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: 

Quadriplegia: involvement of all four limbs and the trunk

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:-

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.

Varus foot
Varus foot
Valgus Feet
Valgus Feet

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
before surgery
after surgery
after surgery

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.

before surgery
before surgery
after surgery

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

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

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
Showing flexion of wrist and fingers