Cerebral palsy is a non-progressive disorder of movement and posture caused by damage to the developing brain. It is characterized by spasticity, abnormal muscle tone and reflexes, delays in development, and impaired motor skills. The most common type is spastic cerebral palsy, which causes stiff, jerky movements. Orthoses are often used to treat cerebral palsy by correcting deformities, providing support, and facilitating training to improve motor skills and gait efficiency. Physiotherapy and occupational therapy also help achieve developmental milestones and independence in daily living activities.
This document provides guidance on evaluating floppy infants. It discusses the importance of assessing muscle tone and differentiating between central, peripheral, and mixed hypotonia. A thorough history and physical exam can help localize the cause and narrow the differential diagnosis, which includes various central nervous system disorders, peripheral nerve and muscle diseases, and metabolic conditions. The document outlines steps for evaluating tone, important exam findings for different etiologies, and differential diagnoses to consider in floppy infants.
Holistic concept in treatment of Cerebral Palsy jitendra jain
it is very difficult to manage cerebral palsy because we cant repair brain damage but we can give good quality of independent life by combination good rehabilitation tool which include advance therapeutic technique, botulinum toxin early age child and SEMLOSSS surgical concept in others. Our aim of management is to take these person to their highest capability and decrease their physical limitation as much as possible. This ppt have brief review about latest concept in mx of cerebral aplsy
Jose Austine- Orthopaedic evaluation of cerebral palsyJose Austine
This document provides an overview of cerebral palsy (CP), including its history, definition, classification, etiology, assessment, and orthopedic evaluation. CP is caused by non-progressive brain lesions early in development that result in abnormal muscle tone and movement. It is important to correctly classify a patient's CP based on their motor function and movement disorder. A thorough orthopedic evaluation includes assessing medical history, physical exam of muscle tone and strength, contractures, deformities, and gait. Gait analysis through observation and in a lab helps document the patient's movement and plan for surgical interventions. The goal of evaluation and classification is to guide appropriate treatment and management of CP.
This document provides information on cerebral palsy (CP), including its definition, risk factors, pathology, classifications, presenting symptoms, and examination findings. CP is defined as a non-progressive brain injury occurring in early development that causes motor impairment. Risk factors include preterm birth, infections, and hypoxic events during the prenatal, natal, and postnatal periods. Common presentations are delays in motor milestones and inability to perform daily activities. Examination assesses tone, strength, posture, gait, contractures and other findings to classify CP and plan management. Investigations such as imaging, EEG, and genetic testing may provide more information.
The document discusses post-polio residual paralysis, including:
1. It provides historical context on polio and describes the etymology and pathology of the virus.
2. Poliovirus attacks the anterior horn cells of the spinal cord, causing flaccid paralysis. This can lead to progressive muscle imbalance and deformities over time if left untreated.
3. Management focuses on strengthening unaffected muscles, stretching shortened muscles, exercises to maintain range of motion, orthotics and bracing, and surgery to correct severe deformities. The goal is maximizing recovery and function.
Spina bifida is a neural tube defect where the vertebrae do not fully close around the spinal cord. It can cause neurological problems depending on the location and severity. The main types are spina bifida occulta (mildest), meningocele (dura protrusion), and myelomeningocele (spinal cord protrusion). Treatment requires a multidisciplinary approach including orthotics, surgery to address foot/spine issues, and management of associated conditions like hydrocephalus. The goal of orthopedic management is to achieve a stable, plantigrade position through bracing and surgery when needed.
A brief introduction to the topic cerebral palsy, prepared by Dr Yash Oza, PG resident in MS Orthopaedics
Etiology, Classification, assessment, diagnosis, treatment
Evaluation of pediatric spinal deformitiesdrshreyash7987
This document provides an overview of evaluating pediatric spinal deformities. It discusses the importance of obtaining a detailed history, including birth and family history. The physical exam should assess neurological function, spinal alignment, and flexibility. Imaging plays an important role, with plain films used initially to measure deformities like Cobb angle. MRI is useful for detecting underlying issues. Etiologies include idiopathic scoliosis and conditions like congenital anomalies or neuromuscular disorders. Infantile idiopathic scoliosis requires special consideration given rapid growth at a young age.
