All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH.
No statement or presentation made is to be regarded as dedicated to the public domain.
IC02-L: The Spastic Upper Extremity: Contemporary
Approaches
Moderator(s): Peter C. Rhee, DO, MS
Faculty: Lindley B. Wall, MD, Jennifer F. Waljee, MD, Caroline MC Leclercq, MD and Michael S. Bednar,
MD
Session Handouts
76th Annual Meeting of the ASSH
September 30 – October 2, 2021
822 West Washington Blvd
Chicago, IL 60607
Phone: (312) 880-1900
Web: www.assh.org
Email: [email protected]
The Spastic Upper Extremity: General Principles in the Surgical Management of the Spastic Upper Extremity
Peter Rhee, DO, MSc
Upper Motor Neuron Syndrome • Disruption of UMN inhibitory pathways • Impaired regulation or loss of voluntary movement • Causes
• Brain Injury • Cerebrovascular accident (CVA) • Traumatic brain injury (TBI) • Anoxic brain injury (ABI)
• Spinal cord injury (SCI) Upper Motor Neuron Syndrome: Signs and Symptoms
• Immediate → Flaccidity • Days to weeks → Increasing motor tone
• Unmasking of primitive reflexes • Spinal reflex hyperactivity
Spinal reflex hyperactivity • Exaggerated muscle activation in response to:
• Quick stretch → spasticity • Slow stretch → rigidity
• Can results in spastic co-activation → dyssynergy Surgical Management Options for Spastic Deformities
• Functional = Volitional muscle control • Non-Functional = No volitional muscle control
9/7/21
1
Flexed Wrist DeformityLindley B. Wall, MD MSc
Washington University Orthopedics | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
Washington University Orthopedics
No Disclosures
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
Case
• 6 year-old female with hemiplegic CP. She has undergone botoxinjection and therapy for years. Not seeing improvement any longer. Primarily difficulty gripping
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
9/7/21
2
Faculty opinion
• Approach?
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
Flexed wrist deformity
• Tendon fractional lengthening• +/- ECU centralization
• Tendon transfer• FCU transfer to wrist extensor
• Partial neurectomy of FCU innervation
• * Wrist arthrodesis
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
Tendon transfer considerations
• Augments weak extensors•Don’t forget the finger flexors•Dynamic vs static transfer• Role of EMG
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
Technical considerations
• FCU origin is long = long incision for harvest• Ensure no fascial entrapment around ulna• Transfer through interosseous space• If worried about too much supination
• Transfer to ECRB or ECRL• Wrist in neutral
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
9/7/21
3
Tie in transfer at neutral*
Patterson et al. JHS 2010
Post-operative Rehabilitation
• Cast for 5 weeks• Wrist brace for 4 weeks with OT for gentle active motion• Young patients full time brace wear
• Brace nighttime for 3-4 weeks
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
9/7/21
4
Thank you
Washington University Orthopedics | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.
Speaker has not
provided a handout for
this presentation.
Session Handouts
OnDemand
76TH ANNUAL MEETING OF THE ASSH
SEPTEMBER 30 – OCTOBER 2, 2021
SAN FRANCISCO, CA
822 West Washington Blvd
Chicago, IL 60607
Phone: (312) 880-1900
Web: www.assh.org
Email: [email protected]
9/7/21
1
Flexed Wrist DeformityLindley B. Wall, MD MSc
Washington University Orthopedics | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
Washington University Orthopedics
No Disclosures
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
Case
• 6 year-old female with hemiplegic CP. She has undergone botoxinjection and therapy for years. Not seeing improvement any longer. Primarily difficulty gripping
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
9/7/21
2
Faculty opinion
• Approach?
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
Flexed wrist deformity
• Tendon fractional lengthening• +/- ECU centralization
• Tendon transfer• FCU transfer to wrist extensor
• Partial neurectomy of FCU innervation
• * Wrist arthrodesis
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
Tendon transfer considerations
• Augments weak extensors•Don’t forget the finger flexors•Dynamic vs static transfer• Role of EMG
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
Technical considerations
• FCU origin is long = long incision for harvest• Ensure no fascial entrapment around ulna• Transfer through interosseous space• If worried about too much supination
• Transfer to ECRB or ECRL• Wrist in neutral
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
9/7/21
3
Tie in transfer at neutral*
Patterson et al. JHS 2010
Post-operative Rehabilitation
• Cast for 5 weeks• Wrist brace for 4 weeks with OT for gentle active motion• Young patients full time brace wear
• Brace nighttime for 3-4 weeks
Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis Washington University Orthopedics | | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
9/7/21
4
Thank you
Washington University Orthopedics | St. Louis Children’s Hospital | Shriner’s Hospital for Children-St. Louis
All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.
Speaker has not
provided a handout for
this presentation.
Session Handouts
OnDemand
76TH ANNUAL MEETING OF THE ASSH
SEPTEMBER 30 – OCTOBER 2, 2021
SAN FRANCISCO, CA
822 West Washington Blvd
Chicago, IL 60607
Phone: (312) 880-1900
Web: www.assh.org
Email: [email protected]
