Upper Extremity Surgical Intervention in Patients with Cerebral Palsy: Musculotendinous Procedures

Chapter 17 Upper Extremity Surgical Intervention in Patients with Cerebral Palsy


Musculotendinous Procedures



Kara Gallagher, MS, OTR/L, CHT, Jennifer P. Lewin, OTR/L


Cerebral palsy is a general term used to describe a condition characterized by irreversible brain damage and associated neuromotor dysfunction in the developing child. Cerebral palsy results from an injury to the brain before birth, during birth, or during the first 2 to 3 years of childhood. The extent of involvement of motor function, sensibility, and intelligence is highly variable. Cerebral palsy occurs in an estimated 0.6 to 2.5 of 1000 live births. It occurs in an estimated 5.2 of 1000 live births in the United States and in approximately 1 of 7 children worldwide. The number of cases is difficult to determine, because there is no system for monitoring the occurrence of cerebral palsy in the United States.


Several systems are used to classify cerebral palsy. The most common systems use the number of involved extremities and type of muscle tone. The main terms used to describe the extent of involved extremities include monoplegia (one limb), hemiplegia (one arm, one leg), quadriplegia (all limbs), and diplegia (quadriplegia with upper limb involvement milder than lower limbs). Terms used to describe muscle tone are spasticity (high tone), flaccidity (markedly low tone), athetosis (mixed tone), and ataxia. Ataxia is associated with primitive movement patterns and decreased coordination, such as dysmetria, dysdiadochokinesia, tremors at rest, and balance. Spastic involvement of a muscle (i.e., agonist) often pairs with a weak antagonistic muscle, which leads to deformity in the direction of the agonist.


Cerebral palsy is a static, nonprogressive condition, although abnormal movement patterns and imbalanced muscle tone, combined with the effects of gravity and normal growth, may cause the child to develop contractures and deformities. As a result, function becomes increasingly impaired. Upper extremity reconstructive surgery in the patient with cerebral palsy improves function and prevents further deformity. The goals of surgery are to correct deformity, rebalance the muscles to increase functional use, and improve hygiene and appearance. Rehabilitation following surgery is essential to facilitate active use of the muscles and integrate the upper extremity into functional activity. The following guideline describes common surgical reconstructive procedures and the preoperative and postoperative therapeutic interventions.



Surgical Overview



• The typical pattern of deformity in the spastic upper extremity is shoulder adduction and internal rotation, elbow flexion, forearm pronation, wrist flexion, finger flexion, and thumb flexion. The pattern of deformity is evident by the time the child reaches the age of 3.

• The goals of upper extremity reconstructive surgery are to correct these patterns and prevent further impairment.

• It is imperative that therapists, patients, and caregivers appreciate that surgery can augment function, yet rarely provides restoration of a normal arm.

• The surgeon establishes a realistic operative plan, based on a thorough physical examination, videotaped motion analysis, and, occasionally, a dynamic electromyography (EMG) test, to meet the patient’s functional goals.

• To rebalance agonistic and antagonistic muscles, the agonist is released and the antagonist is augmented through muscle transfers.

• Muscular release can take several forms, including release of the origin of the muscle, release of the insertion of the muscle, and lengthening of the muscle.

• A spastic muscle often provides a good choice for transfer to a weak muscle.

• Box 17-1 is a summary of the common procedures performed to correct upper extremity deformities in the patient with cerebral palsy.


Box 17-1 Summary of Upper Extremity Surgical Reconstruction in the Patient with Cerebral Palsy



• Shoulder internal rotation
1 Release of subscapularis

• Shoulder external rotation
1 Release of supraspinatus, infraspinatus, and teres minor