1. Cerebral palsy is a motor dysfunction caused by damage to the brain's motor areas, resulting in problems with muscle control and movement.
2. The most common type is spastic cerebral palsy, which causes muscle stiffness. Other types include dyskinetic, ataxic, and mixed forms.
3. Risk factors include prematurity, low birth weight, genetic disorders, infections, and complications during birth. Treatment involves a multidisciplinary approach including physical therapy, medications, surgery, and rehabilitation.
This document provides information on cerebral palsy (CP), including its definition, classification, causes, symptoms, and treatment approaches. CP is a non-progressive brain injury early in life that results in impaired motor function. It is classified based on the type of movement abnormality (e.g. spastic, athetoid) and the parts of the body affected (e.g. hemiplegia, diplegia). Common causes include prenatal infections, complications during birth like hypoxia, and postnatal infections. Treatment involves physical therapy, bracing, medication to reduce spasticity, botulinum toxin injections, and surgery to correct musculoskeletal deformities. The goals are to improve motor function, prevent
SYBPO - Orthotics.This presentation consists of all the pathological reasons affecting the lower extremity causing various deformities. it consists of Cerebral Palsy, polio, CDH etc.
The document discusses low back pain, including its prevalence, causes, types (acute, subacute, chronic), and potential pain generators. It describes the biomechanics of the lumbar spine, including the vertebrae, intervertebral discs, zygapophyseal joints, ligaments, and muscles. Potential causes of low back pain with leg pain greater than back pain and management options are provided. Specific conditions like lumbar spinal stenosis, spondylolysis, and pregnancy-related back pain are explained. The role of ergonomics and lifestyle factors like backpack weight are also summarized.
Some key points include:
- Polio is caused by infection with the poliovirus and can lead to paralysis of muscles.
- It spreads via the fecal-oral or respiratory routes and infects the anterior horn cells of the spinal cord.
- Clinical features may include fever, neck rigidity, asymmetric limb paralysis that often affects the legs. Respiratory muscles can be involved.
- Treatment focuses on supportive care, splinting to prevent deformities, physiotherapy to
SCOLIOSIS - Presentation on SCOLIOSIS .docZaherRahat1
Scoliosis is where the spine twists and curves to the side.
It can affect people of any age, from babies to adults, but most often starts in children aged 10 to 15. Scoliosis can improve with treatment, but it is not usually a sign of anything serious and treatment is not always needed if it's mild.
Cerebral palsy is a motor function disorder caused by a permanent, non-progressive brain lesion present at birth or shortly thereafter. It is a non-curable, lifelong condition that affects muscle strength, movement, balance and coordination. Common causes include prematurity, low birth weight, infections, and lack of oxygen during birth. Treatment focuses on managing symptoms through physical, occupational and speech therapy as well as bracing, medication and sometimes surgery. The goals are to improve functional abilities and quality of life.
Similar to Cerebral palsy in orthopaedics..2..pptx (20)
Diabetes mellitus in children is common problem in most of developing countries due to sedestary life style.
