Cerebral palsy

1. Cerebral palsy and its sequelae.. (consequences)

2. Cerebral Palsy Was first described by William Little in 1862. Then it was known as Little disease. The term Cerebral palsy originated with Freud. Definition In all cases the following must be true… Cerebral palsy is the result of a brain lesion. Therefore, the spinal cord and muscles are structurally and biochemically normal. The brain lesion must be fixed and non progressive. Thus, all of the progressive neuro degenerative disorders are excluded from the definition. The abnormality of the brain result in motor impairment.

3. Epidemiology • The Incidence is between 2.4-2.7 per 1000 live births. • The risk of cerebral palsy in a child born full term is app.1 in 2000. • The incidence has been correlated with gestational age and birth weight.

4. Etiology Divided into 3 time periods… Prenatal • Maternal infection and toxins (TORCHES). • Fetal exposure to drugs and alcohol through maternal .(cocaine, heroin ,marijuana) • Congenital malformations of the brain that occur during early pregnancy. • Rhesus blood group incompatibility resulting in kernicterus. • Maternal health problems. ex: RF-Infections. • Prenatal chorioamnionitis and maternal infections and placental abnormalities. Perinatal • Anoxia as a result of perinatal complications. • Fetal distress. • Premature delivery. • Sepsis in neonatal period. • Bronchopulmonary dysplasia and prolonged ventilation in preterm infants. • Heart surgery before the age of 1mnth. Postnatal • Infections in early childhood (meningitis). • Any episode of hypoxia. • Trauma and head injuries.

5. Classification Physiologic classification Describes the type of movement disorder present… • Spasticity: the most common. Increased tone in the extremities.. (the Clasped knife model) • Hypotonia: usually a phase, leading most frequently to spasticity. • Dystonia: lead pipe model. • Athetosis: abnormal writing movements, patient cannot control. • Ataxic: in cerebellar lesions. Patients frequently have a mixed form of movement disorders. Geographic classification Describes what part of body is affected.. • Hemiplegia: one side, upper usually more involved. • Diplegia: both sides, with both lower extremities and lesser involvement of upper extremities. • Triplegia: both lower and one upper extremity. • Quadriplegia: Total body involvement.

6. Spastic Diplegia Spastic quadriplegia

7. Diagnosing.. Obtaining a complete history (birth history, birth weight, complications following birth..) Asking about the child’s preferential use of one hand or leg. Related medical conditions (seizures, speech disorders) Physical examination.. Increased muscle tone. Deep tendon reflexes are increased. Fine motor activities testing. Retained infantile reflexes. Balance, sitting and gait of child. Evaluation

8. Treatment Treatment, Surgical or nonsurgical, must be goal oriented.. The goals of treatment that have linked to productive lives as adults are: Communication, education, mobility and ambulation. Treatment ranges from observation, physical therapy, medications.. to surgery.

9. Treatment.. Physical therapy.. Often the first rendered to the child with cerebral palsy. No controlled studies have confirmed that regular physical therapy improves the out come of the child with cerebral palsy. The approach to physical therapy is to establish a therapy to monitor the developmental milestones of the very young child around the age 2-3 years. Therapy continue if gains are being made in attaining ambulation.

10. Treatment… Casting.. 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.

11. Ankle Foot Orthoses (AFO)

12. Cerebral palsy The upper limb surgery

13. The upper limb The basic goals can be achieved with operative treatment of upper limb.. • Improvement in function. • Improvement in appearance. • Facilitates nursing care in children who are unable to care for them selves because of more severe involvement. The major surgical methods… • Lengthening of a tight musclotendinous unit. • Augmenting a weak muscle by tendon transfer. • Arthrodesis in the older children.

14. The upper limb.. Non-surgical treatment.. Directed towards.. • Preventing of contracture. • Splinting for positional improvement. • Hand therapy to improve dexterity. • Sensory reeducation. • Muscle relaxants( as Baclofen or Botox) affect in decreasing spasticity. Surgical treatment.. Most procedures attempt to restore balance by combination of soft tissue releases and tendon transfer, or by arthrodesis where soft tissue procedures are inadequate. The typical posture of spastic upper limb is…elbow, wrist and fingers flexion, and forearm pronation.

15. Flexed wrist and hand with pronation of the forearm

16. Elbow flexion contracture • Occurs usually in the globally involved child. • Shoulder adduction contracture may be present • Severe elbow flexion contracture can be relieved by… • Release of the lacertus fibrosis. • Z-lengthening of biceps tendon. • Lengthening of brachialis tendon. • Proximal origin of brachoradialis m. can be released. • Loss of some active flexion may happened.

17. Mital elbow flexion release

18. Forearm pronation • Develops insidiously, and with growth, causes a rotational deformity of radius. • The release or rerouting of the pronatore tendon is the option for correction when the fore arm is passively correctable.

