•25% have MR•CT/MRI- atrophic cerebral hemisphere with dilated lateral ventricle contralateral to the affected side
Spastic Quadreplegia•Most severe form ,most common•All extremities severely impaired•High association with MR and seizures•Flexion Contractures of knees and elbows
After age 1yr –athetoid movements become evident
Speech is affected (slurred, voice modulation impaired) due to involvement of oropharyngeal muscles
Upper motor neuron signs –not present
Seizure uncommon Intellect –preserved Characterized by an exaggerated step,
hip and knee hyperextension, a backwards lean, and shoulder girdle and trunk extension.
Athetoid Cerebral palsy
I Has nearly normal gross motor function II Walks independently, but has limitations with
running and jumping III Uses assistive devices to walk and wheelchair
for long distances IV Has ability to stand for transfers, but minimal
walking ability; depends on wheelchair for mobility
V Lacks head control, can’t sit independently, is dependent for all aspects of care
Gross Motor Function Classification System
Associated Problems Mental Retardation Communication Disorders Behavioral disorder Seizures Vision Disorders Hearing loss Somatosensation (skin sensation, body awareness)
Temperature instability Nutrition Drooling Dentition problems Neurogenic bladder Neurogenic bowel Gastroesophageal reflux Dysphagia Autonomic dysfunction
Gait in cerebral palsy◦Idiopathic toe walking◦Spastic knee gait◦Crouch gait
Gait
Determine grades of muscle strength and selective control.
Evaluate muscle tone and determine type. Evaluate degree of deformity / contracture at each joint. Assess linear, angular and torsional deformities of
spine, long bones, hands and feet. Appraise balance, equilibrium and standing / walking
posture.
Clinical AssessmentGoals of Physical Examination
History Examination X-ray skull-intracranial calcification EEG CT/MRI Test of hearing ,vision IQ test
Diagnosis
Achievable goals should be set The child with CP becomes the adult with CP
Goals based on needs of adults Communication : verbal / nonverbal Mobility Walking Activity of daily living (ADL) feeding, dressing, toileting, bathing Turn focus of parents from the disease to the
goal-oriented approach
Goals of Management (Treatment)
Control of spasticityPhysical therapyOrthoticsOrthopedic surgery
Types of Management (Treatment)
Spasticity is present in most patients with CP (65 % ) When it is reduced patients may : - perform integrated muscle movement - develop muscle strength - function at a higher level Approaches :
• Selective dorsal rhizotomy• Intrathecal baclofen• Botulinum-A toxin
CONTROL OF SPASTICITY
Other oral medicines used in Cerebral Palsy:◦ Dantrolene◦ Flexeril◦ Antiepileptic drugs such as Phenytoin, Sodium Valproate,
Carbamazepine, etc.
Conventional PT :◦ Works on muscles, tendons, and ligaments
Active exercises Passive ROM exercises Passive stretching Bracing
PHYSICAL THERAPY
Involve parents as much as possible (even if they resist)
Do not raise false hopeswhich could increase frustration
Contd…
ORTHOTICSCasting..Short leg casts are applied with extended toe plates, careful
molding of the heel and metatarsal head control.For a period of time varies but usually a minimum of 6 weeks.
and is followed by the use of orthoses.There is a limited role for casting in patients with cerebral palsy.
Orthoses..Can be helpful in improving gait in ambulatory patient with
cerebral palsy.Ankle-foot orthoses are most commonly prescribed to assist the
child with positioning of the ankle and foot during gait.
Ankle Foot Orthoses (AFO)
m
Orthoses
Primary deformity : needs treatment
Compensatory deformity : can improve without intervention
Surgery Prevent structural changes - usually early
Improve function - usually later
ORTHOPEDIC PROCEDURESDistinguish between
Type : spastic Extent : hemiplegics / diplegics : good results quadriplegics : minimal improvement Age : 3- 12 years IQ : good Good upper limb function : for walking Underlying muscle power : not weak Walker / non-walker : surgery hardly changes state but improves gait
Prerequisites for effective surgery
For structural changes : Early e.g. Hip subluxation , usually <5 years To improve function ( gait ) : defer until walking ( independently / with aids ) until gait pattern develops and can be assessed walking : 18 – 21 months in hemiplegia 3 – 4 years in spastic diplegia Optimum time of lower extremity surgery 5 – 7 years: can analyze and observe gait pattern
Timing For Orthopaedic Surgery
Timing For Orthopaedic Surgery
Surgery should not be unduly staged one by one ( with each birthday )
?ETA ? Hams ? Psoas ? Rectus Femoris
Equinus Crouch Flexion Stiff Knee Ok
Hip◦ Flexion contracture◦ Increased hip addduction/ scissoring◦ Subluxating or dislocating hip
Rotational deformities of femur and tibia Knee Foot
◦ Equinus◦ Equinovarus◦ Pes valgus◦ Ankle valgus◦ Hallux valgus◦ Dorsal Bunion
Lower limb involvement
Adduction and flexion deformity Hip at risk Hip subluxation Hip dislocation
Hip Problems
Hip flexion contractures are found most commonly in patients with spastic diplegia and spastic quadriplegia.
