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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
• 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. Campbell’s Operative Orhopaedics, vol 2. 10th Ed.2003) Dept Orthpaaedic & Traumatology
10th Ed.Etiology Natal Causes • • • • • Asfixia (10-20%) Oxytocin augmentation. cord prolaps. Campbell’s Operative Orhopaedics.2003) 08/21/11 Dept Orthpaaedic & Traumatology 4 . vol 2. prematurity Low birth weight (<2268) Periventriculare hemorrhages (Canale ST.
vol 2. Abses • Head injury • Hipoxia-iskemia • 08/21/11 (Canale ST. 10th Ed. Campbell’s Operative Orhopaedics.Etiology Postnatal • Infection : Meningitis.2003) Dept Orthpaaedic & Traumatology 5 .
Classification According to the the type of motor dysfunction (Minear 1956) Spasticity Athetosis Rigidity Ataxia Tremor Mixed Dept Orthpaaedic & Traumatology 6 • 08/21/11 .
Classification According to the topographical distribution (Minear 1956) Monoplegia. Paraplegia. Tetraplegia. Hemiplegia. Diplegia. 08/21/11 • Dept Orthpaaedic & Traumatology 7 .
• Spasticity is characterized by increased muscle activity with increasingly rapid stretch • Increase deep tendon reflex.Spastic • Most common (70-80% of cases) • Most amenable to surgery • Characterized by increased muscle tone and hyperreflexia. • As the chlid grows muscle become shorter (contracture) • 08/21/11 Dept Orthpaaedic & Traumatology 8 .
Contorted Two subtype : a.tension muscle very tense so contorted motions are blocked affected muscle of face & tongue grimacing & drooling • 08/21/11 Dept Orthpaaedic & Traumatology 9 . dystonik or chorea/spontaneous jerking motion at fingers or toe b.Athetosis Dyskinetic • • 10-20% of cases The limb Involuntary purposeless movement.nontension mov describe as rotary(rotation & twisting the limb).
Classification 3. Rigidity • Severe form of spasticity • Usually quadriplegic 08/21/11 Dept Orthpaaedic & Traumatology 10 .
position sense & uncoordinated mov Such children walk as if sailors on the rolling ship at sea Wide based gait • Poorly amenable to surgical correction.Classification 4. Ataxic • 5-10% of cases • Involvement of the cerebellum or its pathways • Lack of balance sensation. 08/21/11 Dept Orthpaaedic & Traumatology 11 .
The lession in the brain Four areas 08/21/11 • Cerebral cortex : spastisity • Midbrain or base of the brain : athetosis • Cerebelum : ataxia • Widespread brain involvement : mixed Dept Orthpaaedic & Traumatology 12 .
6 mths (9 mths) Crawling .9 mths (12 mths) Walking -12 mths (18 mths) • 08/21/11 Dept Orthpaaedic & Traumatology 13 .looking carefully at the infant's medical history • • Prematurity • • Abnormal Developmental milestones : • • • • • Head control -3 mths (6 mths) Sitting independently .8 mths Pulling to stand .DIAGNOSIS History • Abnormal birth history .
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 • 08/21/11 Dept Orthpaaedic & Traumatology 14 .
D. lower extremities stiffen out straight. E. C. Extensor thrust reflex—as infant is held upright under armpits. Symmetrical tonic neck reflex—as neck is flexed. upper limbs extend away from body and come together in embracing pattern. Neck-righting reflex—as head is turned.• • • • • • • Asymmetrical tonic neck reflex—as head is turned to one side. Foot placement reaction—when top of foot is stroked by underside of flat surface. infant places foot on surface. contralateral arm and knee flex. Moro reflex—as neck is suddenly extended. . G. B. arms flex and legs extend. Parachute reaction—as infant is suspended at waist and suddenly lowered forward toward table. F. Opposite occurs as neck is extended. trunk. pelvis. arms and hands extend to table in protective manner. and lower extremities follow turned head. shoulders.
PRIMITIVE REFLEX • Grasp reflex elicited by introducing the clinician’s finger into the infant palm from the ulnar side flexion and grasp firmly. follow by an . with spreading of the finger. allow sudden neck extension abduct the upper limbs. • • Moro reflex elicited by gently lifting the infant with the clinician’s right hand under the upper thoracic spine and the left hand under the head drop the hand.
flexion the .PRIMITIVE REFLEX Ø 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.
