Cerebral palsy

Cerebral palsy is seen in 2-3/1000 live births. Cerebral palsy can be caused due to injury to immature brain either in mother’s womb, during birth or after birth. Maternal infections like rubella, herpes, cytomegalovirus toxolplasmosis increases the risk of cerebral palsy. Hypoxia occurring during birth or after birth can also lead to cerebral palsy. Preterm children and low birth weight (<1500 gram) have increased risk. Injury to brain, meningitis and encephalitis also leads to cerebral palsy. Depending on level of involvement it is divided as

1. Monoplegia: involvement of one limb
2. Hemiplegia: involvement of one side of the body
3. Diplegia: involvement of both lower limbs with minimal involvement of the upper limbs.
4. Paraplegia: implies no upper limb involvement only lower limb involvement
5. Triplegia: involvement of one side of the body, as in hemiplegia, combined with involvement of the contralateral lower limb. The lower limb involvement is always asymmetrical.
6. Quadriplegia: involvement of all four limbs and the trunk

It can also be divided as spastic group (85%) who do very well with injection Botox and Non spastic group which includes dyskinetic, ataxic, hypotoic and mixed. A normal child usually shows neck holding by 3 months, sits by 6 months and starts walking by 15 months. Any child who shows a delay in developmental milestones and persistence of reflex movements should be referred to a physiotherapist. Physiotherapy forms the mainstay of treatment in cerebral palsy and other problems like convulsions, squint, speech and hearing problems should be diagnosed and treated. The role of an Orthopaedic surgeon comes once the child is a little older and abnormal muscle tone is impeding movements. Certain medicines decrease abnormal movements and abnormal tone but it has its own side effects. A recent development has been the use of botox in cerebral palsy. This causes temporary relaxation of muscles and improves the gait of patients. The injection is to be given locally in involved muscles and it has no side effects. The action of this medicine however decreases after 6 months and hence it may have to be repeated. The duration of action can be enhanced by use of splints and physiotherapy. Surgery is preferred after 8 years. Muscles are lengthened using ‘Z’ technique. These children also have high risk of hip dislocation, increased curvature of back and hand problems which need special treatment. The management of cerebral palsy is thus prolonged and they need multi speciality care. Best results however can be obtained if treatment is started early and with regular followup and proper treatment these children can be made independent in life.

Orthopedic surgical intervention

The goals of orthopaedic surgery in a non ambulatory patient are well reduced stable hips and straight spine with good hand function. The goals of orthopaedic surgery in a walking child are stable plantigrade feet, straight knees and stable hips. The problems that frequently need treatment are

1) Foot problems.Valgus feet (outward turned feet) are common. They happen because of tight tendoachills and midfoot break. It often requires calcaneal lengthening or fusion of foot bones. Varus deformity (feet turned inward) may also develop because of spastic tibialis anterior and posterior which may require botulinum toxin injection, lengthening or transfer.

Valgus Feet
Varus foot

2) Tendoachills (heel cord) contracture. This is the commonest muscle that is involved. Botulinum toxin A is usually injected in this muscle. If the involvement is very severe then surgical lengthening is performed.

before surgery
after surgery

3) Knee flexion deformity: The child may have crouch gait because of additional tendoachillis weakness. It is because of tight hamstring muscles and weak quadriceps. Often hamstring lengthening and rectus transfer is required. Photo3a before surgery.

before surgery
after surgery

4) Dislocation of hip joint. It is very common in non-walkers and hence radiographs of hips must be performed every year. In early cases hip adductor muscle release may be sufficient but in severe cases bony hip surgery is required. Photo 4a clinical picture showing scissoring. Photo 4b clinical photo after surgery. Photo 4c radiograph before surgery showing dislocation of left hip.

clinical picture showing scissoring
clinical photo after surgery
radiograph before surgery showing dislocation of left hip
radiograph after surgery showing relocated hip

5) Scoliosis (curvature of spine). This is seen mainly in quadriplegics. In early cases a brace can be given but later surgery may be required for correction of the curve.

Showing curvature of spine

6) Upper limb. Finger flexion, thumb adduction, elbow flexion and shoulder adduction are the commonest deformities, spastic muscle can be controlled with Botulinum Toxin A while contracted muscles need to be released or transferred. Wrist fusion may also be required in severe deformity.

Showing flexion of wrist and fingers