Here are the notes to describe it in details and the management
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The uroculturome indicates the profile of culturable microbes inhabiting the urinary tract, and it is often required to do a urine culture to find an effective antimicrobial to treat UTIs. This study targeted to understand the profile of culturable pathogens in the urine of apparently healthy (128) and humans with clinical UTIs (161). In urine samples from UTI cases, microbial counts were 1.2×104 ± 6.02×103 colony-forming units (cfu)/ mL, while in urine samples from apparently healthy humans, the average count was 3.33± 1.34×103 cfu/ mL. In eight samples (six from UTI cases and two from apparently healthy people) of urine, Candida (C. albicans 3, C. catenulata 1, C. krusei 1, C. tropicalis 1, C. parapsiplosis 1, C. gulliermondii 1) and Rhizopus species (1) were detected. Candida krusei was detected only in a single urine sample from a healthy person and C. albicans was detected both in urine of healthy and clinical UTI cases. Fungal strains were always detected with one or more types of bacteria. Gram-positive bacteria were more commonly (OR, 1.98; CI99, 1.01-3.87) detected in urine samples of apparently healthy humans, and Gram -ve bacteria (OR, 2.74; CI99, 1.44-5.23) in urines of UTI cases. From urine samples of 161 UTI cases, a total of 90 different types of microbes were detected and, 73 samples had only a single type of bacteria. In contrast, 49, 29, 3, 4, 1, and 2 samples had 2, 3, 4, 5, 6 and 7 types of bacteria, respectively. The most common bacteria detected in urine of UTI cases was Escherichia coli detected in 52 samples, in 20 cases as the single type of bacteria, other 34 types of bacteria were detected in pure form in 53 cases. From 128 urine samples of apparently healthy people, 88 types of microbes were detected either singly or in association with others, from 64 urine samples only a single type of bacteria was detected while 34, 13, 3, 11, 2 and 1 samples yielded 2, 3, 4, 5, 6 and seven types of microbes, respectively. In the urine of apparently healthy humans too, E. coli was the most common bacteria, detected in pure culture from 10 samples followed by Staphylococcus haemolyticus (9), S. intermedius (5), and S. aureus (5), and similar types of bacteria also dominated in cases of mixed occurrence, E. coli was detected in 26, S. aureus in 22 and S. haemolyticus in 19 urine samples, respectively. Gram +ve bacteria isolated from urine samples' irrespective of health status were more often (p, <0.01) resistant than Gram -ve bacteria to ajowan oil, holy basil oil, cinnamaldehyde, and cinnamon oil, but more susceptible to sandalwood oil (p, <0.01). However, for antibiotics, Gram +ve were more often susceptible than Gram -ve bacteria to cephalosporins, doxycycline, and nitrofurantoin. The study concludes that to understand the role of good and bad bacteria in the urinary tract microbiome more targeted studies are needed to discern the isolates at the pathotype level.
Chair, Benjamin M. Greenberg, MD, MHS, discusses neuromyelitis optica spectrum disorder in this CME activity titled “Mastering Diagnosis and Navigating the Sea of Targeted Treatments in NMOSD: Practical Guidance on Optimizing Patient Care.” For the full presentation, downloadable Practice Aids, and complete CME information, and to apply for credit, please visit us at https://bit.ly/4av12w4. CME credit will be available until June 27, 2025.
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JMML is a rare cancer of blood that affects young children. There is a sustained abnormal and excessive production of myeloid progenitors and monocytes.
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2. OBJECTIVES
• Introduction
• Epidemiology
• Etiology
• Classification
• Topographic distribution
• Gross motor function classification system (GMFCS)
• Diagnosis
• Management
• Role of orthopedics in Cerebral Palsy and timing of
management in Orthopedics
3. Introduction
The term ‘cerebral palsy’ includes a group of disorders that result
from permanent non-progressive brain damage during early
development and are characterized by abnormalities of
movement and posture.
CP was first described by William Little in 1862.CP is the result of
a brain lesion; therefore, the spinal cord and muscles are
structurally and biochemically normal.
4. Epidemiology
• Incidence of 1 to 3 per 1,000 live births.
• the highest rates in premature babies and those of multiple births.
78 per 1,000 infants weighing less than 1,000 g.
9 to 12 per 1000 in twins
31 to 45 per 1000 in triplets
111 per 1000 in quadruplets.
5. Etiology
• Known causal factors: maternal toxaemia, prematurity, perinatal
anoxia, kernicterus and postnatal brain infections or injury like birth
injury.
• CP can affect childhood motor development, speech, cognition, and
sensation.
• The main consequence is the development of neuromuscular
incoordination, dystonia, weakness and spasticity
6. Classification
• Cerebral palsy is usually classified according to the type of motor
disorder, with subdivisions referring to the topographical distribution
of the clinical signs.
• TYPE OF MOTOR DISORDER:
Spasticity
Hypotonia
Athetosis
Dystonia
Ataxia
Mixed palsy
7. Classification
• Spasticity is the commonest muscle movement disorder and is
associated with damage to the pyramidal system in the CNS. It is
characterized by increased muscle tone and hyper-reflexia with passive
stretch . “clasped knife”.