• Elbow flexion
1 Release of biceps, brachialis, and brachioradialis

2 Flexor-pronator slide

• Forearm pronation
1 Release of PQ and flexor aponeurosis

2 PT rerouting

3 Flexor-pronator slide

• Wrist flexion
1 Wrist arthrodesis

2 Muscle transfers for wrist and digital extension
– ECU to ECRB

– FCU to ECRB

– PT to ECRB

– BR to ECRB

– FCU to EDC

3 Wrist flexor tendon tightness
– Tendon lengthening of FCR

– Tendon lengthening of FCU

4 Volar wrist capsule contracture
– Proximal row carpectomy

– Wedge resection arthrodesis

• Digital flexion tightness
1 Flexor-pronator slide

2 Fractional lengthening of FDS and/or FDP

3 Z-lengthening of FDS and FDP

4 Transfer of FDS to FDP (superficialis to profundus or STP)

• Intrinsic muscle spasticity
1 Interosseous muscle origin slide

2 Ulnar motor neurectomy

3 Central slip tenotomy (for swan-neck deformity)

4 FDS tenodesis (for swan-neck deformity)

• Thumb-in-palm deformity
1 Web space release

2 Release or lengthening of first dorsal interosseous, AP, FPB, and/or FPL

3 EPL rerouting

4 Transfer of BR to EPB

5 Thumb MP joint capsulodesis

AP, adductor pollicis; BR, brachioradialis; ECRB, extensor carpi radialis brevis; ECU, extensor carpi ulnaris; EDC, extensor digitorum communis; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; FPB, flexor pollicis brevis; FPL, flexor pollicis longus; MP, metacarpophalangeal; PQ, pronator quadratus; PT, pronator teres.



Shoulder



• The shoulder postures in adduction and internal rotation. This position is caused by spasm or contracture of the subscapularis and pectoralis major.
1 An adducted and internally rotated shoulder prevents the patient from reaching overhead and out to the side.

2 With the arm in this position, tasks such as bathing and dressing are difficult to perform.

3 Hygiene within the axilla may also be a problem in more severe cases.

4 A lengthening or release of the subscapularis is performed to correct the adduction and internal rotation deformity.

• Occasionally, a patient postures in external rotation and abduction of the shoulder.
1 This position makes it difficult to perform activities in midline.

2 A release of the supraspinatus, infraspinatus, and teres minor can place the shoulder joint in a more functional position, permitting midline activities.

• Glenohumeral dislocation can occur in athetoid cerebral palsy and is treated surgically with a glenohumeral arthrodesis.


Elbow



• The elbow typically postures at rest in some degree of flexion. The degree of flexion increases with associated reactions caused by spastic contracture of any or all of the muscles of the elbow (biceps, brachialis, and brachioradialis [BR]).

• Long-standing deformities may result in soft tissue contractures and skin breakdown in the antecubital fossa.

• Elbow flexion contractures inhibit the patient’s ability to reach forward for objects and effectively perform bimanual activities, such as placing an object on a table with two hands.

• Elbow flexion deformities, in a functional upper extremity, that are greater than 45 degrees at rest, with activity, or during ambulation benefit from surgical correction.

• Elbow flexion deformities, in the nonfunctional upper extremity, that are greater than 100 degrees benefit from surgery to improve functional transfers and hygiene.

• Elbow flexion deformities between 45 and 100 degrees in the nonfunctional elbow may be surgically addressed only if cosmesis is a concern.

• Surgery to correct an elbow flexion deformity includes a musculocutaneous neurectomy, a flexor-pronator slide, or lengthening of the elbow flexor muscles.

• The most direct method to address an elbow flexion deformity is via fractional lengthening of the biceps, brachialis, and brachioradialis (BR). The patient can anticipate a gain of 40 degrees of elbow extension with minimal loss of flexion or functional power.

• Musculocutaneous neurectomy is contraindicated for a functional upper extremity because active control of the biceps and brachialis is required for elbow flexion. It is also contraindicated in situations where muscle contracture exists.


Forearm



• Spasticity in the pronator teres (PT) and pronator quadratus (PQ) creates a pronation deformity.
1 This prevents the patient from being able to bring the palms together for tasks requiring bimanual manipulation of objects.

2 Furthermore, the pronated forearm cannot be used effectively to carry large objects because of the palm-down position of the hand.

• Procedures to correct pronation deformity include a flexor pronator slide, release of the pronator quadratus, pronator teres (PT) and flexor aponeurosis, and a pronator rerouting.
1 A flexor-pronator slide involves the release of the PT at its origin, whereas a pronator tenotomy, or rerouting, involves the release of the PT at its insertion.

2 When active pronation is present in the absence of active supination, a PT rerouting provides active supination.

3 When both active supination and pronation are lacking, a pronator teres rerouting suspends the forearm in a neutral position, using a tenodesis effect.


Wrist and Digits: Extrinsic Musculature



• The wrist often postures in flexion with fisted digits, which is a result of weak wrist and digital extensors, contracted or spastic wrist and digital flexor tendons, or a volar wrist capsular contracture.
1 The flexed position interferes with the normal tenodesis balance between the wrist and digital flexor and extensor muscles, thereby impairing grasp and release of everyday objects.
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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Upper Extremity Surgical Intervention in Patients with Cerebral Palsy: Musculotendinous Procedures

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