summary Cerebral Palsy is a common congenital condition caused by injury to the immature brain that leads to upper motor neuron disease and presents with cognitive and musculoskeletal manifestations of varying severity. Diagnosis is made clinically with evaluation of developmental milestones, cognitive function, and musculoskeletal abnormalities including spasticity, loss of motor control, and impaired balance. Treatment involves a multidisciplinary approach to address spasticity, orthopedic manifestations, and cognitive function. Epidemiology Incidence 2-3 per 1000 Demographics 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 Etiology Nonprogressive upper motor neuron disease (static encephalopathy) due to injury to immature brain orthopaedic manifestations contractures (this topic) fractures (this topic) upper extremity deformities hip subluxation and dislocation spinal deformity foot deformities gait disorders Pathophysiology pathoanatomy leads to muscle imbalance with a mixture of weakness and spasticity the encephalopathy is static while the affected portion of the musculoskeletal system changes with growth risk factors prematurity (most common) anoxic injuries prenatal intrauterine factors perinatal infections login to view 5 more bullets meningitis brain malformations brain trauma - NAT Associated conditions orthopaedic manifestations characteristic of CP primary login to view 6 more bullets secondary (growth and spasticity related) login to view 11 more bullets Classification Physiologic Classification Spastic Most common Velocity-dependent increased muscle tone and hyperreflexia with slow, restricted movement due to simultaneous contraction of agonist and antagonist muscles. Most amenable to operative treatments. Athetoid Characterized by a constant succession of slow, writhing, involuntary movements Ataxic Characterized by inability to coordinate muscle movements. Results in unbalanced, wide based gait. Mixed Usually mixed spastic and athetoid features and involves the entire body Hypotonic Usually precedes spastic or ataxic for 2-3 years Anatomic Classification Quadriplegic Total body involvement and nonambulatory Diplegic Legs more than arms but usually still ambulatory. IQ may be normal (injury in brain is midline) Hemiplegic Arms and legs on one side of the body, usually with spasticity Will eventually be able to walk, regardless of treatment Gross Motor Function Classification Scale (GMFCS) Type I Near normal gross motor function, independent ambulator Type II Walks independently, but difficulty with uneven surfaces, minimal ability to jump Type III Walks with assistive devices Type IV Severely limited walking ability, primary mobility is wheelchair Type V Nonambulator with global involvment, dependent in all aspects of care Evaluation 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 Physical exam 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 login to view 2 more bullets hip instability and dislocations are common, may be looked over as a contracture alone login to view 2 more bullets 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 login to view 1 more bullet provacative Silverskiold test to differentiate gastrocnemius contracture vs achilles contracture Imaging Radiographs standard radiographs should include AP and lateral of hips standing spine radiographs as baseline MRI MRI of brain shows a spectrum of changes including periventricular leukomalacia (PVL) white matter lesions most frequent (56%) while grey matter lesions (18%) brain malformations are less frequent (9%) Treatment Spasticity & Deformity Nonoperative physical therapy, bracing/orthotics, medications for spasticity spasticity control login to view 13 more bullets Operative soft tissue procedures/releases indications login to view 1 more bullet techniques login to view 4 more bullets selective dorsal rhizotomy indications login to view 1 more bullet neurosurgical resection of dorsal rootlets that do not show a myographic or clinical response to stimulation contraindications login to view 2 more bullets falling out of favor due to limited functional gains and no reduced risk of subsequent musculoskeletal surgeries bony procedures/deformity correction indications login to view 2 more bullets SEMLS surgery (Single-Event, Multi-Level Surgery) login to view 4 more bullets specific procedures login to view 5 more bullets Prognosis Most reliable predictor for ability to walk is independent sitting by age 2