Updated: 12/7/2019

Cerebral Palsy - Upper Extremity Disorders

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Introduction
  • See Cerebral Palsy General 
  • Introduction
    • typically seen in in patients with hemiplegia and quadriplegia
    • treatment of upper extremity conditions can be divided into
      • hygienic procedures
        • indicated to maintain hygiene in patients with decreased mental and physical function
      • functional procedures
        • indicated in patients with voluntary control, IQ of 50-70 or higher, and better sensibility
  • Characteristic deformities include
    • shoulder internal rotation contracture
    • forearm-pronation / elbow flexion deformity
    • wrist-flexion deformity
    • thumb-in-palm deformity
    • finger-flexion deformity
Shoulder IR Contracture
  • Overview
    • characterized by glenohumeral internal rotation contracture 
  • Treatment
    • shoulder derotational osteotomy and/or subscapularis and pectoralis lengthening with biceps/brachialis lengthening capsulotomy
      • indications
        • severe contracture (>30 degrees) interfering with hand function
Forearm-Pronation / Elbow-Flexion Deformity
  • Overview
    • usually consists of a combination of a
      • forearm pronation deformity and
      • elbow flexion contracture
  • Treatment
    • lacertus fibrosis release, biceps and brachialis lengthening, brachioradialis origin release
      • indications
        • elbow flexion contracture
    • pronator teres release
      • indications
        • forearm pronation deformity
      • technique
        • transfer to an anterolateral position
      • complication
        • supination deformity
          • this is less preferable than a pronation deformity
    • FCU transfer
      • transfer of the FCU to the ECRB
        • indications
          • another option for pronation deformity
Wrist-Flexion Deformity
  •  Overview
    • wrist is typically flexed and in ulnar deviation
    • associated with weak wrist extension and pronation of the forearm
  • Treatment
    • FCU or FCR lengthening
      • indications
        • when there is good finger extension and little spasticity on wrist flexion
    • FCU to ECRB transfer or FCU to EDC transfer
      • indications
        • as a functional procedure in patients with voluntary control, IQ of 50-70 or higher, and better sensibility
        • technique
          • with good grasp ability
            • transfer FCU to EDC
          • with poor grasp ability
            • transfer FCU to ECRB
    • flexor release
      • indications
        • weakening of the wrist flexors
      • technique
        • release of the flexors of the wrist and pronator teres from the medial epicondyle
    • wrist arthrodesis 
      • indications
        • as a hygienic procedure in low functioning patients
Thumb-in-Palm Deformity
  •  Introduction
    • flexed thumb into palm prevents grasping and pinching activities 
      • can preclude appropriate hygiene
  • Classification (House)

House Classification
Type

Characteristics

Treatment
Type I 1st metacarpal adduction contracture

 

  • adductor release
  • possible 1st dorsal interosseous release
  • z-plasty of the skin contracture in the 1st web

 

Type II

1st metacarpal adduction contracture + contracture of the MP joint 

  • adductor release
  • release of FPB
Type III

1st metacarpal adduction contracture + unstable or hyperextendable MPJ 

  • adductor release
  •  fusion or capsulodesis of the MP joint 
Type IV

1st metacarpal adduction contracture + MPJ and IPJ flexion contractures

  • adductor release
  •  FPB and FPL release or lengthening
 
  • Treatment
    • release of the adductor pollicis, transfer of tendons, and stabilization of the MCP joint
      • indications
        • as a functional procedure in patients with voluntary control, IQ of 50-70 or higher, and better sensibility
Finger-Flexion Deformity
  • Introduction
    • a result of intrinsic muscle tightness along with extrinsic overpull of the finger extensors
  • Treatment
    • swan-neck deformities can often be helped with correction of the wrist flexion deformity 
 

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