CP

Talking the talk

• CP is a complex problem that effect the cognition, motor and sensory function of the patient. This require a comprehensive treatment and a MDT approach. I will take a detailed history and examine the patient to establish the level of function, type of CP, pattern of involvement and walking potential. I will specifically look for spasticity and deformities associated with spasticity

Walking potential

GMFCS

• I: walks unrestricted
• II: restricted walking with out aid
• III: Restricted walking with aid
• IV: Wheel chair bound with good head control
• V: Wheel chair bound with out head control

Permanent non progressive motor disorder due to damage in the brain before birth or with in 2 years of life

Classification

• Physiolgic
  • Spastic
  • athetoid: Basal ganglia
  • Ataxic: Brain stem
  • Mixed
• Anatomic
  • Mono
  • Diplegia
  • Hemiplegia
  • tetraplegia

Cause

• Prenatal
  • Infections :TORCH
  • Alcohol
  • Smoking
• Perinatal
  • Prematurity
• Postnatal
  • Trauma
  • tumor
  • infection

Problems

• Cognitive
• Motor
  • Spasticity
  • weakness
  • lack of coordination
• Sensory

What Orthopaedic surgeon can offer

• Can address only spasticity and deformities related to spasticity
• Dynamic contracture
• Fixed contracture
• Fixed contracture with bony changes

Lower limb and spine

• Scoliosis
• Hip subluxation and dislocation
  • Migration index
• Knee flexion deformity
  • Hamstring
• Equinous
  • Gastro-solus
• Equinovarus
  • TPost
• Equinovalgus
  • Peroneals
• Crouch gait: Hip and knee flexed with ankle dorsiflexed
  • Iliopsoas, hamstring or both contracture
  • Ach tendon lengthening

Upperlimb

• Flexion deformity of hand and fingers

Scissoring

• Due to adductor spasticity
• Ankle is in plantar flexion

Philosophy

• Shark attack SEMLS
• Successive procedures, Birthday syndrome

Hip in CP

• Hip at risk: migration index >15, <40
  • Monitor
  • adductor tenotomy
• Subluxated hip:
  • 40-60: Likely to proceed to dislocation

  • 60: require urgent intervention

• Dislocated hip
  • U/L
  • B/L

Treatment options

• Preventive
  • Adductor release
  • Psoas release
• Reconstructive
  • Femoral shortening, versioning and derogation osteotomy
  • Acetabular osteotomy
• Salvage
  • PSO
  • Proximal resection

GMFCS IV and V

• High chance of hip dislocation
• NICE guideline advices screening at 3 years and then yearly
• Aim is to get b/l symmetrical hip and to avoid pelvic tilt
• U/L subluxation/dislocation require B/L procedure
  • Treating one side only removes the split to other side and draws that side out
  • Causes pelvic tilt and progressive scoliosis

Knee

• Popliteal angle
  • 135 in ambulatory
  • 90-100 in non ambulatory
• Hamstring lengthening and address co-spasticity of quadriceps