• Hypotonia Infants are described as floppy.it is usually a phase, lasting
several years during early childhood before the features of spasticity
become obvious.
8. Classification
• Athetosis manifests as continuous, involuntary, purposeless
movements that may be exacerbated by environmental stimulation. It
is caused by damage to the extrapyramidal systems of the CNS. In pure
athetoid cerebral palsy, joint contractures are unusual and muscle tone
is not increased.
• Dystonia There is a more generalized increase in muscle tone and
abnormal positions induced by activity “lead pipe”. This occurs in the
absence of hyperreflexia, spasticity, and clonus and it may occur with
athetosis.
9. Classification
• Ataxia appears in the form of muscular incoordination during
voluntary movements. It is usually due to cerebellar damage. Balance
is poor and the patient walks with a characteristic wide-based gait.
• Mixed palsy appears as a combination of spasticity and athetosis.
The presence of both types of motor disorder can make the results of
surgical intervention unpredictable.
11. TOPOGRAPHIC DISTRIBUTION
• Hemiplegia: is the commonest. This usually appears as a spastic palsy
on one side of the body with the upper limb more severely affected
than the lower. Most of these children can walk and they respond
reasonably well to treatment.
• Diplegia: involves both sides of the body, with the lower limbs always
most severely affected. Side to side involvement may be asymmetrical,
Intelligence is often normal.
12. TOPOGRAPHIC DISTRIBUTION
• Total body involvement: general and often more severe disorder
affecting all four limbs, the trunk, neck and face with varying degrees
of severity. Patients usually have a low IQ, they may have epilepsy,
they are often unable to walk and the response to treatment is poor.
• Monoplegia: very rare, occasionally appears in an upper limb.
13. gross motor function classification system
(GMFCS)
• GMFCS is most commonly used to describe the patient’s level of
function before and after an intervention.
• The GMFCS scale which was developed by Palisano et al. in 1997 , has
five levels:
GMFCS 1: ambulates without aids on all surfaces and keeps up with
peers.
GMFCS 2: fully ambulatory, may use lower extremity orthoses, and does
not keep up fully with peers.
GMFCS 3: uses ambulatory aids such as a walker or crutches and may
use a wheelchair for longer distances.
GMFCS 4: nonambulatory patients who are able to propel their own
wheelchair.
14. gross motor function classification system
(GMFCS)
• GMFCS 5 : inability to transfer, propel a wheelchair, or support the
trunk.
GMFCS levels:
level 1
35%
level 2
16.4%;
level 3
14.2%
level 4
16.1%
level 5
18%
15. Diagnosis
• Diagnosis in infancy:
The full-blown clinical picture may take months or even years to develop.
history of prenatal toxaemia, haemorrhage, premature birth, difficult labour, foetal
distress or kernicterus should arouse suspicion.
A neonatal ultrasound scan of the head may identify intracerebral bleeding that
would increase the likelihood of later problems.
Early symptoms include difficulty in sucking and swallowing, with dribbling at the
mouth.
Motor milestones are delayed.
16. Diagnosis
• Diagnosis in later childhood:
Most children have already had the diagnosis made.
the child should be carefully observed sitting, standing, walking and lying.
gross motor function classification system (GMFCS) is used to evaluate there
condition, which categorizes the child, relative to their age, in terms of mobility and
bases this on their average function
There are no definitive laboratory studies
17. Diagnosis
• GAIT assessment: Gait should be observed with and without shoes or
orthotic supports.
Clinical gait analysis; Each limb must be observed in both the stance and swing
phases of gait and in the coronal, sagittal and transverse planes.
Computerized gait analysis; it supplements clinical gait analysis, includes
Kinematics, kinetics, EMG, pedobarography (foot pressures), and metabolic energy
analysis.
Sutherland and Davids at (1993) described four pathological gait patterns based on
knee motion in the sagittal plane:
o Toe-walking (jump knee) gait
o crouch knee gait
o Stiff knee gait
o Recurvatum knee gait
18. Diagnosis
A.Toe-walking (jump knee) gait: due to tightness in
the hamstring muscles, hip adductors and
gastronomies muscles
B.crouch knee gait; due to long lasting of the knee
extensor muscles mainly rectus femoris in stance
phase .this also causes pelvis to bend forward and
causes a crouch in body.
