Review Question - QID 219551

This patient presents with the classic wrist flexion and ulnar deviation contracture deformity seen in cerebral palsy patients. Sustainable correction for flexible deformities utilizes muscle lengthening, tendon releases, and/or tendon transfers (Answer 4).

Upper extremity contractures commonly encountered in spastic cerebral palsy include shoulder internal rotation, elbow flexion, flexion/ulnar deviation of the wrist, finger flexion, and thumb-in-palm deformity. Initial, nonoperative treatment includes routine stretching, bracing, and botulinum injections. However, many patients progress to having painful contractures recalcitrant to these conservative measures. In the setting of flexible (i.e., correctable) deformities, targeted tendon release/lengthening and/or tendon transfers can provide sustainable deformity correction, improved function, and psychosocial benefit. This patient underwent tenotomy of his FDS tendons (correction of finger flexion contractures) and FCU (correction of wrist flexion/ulnar deviation contracture) with ECU transfer to the extensor carpi radialis brevis (to improve wrist extension strength and prevent wrist deformity recurrence; Illustrations A/B).

Chaudhry and colleagues provide a comprehensive review of the various operative procedures utilized for the treatment of spastic upper extremities in children. The authors highlight the appropriateness of single-event, multilevel surgery. Further, they emphasize that surgeons/patients/families must carefully balance the benefits of contracture release and tendon transfers with their subsequent weakening effects. The authors conclude that appropriate interventions and expectation management optimize limb appearance and function while avoiding unexpected sequelae.

Van Heest and colleagues performed a prospective trial comparing tendon transfers, botulinum injections, and physical/occupational therapy to treat upper-extremity cerebral palsy deformity. They found that patients treated with tendon transfers had significantly greater improvements in functional outcomes at one year compared to the other treatment modalities alone. The authors conclude that cerebral palsy patients who are candidates for standard tendon transfers should undergo operative treatment followed by botulinum injections or routine stretching as needed.

Figure 1 demonstrates this patient’s resting wrist flexion/ulnar deviation and finger flexion contractures that worsen with attempted supination. Illustration A demonstrates an intra-operative photo of the ECU>ECRB transfer utilizing a pulvertaft weave, end-to-side technique. Illustration B demonstrates this patient’s two-week follow-up with neutral wrist positioning and improvement in function performing activities of daily living (i.e., brushing his hair). Illustration C demonstrates how to measure Volkmann’s angle; first, place the wrist into flexion, then extend the wrist while keeping the fingers extended. If extrinsic finger flexor contracture is present, it results in finger flexion when the wrist position is less than neutral. In such circumstances (i.e., higher Volkman angles), surgical correction of the wrist to a neutral or extended position will result in a clenched fist unless the extrinsic finger flexors are corrected simultaneously.

Incorrect Answers:
Answer 1: Physical therapy stretching may provide some benefit as an initial treatment option or in patients/families seeking to avoid surgery. However, performing muscle/tendon lengthening or releases provides long-term, sustainable results. Patients should still be monitored long-term for recurrences.
Answer 2: Similar to physical therapy, botulinum injections can help treat painful contractures and provide temporary functional improvement. However, tendon releases or transfers provide a longer-lasting correction.
Answer 3: An FCU tenotomy would help correct this patient’s wrist flexion/ulnar deviation contracture. However, given his 25-degree Volkmann angle, the resultant neutral wrist positioning would worsen his finger flexion contractures. Therefore, an added FDS tenotomy is required. The added ECU > ECRB transfer improves wrist extension strength and prevents wrist deformity recurrence.
Answer 5: Proximal row carpectomy shortens the wrist length to remove tension on extrinsic musculature and can be combined with flexor tendon releases to achieve a neutral wrist position in severe cases. The concomitant fusion provides long-term sustainment for deformity correction. While this is an appropriate treatment option in older patients (i.e., arthritic) or those with severe rigid contractures, it should not be the first-line option in this adolescent patient with a flexible deformity.