Flexion contracture is due to increased tone in the hip flexors (primarily the iliopsoas) and relative weakness of the hip extensors (such as the gluteal muscles)
The contracture is identified during the physical examination by performing the Thomas and Staheli maneuvers.
Flexion Deformities in Hip
Thomas test
Staheli test
Clinical AssessmentHip Flexors
Ely / Rectus Femoris Test
Flexion internal rotation deformity should be differentiated from True Adduction deformity.
Increased femoral anteversion when combined with crouch at the knee can produce the appearance of scissoring which termed as pseudo adduction
Adductor surgery will be ineffective in improving the child’s ability to walk when the narrow base of gait is secondary to pseudo adduction.
Single-stage multilevel procedures are preferable to staged single-level procedures because hospitalization, immobilization, and rehabilitation time and the number of anesthetic exposures are decreased
Hip flexion contractures from 15 to 30 degrees usually are treated with psoas lengthening
Contractures of more than 30 degrees may require more extensive releases of the rectus femoris, sartorius, and tensor fasciae latae and the anterior fibers of the gluteus minimus and medius, in addition to the iliopsoas
Treatment
Iliopsoas recession (Skaggs et al technique)
Contd…
Iliopsoas release at the Lesser trochanter(Miller technique)
Iliopsoas tenotomy / lengthening / recession
Tenotomy : Should not be done in ambulatory patients
Recession : Doesn’t cause excessive hip flexion weakness
Lengthening (z plasty) : best / easy /satisfactory in ambulating patients no risk of too much weakening of flexion power
Contd…
Most common deformity Spasticity in the adductor muscles in cerebral palsy results
in a narrow base of gait and scissoring, hip subluxation, and, in severely affected children, difficulty with perineal hygiene
Adduction deformities in Hip
Adductor tenotomy and release◦ Resection of tendon of adductor longus and anterior half of
addductor brevis and gracilis ,if required◦ Avoid neurectomy of ant. branch of obturator nerve
Operative treatment:
Deformities of the hip in patients with cerebral palsy range from mild painless subluxation to complete dislocation with joint destruction, pain, and impaired mobility
In most patients, the hip is normal at birth, and radiographic changes typically become apparent between 2 and 4 years of age.
Subluxation and dislocation
Hip subluxation in patients with cerebral palsy can be difficult to detect clinically
Routine clinical and radiographic examinations should be done every 6 months
A practical radiographic method for quantifying the amount of hip subluxation present, which was described by Reimers as the “migration percentage.”
Hip subluxation ( partially out)Hilgenreiner line
Contd…
Dislocated Subluxated50 %
Reimer’s migration index
Hip subluxation ( partially out )( > 30 % uncoverage / broken Shenton’s line )
Contd…
Hip at risk
Because early intervention can be very effective in preventing or delaying the development of dislocation, considerable work has been done to identify hips at risk
Hip at Risk Hip subluxation
Contd…
At 2.5 years At 7 years
Varus Derotational Osteotomy, usually combined with soft-tissue releases, is indicated for patients with excessive anteversion and valgus deformity of the proximal femur and a hip that is either subluxated or dislocated
Operative Treatment
Combined One-Stage Correction of Spastic Dislocated Hip (San Diego Procedure) ◦ medial approach (soft-tissue release) ◦ anterior approach (open reduction)◦ lateral approach (femoral osteotomy) ◦ anterior approach (pericapsular pelvic osteotomy)
Operative treatment
Proximal Femoral Resection
Painful dislocated > 1 year
Surgical resection
Hip Arthrodesis The ideal candidate is a patient with unilateral disease and no spinal involvement. Hip arthrodesis may be preferable in ambulatory patients because it allows weight bearing, in contrast to proximal femoral resections.
Contd…
Deformities of the knee rarely occur in isolation
The hip and the knee are tightly coupled because of the muscles that cross both joints, the “two-joint muscles.”
