Management of upper limb in cerebral palsy. Dr Sameer Desai Pediatric Orthopedic Surgeon KEM, Ruby Hall, Sahyadri Hospital, Unique Childrens Hospital
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1 Management of upper limb in cerebral palsy Dr Sameer Desai Pediatric Orthopedic Surgeon KEM, Ruby Hall, Sahyadri Hospital, Unique Childrens Hospital
2 Importance of upper limb in CP Activities of daily living Feeding Toilet care Walker and wheelchair Support hand
3 Problems in upper limb Shoulder adduction and internal rotation contracture Elbow flexion contracture Forearm pronation Wrist palmer flexion Finger flexion Thumb in palm
4 Aims and objectives Document improvement in hand and upper limb function using Botulinum toxin A or surgical approach in children with cerebral palsy
5 Material and Methods 20 children diagnosed with spastic type of cerebral palsy with upper limb involvement Age 3 yrs-18 yrs. Follow up of 1-4 yrs. All children were undergoing regular physiotherapy 8 Children-less than 8 yrs - with spasticity were injected with Botulinim toxin A 12 Children-more than 8 yrs. were operated
6 Botulinum toxin A - 8 children Pronator teres -8 Wrist flexors- 6 Biceps-2 Thumb adductors-2 Pectoralis-1
7 Surgery - 12 children Pronator release- 5 cases Flexor carpi ulnaris to extensor carpi radialis brevis transfer 12 cases Biceps aponeurotic release 1 case Thumb adductor release 1 case
8 Flexor carpi ulnaris (FCU) to extensor carpi radialis brevis transfer(ecrb)
9 Flexor carpi ulnaris to extensor carpi radialis brevis transfer
10 Flexor carpi ulnaris to extensor carpi radialis brevis transfer
11 Flexor carpi ulnaris (FCU) to extensor carpi radialis brevis transfer(ecrb)
12 Flexor carpi ulnaris to extensor carpi radialis brevis transfer Before surgery After surgery
13 Results Mean improvement in range of supination: 40 degrees Mean improvement in wrist dorsiflexion: 50 degrees Mean improvement in elbow extension: 30 degrees
14 House scoring system of upper extremity functional use Level Category Description 0 Does not use Does not use 1 Poor passive assist Uses as stabilizing weight only 2 Fair passive assist Can hold object placed in hand 3 Good passive assist Can hold object and stabilize it for use by other hand 4 Poor active assist Can actively grasp object and hold it weakly 5 Fair active assist Can actively grasp object and stabilize it well 6 Good active assist Can actively grasp object and manipulate it 7 Spontaneous use, partial 8 Spontaneous use, complete Can perform bimanual activities and occasionally uses hand spontaneously Uses hand completely independently without preference
15 Results
16 Supination Botulinum toxin A Surgical group before (Passive) After (passive) Before (active) neutral Full supination 20 deg pronation After (active)
17 Botulinum Toxin A Before Botox After Botox
18 Surgery - House scoring system of upper extremity functional use Level Category Description before after 0 Does not use Does not use 1 Poor passive assist Uses as stabilizing weight only 2 Fair passive assist Can hold object placed in hand 3 Good passive assist Can hold object and stabilize it for use by other hand 4 Poor active assist Can actively grasp object and hold it weakly 5 Fair active assist Can actively grasp object and stabilize it well 6 Good active assist Can actively grasp object and manipulate it 7 Spontaneous use, partial 8 Spontaneous use, complete Can perform bimanual activities and occasionally uses hand spontaneously Uses hand completely independently without preference
19 After FCU to ECRB transfer
20 After FCU to ECRB transfer Before Surgery After Surgery
21 Conclusion Both Botulinum Toxin A and Surgery improved the upper extrimity functional use Duration of action of Botox for upper limb was short lived Full active supination was not possible even after botox or release of pronator Tendon transfer to augment supinator action can be considered
22 Conclusion Early surgical transfer (Before 12 yrs.) can lead to late deformities like wrist extension contracture and supination contracture Tendon transfer may be required for thumb in palm deformity An accurate assessment of hand sensation, power and spasticity is essential to get the best results
23 Literature Review Upper extremity spasticity in children with cerebral palsy: a randomized, double-blind, placebo-controlled study of the short-term outcomes of treatment with botulinum a toxin. Koman LA, Smith BP, Williams R, Richardson R, Naughton M, Griffin L, Evans P.J Hand Surg Am Mar;38(3): Arm and hand function in children with unilateral cerebral palsy: a oneyear follow-up study. KlingelDev Med Child Neurol Jun;48(6):533-9 Management of the upper limb in cerebral palsy.chin TY, Duncan JA, Johnstone BR, Graham HK.J Pediatr Orthop B Nov;14(6): Late deformities following the transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis in children with cerebral palsy.patterson JM, Wang AA, Hutchinson DT. J Hand Surg Am Nov;35(11): doi: /j.jhsa
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Contents Preparation for Functional Sitting Partial Pull to Sit.......................................................... 2 Pull to Sit................................................................ 3
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