CEREBRAL PALSY

COASS

Definition Difficult to define It is not a single disease entity Criteria of the symptom :
Due to a fixed, non progressive brain lession or lessions The original lession must occur prenatally, at birth, or early post natal period Primary disorder involves (Tachdjian MO. Tachdjian Pediatric Orthopaedics , vol 3, 2nd ed.1990) musculoskeletal system and lack of motor Orthpaaedic & Traumatology control is the greater handicap 2 Dept

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Etiology
Prenatal
infection

TORCH (toxoplasma, rubella, cytomegalovirus, and herpes) Metabolic disturbance (DM, Thyroid abn) Anoxia (ruptured placenta, placental infection, cardirespiratory disease Chemical, alcohol, cocain Brain abnormalities

( Canale 08/21/11

ST. Campbells Operative Orhopaedics, vol 2. 10th Ed.2003) Dept Orthpaaedic & Traumatology

Etiology

Natal Causes

Asfixia (10-20%) Oxytocin augmentation, cord prolaps, prematurity Low birth weight (<2268) Periventriculare hemorrhages

(Canale ST. Campbells Operative Orhopaedics, vol 2. 10th Ed.2003)

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Etiology

Postnatal Infection : Meningitis, Abses Head injury Hipoxia-iskemia

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(Canale ST. Campbells Operative Orhopaedics, vol 2. 10th Ed.2003)

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Classification

According to the the type of motor dysfunction

(Minear 1956)

Spasticity Athetosis Rigidity Ataxia Tremor Mixed

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Classification

According to the topographical distribution

(Minear 1956)

Monoplegia. Hemiplegia. Paraplegia. Diplegia. Tetraplegia.

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Dept Orthpaaedic & Traumatology

Spastic

Most common (70-80% of cases) Most amenable to surgery Characterized by increased muscle tone and hyperreflexia. Spasticity is characterized by increased muscle activity with increasingly rapid stretch Increase deep tendon reflex. As the chlid grows muscle become shorter (contracture)

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Dept Orthpaaedic & Traumatology

Athetosis Dyskinetic

10-20% of cases The limb Involuntary purposeless movement. Contorted Two subtype : a.nontension mov describe as rotary(rotation & twisting the limb), dystonik or chorea/spontaneous jerking motion at fingers or toe b.tension muscle very tense so contorted motions are blocked affected muscle of face & tongue grimacing & drooling

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Dept Orthpaaedic & Traumatology

Classification
3. Rigidity Severe form of spasticity Usually quadriplegic

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Classification

4. Ataxic

5-10% of cases Involvement of the cerebellum or its pathways Lack of balance sensation,position sense & uncoordinated mov Such children walk as if sailors on the rolling ship at sea Wide based gait Poorly amenable to surgical correction;

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The lession in the brain

Four areas

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Cerebral cortex : spastisity Midbrain or base of the brain : athetosis Cerebelum : ataxia Widespread brain involvement : mixed
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DIAGNOSIS
History Abnormal birth history ,looking carefully at the infant's medical history Prematurity Abnormal Developmental milestones :

Head control -3 mths (6 mths) Sitting independently - 6 mths (9 mths) Crawling - 8 mths Pulling to stand - 9 mths (12 mths) Walking -12 mths (18 mths)

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Assessment

Primitive reflexes Predictors of Walking (from 1 year of age):

(Bleck 1987)

The primitive Neck righting reflex The asymmetrical tonic neck reflex The symetrical tonic neck reflex Moro reflex Extensor thrust Parachute reflex Foot placement reaction

% accuracy) Inability sit alone after 4 y.o poor prognostic nonwalker

Poor diagnosis score 2 or more (95

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Asymmetrical tonic neck reflexas head is turned to one side, contralateral arm and knee flex. B, Moro reflexas neck is suddenly extended, upper limbs extend away from body and come together in embracing pattern. C, Extensor thrust reflexas infant is held upright under armpits, lower extremities stiffen out straight. D, Neck-righting reflexas head is turned, shoulders, trunk, pelvis, and lower extremities follow turned head. E, Parachute reactionas infant is suspended at waist and suddenly lowered forward toward table, arms and hands extend to table in protective manner. F, Symmetrical tonic neck reflexas neck is flexed, arms flex and legs extend. Opposite occurs as neck is extended. G, Foot placement reactionwhen top of foot is stroked by underside of flat surface, infant places foot on surface.