KNEE
Flexion Deformity Recurvatum of the Knee Knee Valgus Patella Alta
Deformities in knee
Most common knee deformity in patients with cerebral palsy and frequently occurs in ambulatory children
Crouching gait.
Flexion Deformity
Straight leg raising◦ Angle< 70 … Indication
The Hamstring Test◦ Holt’s method◦ Popliteal Angle< 135 - Indication
Clinical AssessmentKnee Flexion
Fractional Lengthening of Hamstring Tendons
Operative management
Distal Transfer of Rectus Femoris
Combined Hamstring Lengthening and Quadriceps Shortening along with posterior capsule release
Hip flexion Deformity increases after
hamstring release
Better to transfer hamstring insertion to keep hip extended
Effect of Knee Surgery on The Hip
Caused by Quadriceps spasticity or long standing Knee FFD.
Can lead to repeated to micro trauma to patellar tendon and quadriceps tendon and stress fractures of patella and tibial tubercle.
Usually painless, so intervention is not required.
Correction of FFD of knee with hamstring lengthening causes improvement.
Patella alta
DEFORMITIES◦ Equinus Deformity◦ Varus or Valgus Deformity
Equinovarus Deformity Equinovalgus Deformity
◦ Calcaneus Deformity◦ Cavus Deformity◦ Forefoot Adduction Deformity◦ Hallux Valgus Deformity◦ Claw Toes
FOOT
Most common foot deformity in patients with cerebral palsy
It is an increased plantar flexion due to a plantar flexion contracture or dynamic plantar flexion due to over activity of the gastrocsoleus during gait
Equinus deformity
Toe-walking patients must be considered as two different groups:◦ equinus patients◦ as a consequence of crouch at the hip and knee with
natural ankle. Cerebral palsy must be differentiated from:
Idiopathic toe walking as a congenital short Achilles tendon
Muscular dystrophy (as Duchenne’s)produces toe walking.
Equinus.. Clinical examination..
Inability to fully dorsiflex the ankle
The Silverskiold test:If the ankle can be passively dorsiflexed with the knee bent to 90 degree but cannot be dorsiflexed with the knee extended it is believed that the gastrocnemius is tight, but the soleus is not contracted
This test is used to determine which type of surgical lengthening to perform
The Silfverskiold test
Dynamic : Treat by : Bracing Spasticity reduction Surgery Fixed : Treat by : Serial casting Surgery
Treatment
Open Lengthening of the Achilles Tendon
Surgical treatment
Z-Plasty Lengthening of the Achilles Tendon
Percutaneous Lengthening of the Achilles Tendon
Lengthening of the Gastrocnemius-Soleus Muscle
Vulpius technique.. Strayer procedure
Baker technique(tongue-in-groove)
Diplegic patients typically have internally rotated and adducted hips, flexed knees, and external rotation deformity of the tibia. This combination of deformities causes the foot to assume a valgus position.
In hemiplegic patients, the internally rotated thigh with the knee coming to full extension in stance phase causes the foot to internally rotate and produce a varus deformity
Varus or Valgus Deformity
Muscle imbalance in which the invertors of the foot over power the evertors, most commonly Tibialis post.
Gastrocnemius contributing equinus
Surgery is indicated to1. Improve foot contact.2. Relieve pain.3. Relieve skin changes
Equinovarus Deformity
Contd…The confusion test:
The patient flexes the hip against resistance If supination of the forefoot is seen, then
anterior tibialis is contributing to equinovarus deformity .When dorsiflexion is seen without supination, the deformity is less likely to respond to surgery on the anterior tibialis
It also is important to determine whether or not the deformity is flexible and correctable or rigid because patients with flexible deformities are more likely to be successfully treated nonoperatively with orthotics and shoe modifications and operatively with soft-tissue procedures such as tendon lengthenings, releases, or transfers (usually of the abnormally active muscle)
Patients with rigid varus deformities generally require bone procedures, such as calcaneal osteotomy.
Contd…
Lengthening of the Posterior Tibial Tendon◦ Z-Plasty Lengthening of the Posterior Tibial Tendon◦ Step-Cut Lengthening of the Posterior Tibial Tendon◦ Intramuscular lengthening of the Posterior Tibial Tendon
Surgical treatment
Split Tendon Transfers◦ Split posterior tibial
tendon transferIt is one of the most
common procedures for equinovarus deformity treatment.
The posterior one-half of the posterior tibialis tendon is rerouted posterior to tibia and woven into the peroneus brevis
tendon.
