■ It is a common congenital condition, where the child presents with musculoskeletal and cognitive problems, caused by injury to the immature brain.

What causes Cerebral Palsy?

■ prematurity (most common)
■ prenatal intrauterine factors
■ anoxic injuries
■ perinatal infection such as toxoplasmosis, CMV, ToRCH, herpes simplex, rubella
■ brain malformations
■ meningitis
■ brain trauma – NAT
■ orthopaedic manifestations characteristic of CP
■ abnormal tone
■ loss of motor control

■ impaired balance
■ spasticity
■ (hypotonia)
■ (dyskenesias such as chorea and
athetosis)
○ secondary (growth and spasticity related)
■ contractures
● starts as dynamic contractures, become static with time (continuous muscle contraction
results in shortening) and growth (growth of bones occurs at a faster longitudinal rate than muscles in spastic cerebral palsy)
■ upper extremity deformities
■ hip subluxation and dislocation
■ spinal deformity
■ foot deformities
■ gait disorders
■ fractures
● often associated with non-ambulators secondary to low bone mineral density
● bisphosphonates may be useful IV pamidronate considered
with >3 fractures and a DEXA z-score <2 SD

Classification of Cerebral Palsy ?

Gross Motor Function Classification Scale (GMFCS)

Type I

Near normal gross motor function, independent ambulator.
Type II

Walks independently, but difficulty with uneven surfaces, minimal ability to jump.
Type III

Walks with assistive devices.
Type IV

Severely limited walking ability, primary mobility is wheelchair.
Type V

Nonambulator with global involvment, dependent in all aspects of care.

How is Cerebral Palsy diagnosed?

■ Clinically
○ developmental milestones,
○ cognitive function, and
○ musculoskeletal abnormalities such as:
■ spasticity,
■ impaired balance,
■ loss of motor control.
■ Examination.
○ general musculoskeletal exam.
■ motion, tone, and strength.
■ Rotational limb profiles for torsional deformities.

● gait
○ gait lab analysis
○ plantigrade feet
○ crouch
○ stiff knee gait
● spine exam
○ presence and flexibility of scoliosis
○ spinal balance and shoulder height
○ pelvic obliquity
○ resting head posture
○ hamstring contractures (lead to
decreased lumbar lordosis)
● hips
○ hip contractures
■ flexion contracture (lead to excessive lumbar lordosis)
■ adduction contracture
○ hip instability and dislocations are
common, may be looked over as a contracture alone.
■ observe thigh length in sitting, leg length when supine, or galleazzi test
■ adductor contracture can make examination difficult.
● foot and ankle
○ equinovarus and planovalgus deformities common.
○ observe wear patterns, callouses
○ note hypertonicity
○ toe walking or absent heel strike during gait secondary to gastrosoleus spasticity and contracture.
■ may hyperextend knee to obtain heel contact.
○ provacative Silverskiold test to differentiate gastrocnemius contracture vs achilles contracture.

How is Cerebral Palsy treated?

■ physical therapy
■ bracing/orthotics,
■ medications for spasticity
Role of Botulinum Toxin in management of cerebral palsy?
■ Blocks spasticity causing receptors, for limited time.
■ It helps in maintaining motions of upper limb and lower limbs, specially during rapid growth periods.
■ It acts as a time buying strategy for kids.Surgery of these kids to be avoided till the age of 8 yrs.
■ often injected into calf muscles.
■ It act only when the deformity is not fixed , that is when joints can be moved. It has no role when there are fixed contractures.

Surgical Management of Cerebral Palsy?

■ SEMLS surgery (Single-Event, Multi-Level Surgery)
■ Multiple deformities i.e deformities at hip, knee and ankle are addressed in single sitting.
■ This helps for early rehabilitation, and less anaesthetic exposure to it.
■ Fascial lengthenings are done so as to cause minimal damage to the muscle.
■ soft tissue procedures/releases
■ indications
● to improve function in child from 3-5 years of age with spasticity and voluntary muscle control
■ techniques
● tenotomies for continuously active muscles (e.g. hip adductor)
● tendon lengthening for continuously active muscles (e.g. achilles tendon or hamstring)
● tendon transfers for muscles firing out of phase (e.g. rectus tendon or tibialis posterior)
● tendon transfers in the upper extremity show the best improvement in function in patients with voluntary motor
control.
■ Surgeries at hip
■ Hip adductor and psoas release with abduction bracing.
■ goals of treatment.
● prevent hip subluxation and dislocation.
● maintain comfortable seating.
● facilitate care and hygiene.
● >45 degrees of hip abduction after releases.
■ technique
● begin with tenotomy of the adductor longus, sequentially release gracilis and adductor brevis as needed.
● release the psoas tendon either at the level of the insertion (non-ambulatory patients) or proximally at the pelvic brim in the myotendonous junction (ambulatory patients).
■ complications.
● careful of obturator nerve if brevis release is needed:
○ a neurectomy of the obturator nerve can cause an abduction contraction.
● higher rate of treatment failure in patients with >40% hip subluxation percentage.
● Proximal femoral osteotomy and soft-tissue release, possible acetabular osteotomy.

○ goals of treatment
■ hip containment in the severely dysplastic hip with progressive subluxation
■ single-stage osteotomies may have improved outcome
○ technique
■ shortening varus derotational osteotomy to correct increased valgus and anteversion.
■ may need pelvic osteotomy to correct acetabular dysplasia; the indications to combine pelvic osteotomy at the time of femur osteotomy remain controversial.
● Valgus support osteotomy (femoral head resection + valgus subtrochanteric femoral osteotomy (e.g McHale Technique).
○ non-anatomic arthroplasty that relieves pain and improves hip abduction
○ technique
■ anterolateral approach to remove femoral head and neck leaving ligamentum teres attached to acetabulum
■ perform a closing wedge subtrochanteric valgus-producing osteotomy and fix with lateral plate.
■ attach ligamentum teres to psoas tendon or anterior capsule.
■ the lesser trochanter will articulate with the dome of the acetabulum.
○ successfully relieves pain despite non-anatomic articulation.

For More Details , Please Contact
Dr Gaurav Jain
20 B Sainath Colony , Indore
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