C.Stiff knee gait; due to stiffness in the posterior
capsule of knee in the flexed position
D.Recurvatum knee gait; due to long lasting of the
knee flexor muscles mainly biceps femoris in stance
phase .
19. Diagnosis
• Deformity assessment:
MUSCLE CONTRACTURE: longstanding spasticity leads to relative shortening of the
muscles and hence fixed contractures and changes in joint congruity.
BONY DEFORMITY: it is influenced by muscle contracture.
STRUCTURAL SCOLIOSIS: Flexible curves are common in CP, but it may become structural.
• Imaging studies:
CT & MRI of the brain
• Electroencephalography: Important in the diagnosis of seizure disorders
• Electromyography and nerve conduction studies: Helpful when a muscle or
nerve disorder is suspected
20. management
• There is no single ‘blueprint’ for the management of all patients with
cerebral palsy; each patient and his or her family provides a different
challenge.
• For all patients with cerebral palsy the priorities are:
(1) an ability to communicate with others
(2) an ability to cope with the activities of daily living (including personal hygiene)
(3) independent mobility , which may mean a motorized wheelchair rather than
walking.
21. management
• For the child who from an early age is recognized to be ‘non-walking’
realistic goals should be:
(1) a straight spine with a level pelvis
(2) located, mobile and painless hips that flex to 90 degrees (for comfortable
sitting) and extend sufficiently to allow comfortable sleeping and participation
in standing/swivel transfers
(3) knees that are mobile enough for sitting, sleeping and transferring
(4) plantigrade feet that fit into shoes and rest on the footplates of the wheelchair
comfortably.
22. management
• TONE MANAGEMENT:
• Medical treatment:
anticonvulsants for seizures, short-term benzodiazepine use for postoperative pain
trihexyphenidyl for dystonia.
oral tizanidine (muscle relaxant ) has been used to relieve spasticity
• Physical therapy; is considered to be most helpful in early childhood up to the age
of 7 or 8 years
• Positioning and splinting; Splints are used to prevent muscle contracture, maintain
joint position and improve movement and hence function.
• Manipulation and serial casting: have limited role.
23. management
• Intrathecal Baclofen:
γ-aminobutyric acid agonist, acts at the spinal cord level to impede release
of the excitatory neurotransmitters that cause spasticity.
implantable pumps filled with baclofen are surgically inserted into the
anterior abdominal wall and the dose of medication is titrated.
Continuous infusion of the medication is delivered by
the pump, which requires refilling approximately every 3 months.
Studies have shown decreased upper and lower extremity tone and
improvements in range of motion.
24. management
• Botulinum Toxin:
blocks the release of acetylcholine at the neuromuscular junction.
botulinum toxin injection is of use in the treatment of lower extremity
spasticity.
It is injected at known anatomic sites of innervation, often guided by EMG.
The drug begins taking effect after 2 to 3 days, and its effect wears off after
approximately 3-6 months.
botulinum toxin may allow tendon surgery to be delayed until a later age,
when the risk for recurrence is lower.
25. management
• Selective dorsal rhizotomy;
Neurosurgical procedure in which selected dorsal nerve roots from L1 to S2
are severed at the level of the cauda equina to reduce spasticity.
Candidates must have purely spastic CP.
Studies have shown decreased tone and increased joint range of motion
after rhizotomy
Residual contractures, hip subluxation, and spinal
deformity, in general, may occur in 36% of selective
dorsal rhizotomy patients.
26. management
• Operative treatment:
The indications for surgery are:
(1) a spastic deformity which cannot be controlled by conservative measures
(2) fixed deformity that interferes with function
(3) secondary complications such as bony deformities, dislocation of the hip and
joint instability.