19. Fractional lengthening of pronator teres at its insertion to the radius.

20. Wrist and fingers flexion • The goal of surgical procedure on the wrist and fingers is to allow the fingers to open with wrist flexion for release, and to close with wrist extension for grasp. • The lengthening of the wrist flexors, flexor carpi ulnaris at the intramuscular level, Z- lengthening of flexor carpi radialis, release of palmaris longus and super fascia and with fractional lengthening of the flexor profundus. all that will allow the wrist to be brought into extended position. • The extensor carpi ulnaris is the preferred tendon to transfer into the extensor carpi radialis brevis. • Severe deformity: especially in non functional hand, wrist arthrodesis is a solution for hygiene and care problems.

23. The thumb • Thumb-in-palm deformity is common in cerebral palsy patients. • The deforming forces are: adductor pollicis and all the intrinsic muscles. • The approach is to release contracted soft tissue and then augment weak extensors and abductors by… • Simple release of the contracture when child demonstrates active thumb interphalangeal extension and a palpable extensor pollicis longus. • Release of the origins of the thenar musculature, and the two heads of adductor pollicis. • Release of the first dorsal interosseous fascia with release of the thumb-index web space.

24. Release of the origins of intrinsic muscles acting on thumb. Deformities of thumb in cerebral palsy

25. Cerebral palsy The lower limb surgery

26. Foot surgery

27. Foot surgeryEquinus • 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. • 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 Duchenn’s)produces toe walking.

29. Equinus.. • Clinical examination.. Of the child with equinus due to cerebral palsy shows inability to fully dorsiflex the ankle. • The Silverskiold test: If the ankle can be passively dorsiflexed with the knee bent to 90 deg. but cannot be dorsiflexed with the knee extended.. It’s felt that the gastrocnemius is tight, but the soleus is not contracted. • This test is used to determine which type of surgical lengthening to perform.

30. The Silverskiold test

31. Equinus… Leads to… • Gait is less efficient. • Foot drop results if anterior tibialis is unable to lift the foot to natural during swing phase. • Genu recurvatum is seen. • Valgus positioning of the hind foot. • Calcaneus is actually in equinus. • Pain and callosities result over the head of talus. • Hallux valgus can develop.

32. Surgical treatment of equinus • It is selective lengthening of the Achilles tendon or the gastrocnemius. • It is believed that a gastrocnemius recession should be performed when Silverskiold test (performed under anesthesia) is positive and dynamic EMG shows more abnormality of the gastrocnemius than the soleus during gait.

33. Achilles tendon lengthening.. - Casting is necessary. Can be done per cutanously. Gastrocnemius recession.. Preserve push-off power. Immobilization is minimized following operation. Open methods. Almost no risk of over correction. Greater recurrence rate (up to 48%) Surgical treatment of equinus..

34. Gastrocnemius recession techniques • Vulpius technique.. • Strayer procedure • Baker technique.. (tongue-in-groove)

35. Vulpius technique.. Strayer procedure

36. Baker technique

37. Achilles tendon lengthening techniques • Open technique.. with Z-fashion lengthening • Per cutaneous techniques.. White.. Two-cut technique. Hoke.. Three-cut technique.

38. Z lengthening of Achilles Tendon

39. Hoke per cutaneous Achilles T. lengthening

40. Equino varus deformity • Muscle imbalance in which the invertors of the foot over power the evertors. with the gastrocnemius contributes equinus. • Surgery is indicated to.. • Improve foot contact. • Relieve pain. • Relieve skin changes. • Tendon surgery can be done if the foot can passively corrected with manipulation to the natural position. • Bony surgery is necessary when the deformity is stiff and cannot be manipulated into a plantigrade position foot.

42. Equinovarus deformity.. The confusion test: The patient flexes the hip against resistance.. If the supination of the forefoot is seen, the a.tibialis is contributing to equinovarus deformity.. When dorsiflex is seen without supination, the deformity is less likely to respond to surgery on the a.tibialis.

44. Equinovarus surgeryp.tibialis tendon lengthening • Usually done in conjunction with Achilles tendon lengthening. • It is done In young patients with mild varus with equinus. • Can be performed as intramuscular lengthening or as tendon Z lengthening. • Complications.. • Recurrence of the deformity. • Development of postoperative valgus.

46. Equinovarus surgeryTransfer of the p.tibialis tendon to the dorsum It is not a preferred procedure because of its disastrous complications: heel valgus in 68% of patients.

47. Equinovarus surgerySplit p.tibialis tendon transfer • Popularized by Kaufer& Green. • It is one of the most common procedures for equinovarus deformity treatment. • The posterior one-half of the p.tibialis tendon is rerouted posterior to tibia and woven into the peroneus brevis tendon.

48. Kaufer split transfer of tibialis posterior tendon

49. Kaufer split transfer of tibialis posterior tendon

50. Equinovarus surgerySplit a.tibialis tendon transfer • The lateral one-half of a.tibialis is detached from it’s 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 p.tibialis lengthening.