CEREBRAL PALSY

DEFINITION
• Cerebral palsy is a disorder of movement and
posture that results from permanent and non-
progressive damage to the immature brain in
the antenatal period or the first 2 years of life.
• Although the brain damage is not progressive;
secondary effects on the growth and function
of the musculoskeletal system may progress
until skeletal maturity.
ANATOMICAL

• Monoplegia : Single limb,

• Hemiplegia : One side of body,
• Diplegia : Both lower limbs involved,
mild upperlimb involvement
• Quadriplegia: Total body involvement.
FUNCTIONAL
• The ‘Gross Motor Function Classification System’ (GMFCS)
• describes the child’s abilities based on self-initiated
movement,
• with emphasis on mobility:
• I. Walks without limitation,
• II. Walks with limitations,
• III. Walks with a hand-held mobility device (e.g. crutch),
• IV. Self-mobility limited, may use powered mobility,
• V. Transported in a manual wheelchair.
PATHOPHYSIOLOGY
Pathoanatomy
– leads to muscle imbalance with a mixture of
weakness and spasticity
– the encephalopathy is static while the affected
portion of the musculoskeletal system changes
with growth
RADIOGRAPHS
• AP and frog lateral (if possible)
– Hip abduction of <45° with partial uncovering of the
femoral head on radiographs represents an at risk hip
• Reimers migration index 
– percent of femoral head with no acetabular coverage
– most accurate method to identify and monitor hip
stability
– < 33% = at risk
– > 33% = subluxated hip
CLASSIFICATION
TREATMENT PRINCIPLES

• Range of movement – physiotherapy-led stretching

• programme,
• Maintain position and accommodate weakness –
• appropriate splintage,
• Decrease spasticity:
– General (baclofen),
– Regional (selective dorsal rhizotomy),
– Specific (botulinum toxin).
• Correct deformity – musculotendinous or bony surgery.
TREATMENT OF SPASTICITY

• Oral medications (baclofen, benzodiazepines,

dantrolene
• and tizanidine),
• Intramuscular (botulinum toxin A, phenol and
alcohol),
• Intrathecal baclofen,
• Selective dorsal rhizotomy.
 ORTHOSES

Orthoses are frequently employed in children

with cerebral palsy. They are often employed to:
• Maintain position
• Redirect forces
• Improve function
• Thoracolumbar orthoses
SURGICAL INTERVENTIONS

Traditional ‘birthday surgery’ (an operation

every year determined by the child’s annual
review appointment) has been largely
superseded by single event multilevel surgery,
where necessary procedures are combined to
restore more normal anatomy
• Soft-tissue surgery
• Bony surgery
• Salvage surgery
SURGICAL TREATMENT

The hip
• At the hip, particular attention is paid to abduction range, since
limitation of abduction (<30°) is a herald of joint subluxation.
Standardized AP pelvis radiographs are used where necessary
and often in a surveillance protocol.
• There is strong evidence from Swedish studies in support of this
approach to reduce the incidence of dislocation. Other
radiographic parameters used to evaluate the hip in children with
cerebral palsy are the femoral neck-shaft angle, Shenton’s line,
Reimer’s migration index (RMI) and the acetabular index (AI)
• Reimer’s migration index is the percentage of uncovered head.
Normal RMI is less than 30%. Traditionally, an RMI between 30%
and 50% is considered subluxation, >50% indicates a dislocation,
and >90% a severe dislocation.
 ORTHOSES
Surgery for neurogenic hip dysplasia could involve any of the following
procedures, depending on the severity:
1. Adductor release through a small medial incision. The adductor longus,
gracilis and adductor brevis can be released while protecting the anterior
division of the obturator nerve. In a non-ambulatory child, the psoas
tendon can be released by the same approach.

2. Flexion contracture is usually released by intramuscular lengthening of the

iliopsoas tendon over the pelvic brim (Smith-Petersen approach). This
preserves muscle power and prevents excessive weakness associated with
dividing the tendon.

3. Femoral varus and derotation osteotomy through a lateral subvastus

approach. The main purpose of the femoral osteotomy is to reduce the
excessive femoral anteversion; however, it may be useful to add varus to
better direct the femoral head. Excessive varus should be avoided in an
ambulatory child (keep the neck–shaft angle above 110°).
4. Pelvic osteotomy is usually undertaken through an anterior hip
approach. In contrast with DDH, the acetabular deficiency in a
neurogenic hip is usually posterior and lateral or global, rendering
Salter’s osteotomy inappropriate, as it uncovers the hip further. A Dega
osteotomy (or one of its modifications) is usually indicated for
acetabular dysplasia. A curved osteotomy is made 1 cm above and
parallel to the acetabular margin. It is then deepened toward the
triradiate cartilage and the acetabulum is levered down to reduce the
acetabular size and provide lateral and posterior cover

5. Salvage procedures for non-reconstructable hip dislocation:

– Proximal femoral resection at the subtrochanteric level,
– Proximal valgus osteotomy
– Hip fusion (unpopular),
– Prosthetic replacement (either total hip replacement or hemi-arthroplasty
using a humeral prosthesis) in patients who can walk and have good muscle
strength and no pelvic obliquity.
ORTHOSES
ORTHOSES