(4) Shoe wear problems
(5) Pain
(6) Perineal hygiene problems
27. Timing of Surgery in CP
Delaying surgery is advocated until age of 7–8
years because development of the CNS and
the gait pattern matures around this age and
then doing all the necessary operations at one
or two sittings.
some patients surgery cannot be delayed like
hip subluxation which should undergo surgery
when the problem is first recognized to
improve coverage of the hip.
children who are nearly ambulatory but whose
progress has been halted by contractures,
earlier surgery may allow them additional
range of motion to make walking less
cumbersome.
28. The Role of Orthopedic Surgery in the
Management of CP
• Management of Foot Involvement:
Equinus deformity:
o An equinus foot and ankle deformity is a condition of the foot and ankle where the
foot is held in a downward position; it becomes difficult to pull the ankle and foot
upselective lengthening of the Achilles tendon .It also known as tight calf.
• Lengthening may be performed by open or
percutaneous techniques.
• The tendon must be repaired with sufficient tension
to avoid postoperative calcaneus gait
• ankle is then immobilized in a short-leg cast for 6 weeks
o gastrocnemius fascial recession involves lengthens the muscles and tendons at the
back of the leg, allowing the heel to shift downward into a more natural position. In
many cases, this
• the aponeurosis of the gastrocsoleus is divided in chevron fashion
• the soleus muscle fibers are not disturbed
• Immobilization is minimized
FIGURE 35-20 Lengthening of the
gastrocnemius by the Vulpius technique.
29. The Role of Orthopedic Surgery in the
Management of CP
• Management of Foot Involvement:
Equinovarus deformity:
o Posterior Tibialis Tendon Lengthening:
• usually done in conjunction with an Achilles tendon–lengthening
• patient is placed in a short-leg cast for approximately 6 weeks.
o Transfer of the Posterior Tibialis Tendon to the Dorsum:
• Calcaneovalgus can be a disastrous result and occurs in up
to 68% of patients.
• The only indication is when the posterior tibialis is
Completely silent during stance phase and active
during swing phase.
30. The Role of Orthopedic Surgery in the
Management of CP
• Management of Foot Involvement:
Equinovarus deformity:
o Split Posterior Tibialis Tendon Transfer:
• posterior half of the posterior tibialis tendon is detached
from its insertion, split proximally to a level just proximal to the
ankle, rerouted posterior to the tibia and fibula, and then re-
attached into the tendon of the peroneus brevis.
31. The Role of Orthopedic Surgery in the
Management of CP
• Management of Foot Involvement:
Equinovarus deformity:
o Split Anterior Tibialis Tendon Transfer:
• the lateral half of the anterior tibialis is detached from
the base of the first metatarsal.
• The tendon is passed beneath the extensor retinaculum
and inserted through a bone tunnel into the cuboid bone.
• usually combined with an Achilles tendon–lengthening procedure.
o Bone Surgery:
• If the varus deformity of the foot is fixed. heel varus will respond
to calcaneal osteotomy.
• If the deformity is very severe, calcaneal osteotomy will be insufficient and triple arthrodesis
should be performed.
32. The Role of Orthopedic Surgery in the
Management of CP
• Management of Foot Involvement:
Pes Valgus deformity:
o Valgus deformity of the foot occurs in up to 25% of patients with CP
o Conservative treatment should be vigorously pursued because shoe inserts and
orthosis modifications may be adequate to relieve the pain
o In valgus deformity, bone surgery is the only predictable alternative for full and lasting
correction. Surgical options are:
(1) the Grice extraarticular arthrodesis ( extraarticular fusion of subtalar joint with bone graft)
(2) Lateral column lengthening of the calcaneal neck
(3) Calcaneal osteotomy
(4) triple arthrodesis.
33. The Role of Orthopedic Surgery in the
Management of CP
• Management of Foot Involvement:
Ankle valgus:
o Surgical correction of ankle valgus is performed by either:
• Hemiepiphysiodesis of the distal medial aspect of the tibia provides
gradual correction
• When immediate correction is desired, distal tibial osteotomy is useful.
Hallux Valgus
o develops in response to an equinovalgus deformity of the hindfoot
• first MTP arthrodesis is preferred for the surgical treatment of
hallux valgus in patients with CP
34. The Role of Orthopedic Surgery in the
Management of CP
• Management of knee Involvement:
o Hamstring Lengthening:
• The hamstrings are nearly always affected in patients with CP.
