CP general

Question 1

Cerebral Palsy - General

Answer 1

Nonprogressive upper motor neuron disease (static encephalopathy) due to injury to immature brain

Question 2

orthopaedic manifestations

Answer 2

• contractures (this topic)
• fractures (this topic)
• upper extremity deformities
• hip subluxation and dislocation
• spinal deformity
• foot deformities
• gait disorders

Question 3

Epidemiology

Answer 3

• by definition onset must be before first two years of life, although diagnosis may be delayed in very mild cases
• Most common cause of chronic childhood disability
• Incidence: 2-3 per 1000

Question 4

risk factors

Answer 4

• prematurity (most common)
• anoxic injuries
• prenatal intrauterine factors
• perinatal infections
  
  • toxoplasmosis
  • rubella
  • cytomegalovirus infection
  • herpes simplex
  • ToRCH
• meningitis
• brain malformations
• brain trauma - NAT

Question 5

orthopaedic manifestations characteristic of CP

Answer 5

• primary
  
  • 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

Question 6

Classification

Answer 6

1. Physiologic Classification
2. Anatomic Classification
3. Gross Motor Function Classification Scale (GMFCS)

Question 7

Physiologic Classification

Answer 7

Question 8

Anatomic Classification

Answer 8

Question 9

Gross Motor Function Classification Scale (GMFCS)

Answer 9

Question 10

History

Answer 10

History

• clinical history
  
  • perinatal history
  • growth & development
  • prior medical treatments
• functional status
  
  • sitting/standing posture
  • upper and lower extremities function
  • communication skills
  • acuity of hearing and vision

Question 11

Physical exam

Answer 11

• 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

Question 12

Nonoperative Treatment

Answer 12

physical therapy, bracing/orthotics, medications for spasticity

• spasticity control
  
  • Botox (botulinum - A toxin)
    
    • competitive inhibitor of presynaptic cholinergic receptors with a finite lifetime (usually lasts 2-3 months)
    • used to maintain joint motion during rapid growth when a child is too young for surgery
    • often injected into gastrocnemius
    • helpful treatment in dynamic contractures; little benefit with static contractures
  • baclofen
    
    • reduces tone via unknown mechanism
      
      • thought to act as GABA agonist
      • intra-thecal administration is preferred route to avoid cognitive impairment seen with oral administration (poor bioavailability leads to difficulty with oral dosing)
      • Intra-thecal baclofen tends to be used for non-ambulatory CP (GMFCS IV and V)

Question 13

Operative

Answer 13

• soft tissue procedures/releases
• selective dorsal rhizotomy
• bony procedures/deformity correction

Question 14

soft tissue procedures/releases in CP

Answer 14

• 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

Question 15

bony procedures/deformity correction in CP

Answer 15

• indications
  
  • usually performed in later childhood / adolescence
  • static contractures, progressive joint breakdown, and certain patterned gait-deterioration can be treated with combinations of myotendonous unit lengthening, tendon transfers, and osteotomies
• SEMLS surgery (Single-Event, Multi-Level Surgery)
  
  • concept arose to limit multiple surgeries, anesthetics, and rehabilitation time for children
  • most successful when combined with a thorough gait lab assessment that predicts improvemenet in function with multiple level surgical interventions
  • simple lengthenings can cause deterioration in gait when other contractures are “uncovered”; SEMLS management seeks to avoid these iatrogenic complications
  • can be done on bilateral lower extremities in efforts to improve gait

Question 16

What is SEMLS surgery

Answer 16

(Single-Event, Multi-Level Surgery)

• concept arose to limit multiple surgeries, anesthetics, and rehabilitation time for children
• most successful when combined with a thorough gait lab assessment that predicts improvemenet in function with multiple level surgical interventions
• simple lengthenings can cause deterioration in gait when other contractures are “uncovered”; SEMLS management seeks to avoid these iatrogenic complications
• can be done on bilateral lower extremities in efforts to improve gait