Pediatrics: Cerebral Palsy

Definition – A group of disorders of the development of movement and posture, causing activity limitations that are attributed to a nonprogressive disturbance that has occurred in the developing fetal or infant brain.¹

EPIDEMIOLOGY

Affects 3.6 per 1,000 school-aged children
2/1,000 live births for term infants
5/1,000 live births for 33 to 36 weeks gestation
30/1,000 live births <28 weeks

Risk factors include prenatal, perinatal, and postnatal infection, stroke, toxins, neonatal encephalopathy, complications of prematurity (SGA, BW < 800 g, IVH), maternal chorioamnionitis, fever during labor, coagulopathy or bleeding, placental infarction, thyroid disease, hyperbilirubinemia, and trauma.

The greatest risk factor is prematurity; neonatal encephalopathy is the best predictor of CP in term infants.

CLASSIFICATION

Movement Type

Spastic (70% to 85%)
Dyskinetic
Hypotonic
Ataxic
Mixed

Anatomic Distribution

Hemiparesis (UEx > LEx, one side of body)
Diparesis (LEx > UEx)
Quadriparesis (entire body)

GROSS MOTOR FUNCTION CLASSIFICATION SYSTEM

Level 1. Walks indoors and outdoors and climbs stairs without limitations

Level 2. Walks indoors and outdoors, climbs stairs with a rail, and has limitations walking on uneven surfaces and inclines

Level 3. Walks indoors and outdoors on a level surface with an assistive device; may climb stairs with a rail and use a manual wheelchair

Level 4. May walk short distances with assistive device but may rely on power mobility

Level 5. Self-mobility severely limited

>80% have abnormal neuroimaging, most often PVL following IVH in premature infants, focal cortical infarcts secondary to MCA stroke
in hemiparesis, basal ganglia and thalamic lesions in dystonic CP, brain malformations, and generalized encephalomalacia in spastic quadriparesis.

MRI more likely to show an abnormality compared with CT ²

Persistence of primitive reflexes after 6 months, asymmetry or obligatory response

Early handedness/failure to use the involved hand

Early rolling (from tone)

ASSOCIATED DISORDERS

Sensory impairments, especially in hemiparesis
Hearing, visual, cognitive, psychological, oralmotor, nutritional, genitourinary, respiratory, bone mineral density, and dental impairments
Seizures in 15% to 55%³
Hip dysplasia and dislocation
Spine – kyphosis, lordosis, and scoliosis
Spasticity and contractures
Gait impairment: scissoring due to adductor tone, anteversion – intoeing, and psoas and hamstring tightness – crouch gait. Stiff knee ankle PF tone toe gait

TREATMENT

Therapy: no clear evidence for any particular approach
Stretching, strengthening, tone management, and functional training
Spasticity management
- Oral medications
- Chemical neurolysis
- Intrathecal baclofen
- Selective posterior rhizotomy
  - Sectioning of a portion of abnormal L2-S1 sensory nerve rootlets to reduce excitatory input
  - Favorable in patients aged 3 to 8 years who have selective motor control and functional strength and lack significant contractures
  - Negative effects: hypotonia usually transient, weakness, bladder dysfunction (usually transient), spine deformity including spondylolysis/listhesis, and hip dislocation
- Botulinum toxin: different dosing guidelines for children
  - Reported distant side effects in children with CP
Orthopedic surgery: lengthening, transfers, and osteotomy

CONGENITAL BRACHIAL PLEXUS PALSY

Epidemiology

1 to 2/1,000 live births (United States)

Risk Factors

Increase in birth weight
Shoulder dystocia
Traumatic delivery
Breech
Multiparous

Clinical Presentation

“Waiter’s tip” (shoulder irritation and adduction, elbow extension and pronation, wrist flexion) – Erb palsy – C5, 6, 7 – 80%
Klumpke C7, 8, T1, rare to occur exclusively
Spontaneous recovery in 50% to 90%

Associated Injuries