• hamstring spasticity can be measured via the popliteal angle.
• Normal popliteal angles are variable, with a mean value of 26 degrees in children 4 years and
older. Values greater tha 50 degrees are considered abnormal.
1) Orthotic Management: Mild tightness in the hamstrings
may respond to orthotic management, usually with ground
reaction AFOs.
2) Surgical lengthening of the distal hamstrings is the preferred
surgical treatment of crouched-knee gait
35. The Role of Orthopedic Surgery in the
Management of CP
• Management of knee Involvement
o Rectus Femoris Transfer:
• Surgical treatment of stiff-knee gait and inability to flex the knee in swing
phase consists of rectus femoris transfer.
• It is often performed simultaneously with hamstring lengthening
• The tendon is divided transversely just proximal to the superior pole of the patella, then passed
medially and sewn into the stump of the gracilis tendon
o Bone surgery:
• Bone surgery has become accepted for patients with CP who have fixed
flexion contractures or those who have previously undergone hamstring
lengthening.
• distal femoral extension osteotomy +/- patellar tendon reefing is useful in
older children and teens.
36. The Role of Orthopedic Surgery in the
Management of CP
• Management of Rotational Abnormalities of the Femur and Tibia
o Spasticity in the lower extremities over time leads to the development of rotational
abnormalities in the femur and tibia (increased femoral anteversion and external tibial
torsion ).
o Derotational Osteotomy :
• Femoral anteversion is treated by femoral osteotomy, either
proximally at the intertrochanteric or subtrochanteric level or
distally at the supracondylar level.
• In tibial rotational deformities, surgical correction should be
performed at the distal level. Proximal osteotomies are associated
with a higher risk for neurovascular injury.
37. The Role of Orthopedic Surgery in the
Management of CP
• Management of Hip Involvement in CP:
Hip Flexion Contracture:
o Hip flexion contractures are nearly always seen in combination with increased hip
adduction and internal rotation, with knee flexion secondary to hamstring spasticity,
and equinus, or valgus deformities of the feet. Hence, surgery to improve hip flexion
contractures is part of the SEMLS( Single Event Multilevel Surgery) approach in
conjunction with other soft tissue or bony procedures in patients with CP.
o It is caused by increased tone in the hip flexors, primarily
the iliopsoas muscle.
o The contracture is identified by performing the Thomas
and Staheli maneuvers
o The recommended procedure is psoas tenotomy
performed over the pelvic brim.
38. The Role of Orthopedic Surgery in the
Management of CP
• Management of Hip Involvement in CP:
Adduction Contracture:
o Spasticity in the adductor muscles in CP results in a narrow base of gait and scissoring.
o The muscles leading to the adduction contracture are the adductor longus, adductor
brevis, adductor magnus, gracilis, and occasionally the pectineus.
o Surgery to improve adduction contractures is limited to adductor release, with or
without obturator neurectomy, and posterior adductor transfer.
39. The Role of Orthopedic Surgery in the
Management of CP
• Management of Hip Involvement in CP:
Hip Subluxation or Dislocation:
o Hip dysplasia or instability is a common problem in patients with CP and occurred in
approximately 21%
o Because bony deformity develops in response to muscular spasticity, bone surgery in
the absence of soft tissue release is ineffective in correcting subluxation or dislocation
secondary to CP.
o The goals of treatment include a painless hip that allows stable sitting and positioning in
a non-ambulatory patient and full hip reduction in an ambulatory patient.
o Categories of Surgical Treatment. divided into three categories
(1) soft tissue release for subluxation or a hip at risk
(2) reduction and reconstruction of the subluxated or dislocated hip
(3) salvage surgery for long-standing painful dislocations.
