Download Cerebral Palsy

Neuromuscular conditions
Cerebral Palsy
Dr. Mohammed M. Zamzam
Associate Professor & Consultant
Pediatric Orthopedic Surgeon
Definition
Non progressive, cerebral damage
occurring before brain maturation (1-2 years)
resulting in muscle weakness, spasticity
and other symptoms
Incidence
0.5-2/1000 in premature deliveries
Causes

Prenatal :
Maternal disease/ Toxemia
Cerebral deformity/ Hemorrhage
Inborn error of metabolism

Perinatal :
Labour/ Respiratory complications
Perinatal infections
Causes
 Postnatal
:
Infection
Violence
Convulsion
Classification
Topographic Classification
 Diplegia
: (Arms & Legs much more in
legs), most patients eventually walk
 Tetraplegia
: (Arms & Legs & Trunk)
High mortality rate, most pts unable to
walk. IQ is low
Classification
Topographic Classification
 Hemiplegia
: Upper & lower limbs on
one side (upper more than lower limbs),
with spasticity, patients eventually walks
 Bilateral
Hemiplegia
 Paraplegia (Legs)
 Monoplegia
 Triplegia
Classification
Physiological Classification
Spastic :
 Commonest
50-60%
 Most important for the Orthopedic Surgeon
 Increased muscle tone (Jack knife spasticity)
 Slow restricted movements
 Increased reflexes
 Babinski +ve
Classification
Physiological Classification
Athetosis :
 20-25%
?
Kernicterus
 Involuntary, uncontrolled slow movement
 Normal reflexes
 +/- Muscle rigidity or tremors
 NOT FOR SURGERY
Classification
Physiological Classification
Ataxia :
 1-5%
 Inability
to control /coordinate movement
when they start
 Intention tremor
 Nystagmus / unbalanced gait
 NOT FOR SURGERY
Classification
Physiological Classification
Rigidity :
 5-7
%
 Lead pipe rigidity
Mixed type :
A combination of spasticity and athetosis
with whole body involvement
Presentation
3 year- old boy
Presented with
Inability to stand
or walk
Deformities
Upper limb :
 Shoulder
adduction/internal rotation
 Elbow
flexion
 Forearm
pronation
 Wrist and fingers flexion
Deformities
Lower limb :
 Hip
adduction/flexion/internal rotation
 Knee flexion
 Feet
equinus / varus or valgus
 Gait
scissoring
Spine :
kyphoscoliosis
The two most important x-rays during follow up
Management
Aim of treatment :
 AS
INDEPENDENT AS POSSIBLE
 Avoid pain (hip arthritis)
 Maintain sitting posture
 Maintain spinal stability
 Social benefit
Management
Multidisciplinary :





Orthotics before and after surgery
Physiotherapy/Occupational therapy
Orthopedic Surgery
Neurosurgery/ Pediatric Neurology
Speech therapy
Management
 History
 Exam
 Investigation
 Treatment
The degree of retardation is of great
importance in treatment planning
Management
Exercise :






Start early (1st month) when suspected
Qualified Physiotherapist/ PARENTS
Prevent contractures
Develop coordination
Mental exercise
Use Orthotics/POP/Casts if needed
Management
Surgery :
 Best
in Spastic Hemiplegics and
severe deformities
 Contraindicated
in Athetoid & Ataxic
Management
Goal of Surgery :





Decrease spasm
Release of contractures
Correct deformities
Rebalance muscles
Stabilize flail joints
Management
Options of Surgery :







Neurectomy
Tenotomy
Tenoplasty
Muscle lengthening (Recession)
Tendon Transfer
Bony surgery Osteotomy/Fusion
Spinal surgery
Management
Intramuscular botulinum toxin:
 Temporarily
 It
reduces dynamic spasticity
is thought that its use promotes normal
muscle growth and avoids the development
of soft tissue contracture