Updated: 12/18/2019

Cerebral Palsy - Upper Extremity Disorders

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  • 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
  • Phyiscal exam
    • Assessing a wrist flexion contracture is done by extending all the fingers with the wrist in maximal flexion, then extending the wrist. The degree to which the wrist cannot fully extend is the Volkmann angle. 
  • 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 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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