Palsy


Prenatal

Perinatal

Postnatal (0–2 years)

Prematurity (gestational age less than 36 weeks)

Prolonged and difficult labor

CNS infection (encephalitis, meningitis)

Low birth weight (less than 2,500 g)

Premature rupture of membranes

Hypoxia

Maternal epilepsy

Presentation anomalies

Seizures

Hyperthyroidism

Vaginal bleeding at the time of admission for labor

Coagulopathies

Infections (TORCH)

Bradycardia

Neonatal hyperbilirubinemia

Bleeding in the third trimester

Hypoxia

Incompetent cervix

Severe toxemia, eclampsia

Hyperthyroidism

Drug abuse

Trauma

Multiple pregnancies

Placental insufficiency





Classification





  • Clinical classification






















    Tonus
    Lesion site

    Spastic
    Cortex

    Dyskinetic
    Basal ganglia – extrapyramidal system

    Hypotonic/ataxic
    Cerebellum

    Mixed
    Diffuse

    The importance of the classification is that, in general, surgical results are more reliable in patients with spasticity compared with patients with dystonia.


  • Anatomical classification




























    Location
    Description

    Hemiplegia
    Upper and lower extremity on one side of the body

    Diplegia
    Four extremities, legs more affected than the arms

    Quadriplegia
    Four extremities plus the trunk, neck, and face

    Triplegia
    Both lower extremities and one upper extremity

    Monoplegia
    One extremity (rare)

    Double hemiplegia
    Four extremities, arms more affected than the legs


  • Functional classification – gross motor function classification system



    • Walks independently and speed, balance, and coordination reduced


    • Walks without assistive devices but limitations in community


    • Walks with assistive devices


    • Transported or uses powered mobility


    • Severely limited, dependent on wheelchair


Investigations and Clinical Assessment





  • Obtain baseline hip and spine radiographs. It is necessary to monitor hip instability. Reimer’s index which is the percentage of femoral head coverage by the acetabulum (Fig. 1).

    A314795_1_En_21_Fig1_HTML.gif


    Fig. 1
    Reimer’s migration index

In a normal hip, the entire femoral head is located medial to the lateral margin of the acetabulum. In a spastic hip, the lateral migration is measured as AC/ AB ×100.



  • Cranial magnetic resonance imaging (MRI) – useful for diagnosing lesions in the white matter.


  • Electroencephalogram – useful for diagnosis and follow-up of seizure disorders.


  • The typical clinical picture is established towards the age of 1 year. Primitive reflexes persist, and advanced postural reactions do not appear in the child with CP.


  • Musculoskeletal examination includes evaluation of joint range of motion (ROM), deformities, contractures, balance, posture, sitting, and gait.

Assessing Lower Extremities



  • Thomas test for hip flexion contracture.


  • Range of abduction with hip in flexion and extension. If abduction is limited when the hips are extended but better when they are flexed, then adduction contracture is caused by gracilis and medial hamstring spasticity.


  • The Ely test shows rectus femoris tightness.


  • Test hip rotation in prone position with the knee in flexion. Excessive internal rotation suggests persistent femoral anteversion.


  • Measure the popliteal angle to test for hamstring contracture.


  • Use the Silfverskiöld test to assess triceps surae tightness.


  • Examine tibial torsion with the patient in the prone position. Evaluate the thigh-foot angle with the knee flexed to 90°.


  • A spastic posterior tibialis muscle causes hindfoot varus.


  • A spastic peroneus or gastrocnemius muscle may cause a valgus deformity.

Assessing Upper Extremities



  • Most commonly these patients possess internal rotation contractures at the shoulder, flexion contractures about the elbow, pronation contractures of the forearm, flexion contractures at the wrist, and thumb-in-palm deformity.


  • A higher level of use and recognition of the affected upper extremity or extremities leads to more reliable surgical outcomes.


  • Commonly used assessment tools include the Manual Ability Classification System, the House functional classification system of upper extremity use (see Table 2), the Zancolli classification system of voluntary grasp and release patterns of the upper extremity (Table 3), and modified House classification for thumb deformities (Table 4).


    Table 2
    House functional classification for cerebral palsy
















































    Grade
    Designation
    Activity level

    0
    Does not use
    Does not use

    1
    Poor passive assist
    Uses as stabilizing weight only

    2
    Fair passive assist
    Can hold on to object placed in hand

    3
    Good passive assist
    Can hold on to object and stabilize it for use by the other hand

    4
    Poor active assist
    Can actively grasp object and hold it weakly

    5
    Fair active assist
    Can actively grasp object and stabilize it well

    6
    Good active assist
    Can actively grasp an object and then manipulate it against other hand

    7
    Spontaneous use, partial
    Can perform bimanual activities easily and occasionally uses the hand spontaneously

    8
    Spontaneous use, complete
    Uses hand completely independently without reference to the other hand



    Table 3
    Zancolli classification of active finger and wrist extension















    Level
    Designation
    Description

    1
    Minimal flexion spasticity

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    Sep 18, 2016 | Posted by in ORTHOPEDIC | Comments Off on Palsy

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