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CEREBRAL PALSY

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.

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CEREBRAL PALSY

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  1. CEREBRAL PALSY Thammanoon Srisaarn , MD. Orthopaedic department Pramongkutklao hospital

  2. CEREBRAL PALSY • NON PROGRESSIVE (immature)BRAIN LESION RESULTS IN MOTOR IMPAIRMENT(may be other) • Uncertain cause • Nearly drowning, infectious meningitis • Manifestration progress

  3. CLASSIFICATION • PHYSIOLOGIC (Neuropathic) • GEOGRAPHIC (Anatomic)

  4. PHYSIOLOGIC(NEUROPATHIC) • SPASTICITY(PYRAMIDAL SYSTEM) • ATHETOSIS(EXTRAPYRAMIDAL) • CHOREIFORM • DYSTONIA • HYPOTONIA • ATAXIC (CEREBELLUM) • MIXED

  5. GEOGRAPHIC(ANATOMIC) • DIPLEGIA • HEMIPLEGIA • DOUBLE HEMIPLEGIA • PARAPLEGIA • TRIPLEGIA • QUADRIPLEGIA (TETRAPLEGIA) • TOTAL BODY INVOLVEMENT • MONOPLEGIA

  6. MANIFESTRATION • SPASTIC DIPLEGIA 8- 10 MO. • SPASTIC HEMIPLEGIA 20-24 MO. • ATHETOID > 24 MO. DEPEND ON MYELINATION

  7. 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

  8. 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

  9. SCORE > 2 POOR PROGNOSIS

  10. 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)

  11. PROGNOSIS • SITTING BEFORE 2 YR USUALLY WALK INDEPENDENT • 2-4 YR 50% WALK INDEPENDENTLY • > 4 YR RARELY STAND OR WALK WITHOUT SUPPORT • NEVER LEARN TO WALK BEFORE 8 YR UNLIKELY TO WALK (Motor improve plateau 7 yr.) (Beal )

  12. PROGNOSIS • 2 YR. WITH INDEPENDENT SITTING - NOT A GOOD PREDICTOR FOR WALKING ABILITY • INABILITY TO SIT AFTER 4 YR. - PREDICTED NONAMBULATION (Molnar and Gordon)

  13. EVALUATION • HISTORY • OBSERVATION • EXAMINATION • GAIT ANALYSIS

  14. OBSERVATION • POSTURE • GAIT CROUCH JUMP

  15. PHYSICAL EXAMINATION HIP FLEXION DEFORMITY THOMAS TEST

  16. Modified Thomas test MODIFIED THOMAS TEST

  17. STAHILI TEST

  18. DUNCAN-ELY TEST

  19. PHYSICAL EXAM. ADDUCTION DEFROMITY PHELPS TEST

  20. KNEE EXAMINATION KNEE FLEXION DEFORMITY LACK OF FULL EXTENSION ON INITIAL CONTACT,STANCE AND INITIAL SWING PHASE POPLITEAL ANGLE SLRT

  21. TEST FOR RECTUS TIGHTNESS KNEE EXTENSION DEFORMITY

  22. PHYSICAL EXAMINATION (SILVERSKIÖLD) FOOT : EQUINUS DEFORMITY

  23. MOST OFTEN IN HEMIPLEGIA EQUINOVARUS DEFORMITY

  24. VARUS DEFROMITY TIBIALIS POSTERIOR HINDFOOT VARUS OR TIBIALIS ANTERIOR FOREFOOT SUPINATION, HINDFOOT VARUS(SWING PHASE) WEAK PERONEUS

  25. PES VALGUS DEFORMITY Peroneal hyperactivity

  26. TREATMENTS PRIORITY • COMMUNICATION • ADL • MOBILITY • WALKING

  27. 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

  28. Surgical treatment Hip flexion deformity • Thomas test 30O • Modified Thomas test 20O

  29. Surgical treatmentHip adduction deformity • Passive abduction < 30O both in hip flexion & extension

  30. HIP AT RISK • Quadriplegia, Nonambulator • Age 2-6 yr. • < 30Oabductioninflexorext. • > 20O flexion contracture • valgus and anteversion • Shallow acetabulum AI > 40 • Abnormal migration index FILM PELVIS EVERY 12 MO. FOR NONAMBULATOR

  31. ACETABULAR INDEX A B C AB/AC= MIGRATION INDEX (MI) > 1/3 = subluxation

  32. 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

  33. 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 ==>RELEASE MI > 60%, NOT IMPROVE IN 1 YR.==> OR+ CAPSULORRAPHY+ BONY RECONSTRUCTION • AGE > 8 YR MI > 40% RELEASE & BONE RECONSTRUCTION Flynn JM. AAOS 10(3): 2002

  34. Hip subluxation • MI > 30 % • Soft tissue release for very young • MI > 50% open reduction + femoral osteotomy • AI > 25O pelvic osteotomy

  35. Management of hip dislocation • Observation • Open reduction + osteotomy + soft tissue release • Resection arthroplasty • Arthrodesis • Total hip replacement

  36. Neck shaft angle < 115O Anteversion10-20O (30-45O passive IR)

  37. SURGICAL TREATMENT ON THE KNEE • SLRT < 60O, PA > 45O • MEDIAL HAMSTRINGS RELEASE • LATERAL HAMSTRINGS RELEASE • RECTUS FEMORIS RELEASE • RECTUS FEMORIS TRANSFER

  38. HAMSTRING RELEASE

  39. RECTUS FEMORIS TRANFER

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