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  Team Member Role(s) Profile
SattAR Sattar Alshriyda Section Editor
ND Matthew Nixon Segment Author

Demographics:

  • Hemiplegic UL involvement
  1. 80% motor
  2. 90% sensory
  • 69% loss of control of movement
  • 36% fixed contracture
  • 3 cause most functional problems = functional contracture
  1. wrist flexion
  2. thumb in palm
  3. elbow flexion
  • 19% hand/nail hygiene
  • 8% pain/spasticity

MACS (manual ability classification system)

Similar to GMFCS but for the hand. 

  • Easy and successful
  • Reduced speed
  • Needs adaptations
  • Poor despite adaptations
  • Severe limitations

Abilhand

  • Questionnaire based, strong correlation to MACS

AHA / SHUEE

  • Video analysis of function

<12 yrs

Functional contracture

  • early identification
  • aggressive splinting
  • Botox
  • consider check rein procedure  (e.g. tendon lengthening)

Non-functional contracture

  • less aggressive intervention
  • occasional splinting
  • Botox

Dystonia can be difficult to treat - risk of over-correction. Botox and occasionally check rein procedure.

> 12 yrs

Functional contracture

  • consider re-balancing procedure e.g. tendon transfer, arthrodesis, PRC

Non-functional contracture

  • Likely to cause concerns regarding appearance. Surgery may be indicated for

Dystonia has a high risk of over-correction and check rein procedures and arthrodesis may be indicated

Deformities are similar to that occurred in children with obstetric Erbs palsy which include:

  • Adduction / internal rotation deformity
  • GHJ dysplasia may lead to dislocation ± OA
  • Unable to place hand in functional position
  • Surgery rarely indicated

Surgical treatment

  • IR/add contracture
  1. Pectoralis major lengthening
  2. Subscapularis lengthening
  • Increased ER power
  1. Teres major transfer
  2. Latismus dorsi transfer
  • GHJ dysplasia
  1. Open reduction / capsulodesis
  2. Humeral ER osteotomy
  • Refectory pain
  1. GHJ fusion

Gershwind classification

  • Active supination beyond neutral
  • Active supination to neutral
  • No active supination
  • Tight passive supination

Surgical treatment

Pronator spasticity

  • Release or z-lengthening
  • Re-routing to cause supination

Fixed pronation contracture

  • Radial derotation osteotomy
  • Interosseous membrane release
  • Anterior radio-ulnar ligament release

5.2.1.png

Wrist pronation contracture in CP.

[Image is courtesy of Paediatric Orthopaedics by Matthew Nixon Lulu publishing]

Unbalanced biceps, brachialis, CFO contracture lead to FFD.

Surgical treatment

  • < 30° FFD, non-op as minimal functional impairment
  • 30 - 60° FFD
  1. Biceps Z lengthening
  2. Elevation brachialis origin
  3. Release BR from lat supracondylar ridge

5.2.2.jpg

Elbow flexion contracture in CP.

[Image is courtesy of Paediatric Orthopaedics by Matthew Nixon Lulu publishing]

Problem: long flexors stronger than long extensors

  • Pronation, flexion, ulnar deviation flexed wrist à weak grasp + weak release
  • Often interrelated with finger problems
  • Often a combination of procedures used
5.2.3.jpg
 

Wrist flexion deformity in CP

[Image is courtesy of Paediatric Orthopaedics by Matthew Nixon Lulu publishing]

Surgical treatment

FCU spasticity

  • Transfer to ECRB/ECRL
  • Transfer to EDC
  • Prevents hyper-extension deformity
  • Also strengthens long finger extensors

Residual ulnar deviation

  • ECU transfer to 4th MC
  • FCR lengthening

Severe contracture (> 60° FFD)

  • Proximal row carpectomy
  • Radial shortening ± angulation
  • Wrist fusion
  • FDS to FDP transfer

5.2.4.jpg

FDS to FDP transfer

[Image is courtesy of Paediatric Orthopaedics by Matthew Nixon Lulu publishing]

5.2.5.png

Pre and post op pictures following PRC and wrist fusion in CP

[Image is courtesy of Matthew Nixon 2014]


1-Swan-neck deformity

Caused by joint laxity± FDS spasticity± intrinsic tightness.

5.2.6.jpg

Swan neck deformity in CP

[Image is courtesy of Paediatric Orthopaedics by Matthew Nixon Lulu publishing]

Surgical treatment options

  • Extensor release
  • Central slip release
  • Lateral band translocation
  • Volar plate tenodesis
  • FDS tenodesis
  • PIPJ fusion

2-Clasp hand

FDS or FDP spasticity à contracture EDC weakness

5.2.7.png

Clasp hand deformity in CP

[Image is courtesy of Matthew Nixon 2014]

Surgical treatment options

  • mild
  1. Botox and serial stretching
  2. +- FDS lengthening
  • moderate
  1. FCU to EDC transfer
  2. FDP lengthening
  3. CFO slide
  • Severe
  1. FDS to FDP transfer
  2. proximal row carpectomy

3-Thumb deformity

Thumb FFD

  • FPL lengthening
  • +- BR reinforcement
5.2.8.png
FPL lengthening for thumb FFD Management of thumb deformities in CP.
[Image is courtesy of Paediatric Orthopaedics by Matthew Nixon Lulu publishing]

Web space contracture

  • four flap z-plasty
  • AddPB and 1st DI release
5.2.9.png
Adductor policis release for web space contracture. [Image is courtesy of Paediatric Orthopaedics by Matthew Nixon Lulu publishing]

Abductor weakness

  • BR/PL/FCR to APL transfer
  • EPL lateralisation from Lister tubercle
  • EPL weakness
  • BR/FDS transfer
5.2.10.png
Extensor compartment 3 release to allow EPL to act as a thumb abductor.
[Image is courtesy of Paediatric Orthopaedics by Matthew Nixon Lulu publishing]

MCP instability

  • Volar plate capuslodesis
  • Arthrodesis
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