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Upper Extremity in Cerebral Palsy

- See: Cerebral Palsy Menu:

- Discussion:
    - most pts w/ hemiplegic cerebral palsy have functionless hand marked by:
          - flexion of the elbow with pronation of the forearm;
          - flexion of the wrist and fingers: spasticity, weakness, flexion deformity of the wrist & fingers
          - thumb in palm deformity;
          - loss of sensation and proprioception;

- Physical Exam:
    - note the degree of finger flexion deformity w/ the wrist flexed and extended;

- Treatment Considerations:
    - treatment of upper extremity lesions needs to be directed toward improving specific functions, but care must be taken not to diminish established skills;
          - for instance, a patient w/ the typical wrist flexion deformity may be able to sweep the floor (using the hand as a hook), but may be unable to sweep the
                   floor when the hand is braced in the functional position (w/ wrist extended and MP joints flexed);
          - it is also possible to worsen the finger flexion deformity by taking the wrist out of its flexed position and placing it in extension;
          - preoperative voluntary control and stereogenesis help predict postoperative functional gains;
    - surgery may also be indicated to improve the appearance of hand;
          - cautions: a patient w/ a severe elbow contracture and wrist flexion contracture may not benefit from correct of the wrist flexion deformity alone;
                 - in this situation, correction of the wrist flexion deformity will position the extended wrist right in front of the patient's face;

- Surgical Procedures:
    - elbow contracture:
          - in the study by Manske PR, et al, the authors evaluated anterior elbow release for spastic elbow flexion deformity in children w/ CP;
                - 42 consecutive surgical procedures are reported in 40 children with a minimum of 1 year of follow-up;
                - procedure included incision of the lacertus fibrosus, fractional lengthening of the brachialis aponeurosis, and denuding the peritendinous adventitia
                       rom the biceps tendon to remove afferent nerve fibers and receptors;
                - flexion posture angle improved from 104 deg before surgery to 55 deg after surgery, a reduction of 49 deg active extension improved from 43 deg to 27 deg;
                - there was no significant change in elbow flexion.
                - before surgery, the average percentage use of the arm was 12%, which improved significantly to 44% after surgery;
                - ref: Anterior Elbow Release of Spastic Elbow Flexion Deformity in Children With Cerebral Palsy 
    - wrist flexion deformity:
          - pts may benefit from transfer of FCU around ulnar border of wrist to ECRB to restore active dorsiflexion of the wrist;
          - note that correction of this deformity may worsen the finger flexion deformity;
          - by releasing the flexor pronator origin, one allows the wrist to come to come to neutral w/o causing flexion problems in the fingers;
                 - after relaxing, wrist is extended & fingers can be actively extended;
                 - releasing the flexor pronator origin improves appearance & function of the hand w/ severe flexion deformities of wrist and fingers;
          - in the report by El-Said NS (2001), the author performed a transfer of flexor carpi ulnaris combined with selective release of the
                 flexor pronator origin in 35 patients with hemiplegic CP for a pronation flexion deformity of the forearm, hand and wrist;
                 - procedure reduces the power of wrist and finger flexion by release of the flexor pronator origin, and reinforces the strength of 
                        extension and supination of the wrist by transfer of FCU;
                 - after a mean follow-up of four years the appearance of the hand and forearm improved in all patients;
                 - none lost movement and all gained improved mobility of the forearm, wrist and hand.
                 - there was no overcorrection;
                 - ref: Selective release of the flexor origin with transfer of flexor carpi ulnaris in cerebral palsy 
          - wrist fusion:
                 - procedures involving inlay iliac-crest graft are most successful, and wrist should be held in neutral position by a large Kirshner 
                        wire placed in third metacarpal across the wrist and into radius; 
                 - reference:
                       -Wrist arthrodesis in Cerebral Palsy
     - finger flexion deformity:
          - if finger & thumb flexors remain tight, sublimis tendons are divided at wrist, profundus tendons are lengthened, & thumb is released;
          - in the report by Matsuo T, et al (2001), the authors followed 32 deformed hands of 31 patients with cerebral palsy were
                treated with combined release of the flexor digitorum profundus, FDS, and intrinsic muscles;
                - of these 31 patients, 26 patients (27 hands) were followed up after treatment;
                - improvements of more than one level on an average were observed in the modified classification of Zancolli et al and the classification of House et al.
                - ability to grasp, pinch, and release increased with improvement of 2.5 points in the object handling
                        score, and activities of daily living were enhanced with improvement of 2.4 points;
                - ref: Release of Flexors and Intrinsic Muscles for Finger Spasticity in Cerebral Palsy.   
    - thumb in palm deformity: (surgical options)
          - w/ IP joint contracture, consider FPL release and transfer to the EPB performed along with IP joint fusion;
          - brachioradialis transfer to the abductor pollicis longus;
          - release of the thumb adductor (w or w/o release of 1st dorsal interosseous);
          - abductor pollicis longus and EPB may be plicated, & EPL may be rerouted to a more radial position;
          - fusion of the metacarpophalangeal joint of thumb

Arthrodesis of the metacarpophalangeal joint of the thumb in children and adults. Adjunctive treatment of thumb-in-palm deformity in cerebral palsy.

Tendon Transfer Surgery in Upper-Extremity Cerebral Palsy Is More Effective Than Botulinum Toxin Injections or Regular, Ongoing Therapy

Capsulodesis of the metacarpophalangeal joint of the thumb in children with cerebral palsy.

Surgery of the spastic hand in cerebral palsy.  Report of the Committee on Spastic Hand Evaluation (International Federation of Societies for Surgery of the Hand).

The use of the pathokinesiology laboratory to select muscles for tendon transfers in the cerebral palsy hand.

Management of the upper extremity in cerebral palsy

Upper extremity surgical treatment of cerebral palsy.  

Biomechanic Comparison of 3 Tendon Transfers for Supination of the Forearm.

Surgical Treatment of Swan-Neck Deformity in Hemiplegic Cerebral Palsy

Long-term Results of Lateral Band Translocation for the Correction of Swan Neck Deformity in Cerebral Palsy

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

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