POSTURAL REFLEX Ø The foot-placement reaction elicited by holding the infant under the arms. Ø Positive picks up the extremity as if to step up onto the table. then gently lifting. ØPositive extend the upper extremities and places the hands on table top. then suddenly lowering. . the dorsum of the foot or anterior surface of the tibia comes up against the under side of the table. ØThe parachute reflex elicited by holding the infant in the air in the prone position.
feet equinus • Narrow walking • 08/21/11 Dept Orthpaaedic & Traumatology 19 . trunk leands forward. knee bent.Assessment Over 1 year Gait • Hemiplegic : asymmetric flexed knee toe walking • Spastic diplegia : hip flexed. adducted (scissors gait).
cognitive & speech abilities .Increase the patient’s physical independence .CEREBRAL PALSY Treatment Cerebral palsy can not be cured • • • The Goals : .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 • 08/21/11 Dept Orthpaaedic & Traumatology 20 .
team of health care professionals 08/21/11 Dept Orthpaaedic & Traumatology 21 .
Walking /ambulations 08/21/11 Dept Orthpaaedic & Traumatology 22 .Activities of daily living 3.Communication 2.Treatment Priorities 1.Mobility in the environment 4.
Objectives • Maintain straight spine and level pelvis • Maintain located. incl. mobile. Wheelchairs • Recognise and treat medical problems 08/21/11 Dept Orthpaaedic & Traumatology 23 . painless hips • Maintain mobile knees for sitting and bracing for transfer • Maintain plantigrade feet • Provide appropriate adaptive equipment.
Strategy • • 0-3 yrs .physiotherapy • 4-6 yrs .schooling and psychosocial development • 18 yrs + .surgery • 7-18 yrs .work • 08/21/11 Dept Orthpaaedic & Traumatology 24 .
Treatment of Cerebral Palsy • • • • • • • • Psycological Consideration Therapeutik Drugs Phsysical and Occupational Therapy Speech Therapy Orthopaedic Appliances Surgical Manipulation Orthopaedic Operation Rehabilitaion 08/21/11 Dept Orthpaaedic & Traumatology 25 .
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 .
8th E 08/21/11 Dept Orthpaaedic & Traumatology 29 .Surgery Treatment Indication for Orthopaedic Surgery • Inability to control a spastic deformity • Correct fixed deformity • Correct secondary bony deformities. Apley’s System of Orthopaedics and Fravtures.hip dislocations or joint instability (Solomom L et al.
Dept Ed.) 8th Orthpaaedic & Traumatology 08/21/11 30 .Surgery Treatment Types of surgery include : • Tight muscle Release • Weaks muscles Tendon transfer • Fixed deformities Osteotomies or arthrodesis (Solomom L et al. Apley’s System of Orthopaedics and Fravtures.
Hoke Procedure Heel cord lengthening 08/21/11 Dept Orthpaaedic & Traumatology 31 .
FOOT AND ANKLE DEFORMITIES • Varus Deformities Split Posterior Tibial Tendon Transfer 08/21/11 Dept Orthpaaedic & Traumatology 32 .
FOOT AND ANKLE DEFORMITIES Anterior advancement of tendo achilles for correction of spastic equinus deformity (Murphy Technique) 08/21/11 Dept Orthpaaedic & Traumatology 33 .
• Subtrochanteric Derotation .Hip Deformities Internal Rotation Deformities • Excessive medial femoral torsion (increased femoral anteversion) is very common in spastic CP.
Varus Deformities FOOT & ANKLE DEFORMITIES Calcaneal osteotomy (lat displacement or dwyer) .
FOOT & ANKLE DEFORMITIES Valgus deformities Calcaneal osteotomy (med displacement ) .
• Avoid tying up adolescents with marginal procedures. 08/21/11 Dept Orthpaaedic & Traumatology 37 . • If unsure. • A little knee flexion better than recurvatum. • A little valgus better than varus.Aphorisms • After you operate. wait. the patient still has cerebral palsy. • A little varus better than a lot of valgus. • A little equinus better than calcaneus.
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