40. The Role of Orthopedic Surgery in the
Management of CP
• Management of Hip Involvement in CP:
Hip Subluxation or Dislocation:
o First category: hip at risk is defined as a hip that has significant adduction and flexion
contractures but minimal subluxation, Surgical treatment is aimed at preventing
dislocation ofthe hip. The procedure consists of adductor release and iliopsoas
lengthening or release.
o Second category: The most frequently performed procedure in this setting is femoral
varus derotation osteotomy (VDRO).
o Third category: Indications for surgery in this group of patients include hip pain, inability
to sit in a modified wheelchair, and difficulty with perineal hygiene. Four surgical
options are available: proximal femoral resection, valgus osteotomy of the proximal end
of the femur, hip arthrodesis, and total hip arthroplasty.
41. The Role of Orthopedic Surgery in the
Management of CP
• Management of Hip Involvement in CP:
Hip Subluxation or Dislocation:
varus derotation osteotomy Valgus osteotomy
proximal femoral resections
42. The Role of Orthopedic Surgery in the
Management of CP
• Management of Upper Limb Involvement in CP:
o Operative treatment of the upper limb can improve the function of children with
CP.
o Basic goals are improvement in function and improvement in appearance
o upper limb deformities:
(1) Elbow flexion deformity: no treatment is needed, occasionally
fractional lengthening of the biceps and brachialis tendons with
release of the brachialis origin is done.
(2) Forearm pronation deformity: fairly common, release of pronator
teres may improve the position.
(3) Wrist flexion deformity: it is usually in an ulnar direction it can be
improved by lengthening or releasing flexor carpi ulnaris. In severe cases
wrist arthrodesis is done.
43. The Role of Orthopedic Surgery in the
Management of CP
•Management of Upper Limb Involvement in
CP:
(4) Flexion deformity of the fingers: The flexor tendons can be lengthened
individually, but if the deformity is severe a forearm muscle slide
may be more appropriate.
(5) Thumb-in-palm deformity: due to spasticity of the thumb adductors
and/or flexors. but late there is also contracture of flexor pollicis longus.
In mild cases, function can be improved by splinting. Resistant deformity
may need combined lengthening of flexor pollicis longus and release of
the thenar muscles.
44. The Role of Orthopedic Surgery in the
Management of CP
• Management of Spinal Deformity in CP:
Scoliosis:
o Scoliosis is a significant problem in children with CP that
affects between 25% and 68% of patients.
o Scoliosis leads to difficulty sitting, the functional position
needed by a wheelchair-bound child.
o Nonoperative treatment of scoliosis with adaptive seating and orthoses has not met
with success.
o Indications for spinal fusion are:
1. Curves greater than 40 degrees in ambulatory patients
2. Progressive curves greater than 50 degrees in communicative patients
3. Curves that interfere with seating and nursing in patients whose families desire surgical
correction
45. The Role of Orthopedic Surgery in the
Management of CP
• Management of Spinal Deformity in CP:
Spondylolysis and Spondylolisthesis:
o hip flexion contractures and increased lumbar lordosis may lead to an increased
incidence of spondylolysis and back pain in patients with CP which account for in 21% of
patients.
o Dorsal rhizotomy may predispose patients to spondylolisthesis inasmuch as 12% of
patients
o Treatment is surgical.
47. references
• Solomon L., Warwick D. , Nayagam S.,[2010] Apley’s System of Orthopaedics and
Fractures, 9th ed. Hodderarnold comp.,London, UK.
• Miller M. , Thompson S. , Hart J. ,[2012] REVIEW OF ORTHOPAEDICS [PDF], 6th
ed. by Saunders, an imprint of Elsevier Inc. , Philadelphia, USA.
• Canale S. , Beaty J. , [2007] Campbell’s Operative Orthopaedics [PDF], 11th ed. By
Mosby, An Imprint of Elsevier , Tennessee, USA.
• John A. Herring, [2014] Tachdjian’s Pediatric Orthopaedics [PDF], 5th ed. . by
Saunders, an imprint of Elsevier Inc. , Philadelphia, USA.
• John M. Flynn, [2011] American Academy of Orthopaedic Surgeons, Orthopaedic
Knowledge Update OKU 10 [PDF] , Printed in the USA.
• ORTHOPAEDIC REVIEW [2015] by orthobullets, [PDF], Collected By Islam Gomaa
Beltage.