Contd…
Kaufer split transfer of tibialis posterior tendon
Kaufer split transfer of tibialis posterior tendon
◦ Split anterior tibial tendon transfer
The lateral one-half of anterior tibialis is detached from its insertion.
Passed beneath the extensor retinaculum.Inserted through a bone tunnel into the cuboid.Foot is positioned in 5-10 deg. of dorsiflexion.Known as the Rancho procedure when done in combination
with posterior tibialis lengthening.
Contd…
Split transfer of tibialis anterior tendon
Heel varus will respond to calcaneal osteotomy.
If the deformity is severe, and with rigid component of mid foot supination… Triple arthrodesis should be performed.
Even with bony procedures, muscle imbalance must be corrected.
Bony surgery in Equinovarus
Dwyer closing wedge osteotomy of calcaneus for varus heel
Pes valgus Occurs in up to 25% of patients with cerebral palsy.
and most common in older diplegic or quadriplegic patients.
Can be caused by spastic peroneal muscles, weakness of the p.tibialis and a tight gastrocsoleus.
Radiographs should be obtained in standing position for the foot and ankle.
Conservative treatment should vigorously pursued.. shoe inserts and orthoses may be adequate to relive pain and avoiding surgery.
Surgical treatment of Pes valgus
Bony surgery is the only predictable alternative for full and lasting correction.
Surgical options are…I. The Grice extra- articular arthrodesis.II. Lateral column (calcaneal neck) lengthening.III. Calcaneal osteotomy.IV. Triple arthrodesis.
Grice extra- articular arthrodesis Modifications to the original procedure:
Fibular graft was changed to iliac crest graft. Using internal fixation to keep the position of the subtalar joint in
combination with cancellous iliac crest graft.
Calcaneal osteotomy
Advantage: preserve joint motion of sub talar joint.
Results have been very good.
Contraindications: severe rigid valgus deformity.
Triple Arthrodesis Treatment of choice for rigid symptomatic Pes valgus in adolescent
with cerebral palsy. Resecting the subtalar, calcaneocuboid, talonavicular joints.
Indications:1. Pain2. Skin ulceration over the talar head.3. Deformity interfering with ambulation in child with deformity not
amenable to osteotomy. Satisfactory outcomes are found when deformity is well corrected.
Degenerative changes have been documented in the ankle joint at an average of 18yrs.following arthrodesis in 43% of the pediatric population.
Triple arthrodesis for Pes valgus treatment
Dorsal bunion It is a rare deformity. The first metatarsal head is elevated, but
the great toe is plantar flexed.
Surgical rebalance depends on…Transfer of the flexor tendon to the extensor.Or flexor tenotomy.Or by transferring of the flexor hallucis brevis
to the metatarsal neckOr by all that in combination with closing
wedge plantar flexion osteotomy of first metatarsal.
Hallux valgus Develops in cerebral palsy patients in response to a Equino valgus deformity of the
hind foot. There is a progressive eversion and abduction of foot because of peroneus longus
is spastic. The toe is pushed laterally as weight is borne by the everted foot. The big toe comes to lie beneath the second toe, and the first metatarsal head
becomes uncovered and painful bunion develops.
When this deformity is mild, surgical treatment of Pes valgus will halt the progression of toe deformity.
Bleck& Goldner described soft tissue realignment including:Release of the adductor hallucis t. and lateral capsulotomy of the first metatarsophalangeal
joint. combined with first metatarsal and proximal phalangeal osteotomy.
McKeveer technique: First metatarsophalangeal fusion. That led to better results with less recurrence than soft tissue realignment.
Preferred position for fusion is 15-25 deg. Of dorsiflexion and slight valgus.
Hallux valgus in 14 yrs. Old girl with cerebral palsy.Treated with metatarsophalangeal fusion.
Intoeing Usually caused by femoral ante-version Internal tibial torsion adds to Intoeing Not related to spasticity of internal
rotators
If severe : Derotation osteotomy Delay to late childhood if
possible
Derotation osteotomy of femur might cause tightening of medial hamstrings
( might need lengthening )
In-toeing
Why Does Anteversion Cause In-toeing ?
Anteversion rotates Greater Trochanter posteriorly
On stance phase need Abductor power Abductor power optimized when Greater
Trochanter is lateral not posterior Internal rotation in stance phase brings
Greater Trochanter laterally
In-toeingIndication for derotation osteotomy
Severe femoral anteversion, with loss of all external rotation.
Dynamic in-toeing causing gait abnormalities. Dynamic in-toeing causing secondary foot
deformity. Usually not before 8-10 years.
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