PRIMITIVE REFLEX
Grasp reflex elicited by introducing the clinicians finger into the infant palm from the ulnar side flexion and grasp firmly.

Moro reflex elicited by gently lifting the infant with the clinicians right hand under the upper thoracic spine and the left hand under the head drop the hand, allow sudden neck extension abduct the upper limbs, with spreading of the finger, follow by an

PRIMITIVE REFLEX
Asymmetric tonic neck reflex elicited by turning the head to the side extension the upper and lower limb on the side toward which the head is turned, flexion the

POSTURAL REFLEX

The foot-placement reaction elicited by holding the infant under the arms, then gently lifting, the dorsum of the foot or anterior surface of the tibia comes up against the under side of the table. Positive picks up the extremity as if to step up onto the table.

The

parachute reflex elicited by holding the infant in the air in the prone position, then suddenly lowering. Positive extend the upper extremities and places the hands on table top.

Assessment
Over 1 year

Gait

Hemiplegic : asymmetric flexed knee toe walking Spastic diplegia : hip flexed, adducted (scissors gait), trunk leands forward, knee bent, feet equinus Narrow walking

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CEREBRAL PALSY Treatment

Cerebral palsy can not be cured

The Goals : - Increase the patients physical independence - cognitive & speech abilities - Improve a child's capabilities & quality of life

work with a team of health care professionals first to identify a child's unique needs and impairments plan treatment

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team of health care professionals

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Treatment

Priorities

1.Communication 2.Activities of daily living 3.Mobility in the environment 4.Walking /ambulations

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Objectives
Maintain straight spine and level pelvis Maintain located, mobile, painless hips Maintain mobile knees for sitting and bracing for transfer Maintain plantigrade feet Provide appropriate adaptive equipment, incl. Wheelchairs Recognise and treat medical problems
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Strategy
0-3 yrs - physiotherapy 4-6 yrs - surgery 7-18 yrs - schooling and psychosocial development 18 yrs + - work
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Treatment of Cerebral Palsy

Psycological Consideration Therapeutik Drugs Phsysical and Occupational Therapy Speech Therapy Orthopaedic Appliances Surgical Manipulation Orthopaedic Operation Rehabilitaion

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NON OPERATIVE
NON PHARMACOLOGIST

Physiotherapy Orthosis & Splints Neuromuscular Electrical Stimulations (NEMS)

Orthosis / Splints
Goals for orthotic intervention: prevention of deformity correction of soft tissue deformity Control muscle tone

Orthosis & Splints

AFO

Articulating AFO

Short-leg brace

Abduction Orthosis

KAFO

Surgery Treatment

Indication for Orthopaedic Surgery Inability to control a spastic deformity Correct fixed deformity Correct secondary bony deformities,hip dislocations or joint instability

(Solomom L et al. Apleys System of Orthopaedics and Fravtures, 8th E

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Surgery Treatment

Types of surgery include :

Tight muscle Release Weaks muscles Tendon transfer Fixed deformities Osteotomies or arthrodesis
(Solomom L et al. Apleys System of Orthopaedics and Fravtures, Dept Ed,) 8th Orthpaaedic & Traumatology

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Hoke Procedure

Heel cord lengthening

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FOOT AND ANKLE DEFORMITIES

Varus Deformities Split Posterior Tibial Tendon Transfer

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FOOT AND ANKLE DEFORMITIES

Anterior advancement of tendo achilles for correction of spastic equinus deformity (Murphy Technique)

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Hip Deformities
Internal Rotation Deformities Excessive medial femoral torsion (increased femoral anteversion) is very common in spastic CP. Subtrochanteric Derotation

Varus Deformities

FOOT & ANKLE DEFORMITIES

Calcaneal osteotomy (lat displacement or dwyer)

FOOT & ANKLE DEFORMITIES

Valgus deformities
Calcaneal osteotomy (med displacement )

Aphorisms

After you operate, the patient still has cerebral palsy. If unsure, wait. Avoid tying up adolescents with marginal procedures. A little equinus better than calcaneus. A little valgus better than varus. A little varus better than a lot of valgus. A little knee flexion better than recurvatum.
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