CEREBRAL PALSY

Thammanoon Srisaarn , MD.

Orthopaedic department

Pramongkutklao hospital

CEREBRAL PALSY

NON PROGRESSIVE (immature)BRAIN LESION RESULTS IN MOTOR IMPAIRMENT(may be other)

Uncertain cause Nearly drowning, infectious meningitis Manifestration progress

CLASSIFICATION

PHYSIOLOGIC (Neuropathic) GEOGRAPHIC (Anatomic)

PHYSIOLOGIC(NEUROPATHIC)

SPASTICITY(PYRAMIDAL SYSTEM) ATHETOSIS(EXTRAPYRAMIDAL) CHOREIFORM DYSTONIA HYPOTONIA ATAXIC (CEREBELLUM) MIXED

GEOGRAPHIC(ANATOMIC)

DIPLEGIA HEMIPLEGIA DOUBLE HEMIPLEGIA PARAPLEGIA TRIPLEGIA QUADRIPLEGIA (TETRAPLEGIA) TOTAL BODY INVOLVEMENT MONOPLEGIA

MANIFESTRATION

SPASTIC DIPLEGIA 8- 10 MO. SPASTIC HEMIPLEGIA 20-24 MO. ATHETOID > 24 MO.

DEPEND ON MYELINATION

Factors affect walking ability (diplegia) Severity of lower ext. involvement Seizure Marked flaccidity Persistent abnormal primative reflexes Dislocated hip Intelligence, mental retardation Upper ext. involvement Birth weight

BLECK’S WALKING PROGNOSIS (after 12 mo.)

1. ASYMMETRIC TONIC NECK REFLEX

2. NECK RIGHTING REFLEX

3. MORO REFLEX

4. SYMMETRIC TONIC NECK REFLEX

5. EXTENSOR THRUST

6. PARACHUTE REACTION

7. FOOT- PLACEMENT REACTION

SCORE > 2 POOR PROGNOSIS

PROGNOSIS

GOOD PROGNOSIS FOR WALKING- HEAD BALANCE BEFORE 9 MO.- INDEPENDENT SITTING BY 24 MO.- CRAWLING BY 30 MO.

POOR PROGNOSIS- LACK OF HEAD CONTROL BY 20 MO.

(Camposda paz)

PROGNOSIS

2SITTING BEFORE YR USUALLY WALK INDDDDDDDDD

- 24 50YR % WALK INDEPENDENTLY DD DDDDDD DDDDD DD DDDD DDDDDDD DDD> 4

DDDD DDDDD DD DDDD DDDDDD D DD DDDDDDDD DD D8

DDD (Motor improve plateau 7 yr.)(Beal )

PROGNOSIS

2 YR. WITH INDEPENDENT SITTING- NOT A GOOD PREDICTOR FOR

WALKING ABILITY INABILITY TO SIT AFTER 4 YR.

- PREDICTED NONAMBULATION

(Molnar and Gordon)

EVALUATION

HISTORY OBSERVATION EXAMINATION GAIT ANALYSIS

OBSERVATION

POSTURE GAIT

CROUCH

JUMP

THOMAS TEST

PHYSICAL EXAMINATIONHIP FLEXION

DEFORMITY

Modified Thomas test

MODIFIED THOMAS TEST

STAHILI TEST

DUNCAN-ELY TEST

ADDUCTION DEFROMITY

PHYSICAL EXAM.

PHELPS TEST

POPLITEAL ANGLE

SLRT

KNEE EXAMINATION

LACK OF FULL EXTENSION ON INITIAL CONTACT,STANCE AND INITIAL SWING PHASE

KNEE FLEXION DEFORMITY

TEST FOR RECTUS TIGHTNESSKNEE EXTENSION

DEFORMITY

PHYSICAL EXAMINATION (SILVERSKIÖLD)

FOOT : EQUINUS DEFORMITY

MOST OFTEN IN HEMIPLEGIA

EQUINOVARUS DEFORMITY

VARUS DEFROMITY

TIBIALIS POSTERIOR HINDFOOT VARUS

OR

TIBIALIS ANTERIOR FOREFOOT SUPINATION, HINDFOOT VARUS (SWING PHASE)WEAK

PERONEUS

PES VALGUS DEFORMITY

Peroneal hyperactivit

y

TREATMENTS

PRIORITYPRIORITY COMMUNICATIONCOMMUNICATION ADLADL MOBILITYMOBILITY WALKINGWALKING

SURGICAL TREATMENT

SPASTIC TYPE AGE 4-8 YEAR IS PROPER YOUNGER HIGH RECURRENCE MATURE GAIT ~ 7 YEARS SEQUENTIAL V/S ALL AT THE SAME

TIME

Surgical treatment

Thomas test 30O

Modified Thomas test 20O

Hip flexion deformity

Surgical treatment

Hip adduction deformity

Passive abduction < 30O

both in hip flexion & extension

HIP AT RISK

Quadriplegia, Nonambulator Age 2-6 yr. < 30O abduction in flex or ext. > 20O flexion contracture valgus and anteversion Shallow acetabulum AI > 40 Abnormal migration index

FILM PELVIS EVERY 12 MO. FOR NONAMBULATOR

A B C

AB/AC= MIGRATION INDEX (MI)

ACETABULAR INDEX

> 1/3 = subluxatio

n

SURGICAL TREATMENT ON THE HIP ADDUCTOR LONGUS TENOTOMY ANT. HALF OF ADD. BREVIS GRACILLIS PSOAS TENOTOMY OR LENGTHENING

preserve iliacus RECTUS FEMORIS LENGTHENING PROXIMAL HAMSTRINGS RELEASE

MANAGEMENT OF HIP AT RISK

AGE < 4 YR. SOFT TISSUE RELEASE(45O Abd in Ext,60O in Flex.)

AGE 4-8 YR. MI 25-60%, ABDUCTION <30O ==>RELEASEMI > 60%, NOT IMPROVE IN 1 YR.==> OR+

CAPSULORRAPHY+ BONY RECONSTRUCTION

AGE > 8 YR

MI 40> % RELEASE & BONE RECONSTRUCTION

Flynn JM. AAOS 10(3): 2002

Hip subluxation

MI > 30 % Soft tissue release for very young MI > 50% open reduction + femoral

osteotomy AI > 25O pelvic osteotomy

Management of hip dislocation Observation Open reduction + osteotomy + soft tissue

release Resection arthroplasty Arthrodesis Total hip replacement

Neck shaft angle < 115O

Anteversion10-20O (30-45O passive IR)

SURGICAL TREATMENT ON THE KNEE

SLRT < 60O, PA > 45O

MEDIAL HAMSTRINGS RELEASE LATERAL HAMSTRINGS

RELEASE RECTUS FEMORIS RELEASE RECTUS FEMORIS TRANSFER

HAMSTRING RELEASE

RECTUS FEMORIS TRANFER