Cerebral Palsy Coass

8/4/2019 Cerebral Palsy Coass

http://slidepdf.com/reader/full/cerebral-palsy-coass 1/37

CEREBRAL PALSY

COASS



08/21/11 Dept Orthpaaedic & Traumatology 2

Definition

• Difficult to define

• It is not a single disease entity

• Criteria of the symptom :• Due to a fixed, non progressive brain

lession or lessions

• The original lession must occur

prenatally, at birth, or early post natalperiod

• Primary disorder involvesmusculoskeletal system and lack of

motor control is the greater handicap•

( . , ,Tachdjian MO Tachdjian Pediatric Orthopaedics vol 3 2nd . )ed 1990




Etiology

Prenatal

• TORCH (toxoplasma, rubella, cytomegalovirus, and herpes)infection

• Metabolic disturbance (DM, Thyroid abn)• Anoxia (ruptured placenta, placental infection,

cardirespiratory disease• Chemical, alcohol, cocain• Brain abnormalities

•

•

•

( . ’ , .Canale ST Campbell s Operative Orhopaedics vol 2 10th

. )Ed 2003




Natal Causes

• Asfixia (10-20%)

• Oxytocin augmentation, cord prolaps,

• prematurity

• Low birth weight (<2268)

• Periventriculare hemorrhages

Etiology

( . ’ , .Canale ST Campbell s Operative Orhopaedics vol 2 10th . )Ed 2003




Postnatal

• Infection : Meningitis, Abses

• Head injury

• Hipoxia-iskemia

•

Etiology

( . ’ , .Canale ST Campbell s Operative Orhopaedics vol 2 10th . )Ed 2003




Classification

According to the the type of motor dysfunction

(Minear 1956)

Spasticity Athetosis

Rigidity Ataxia Tremor Mixed

•




According to the topographicaldistribution (Minear 1956)

Monoplegia. Hemiplegia.

Paraplegia. Diplegia.

Tetraplegia.•

Classification




Spastic

• Most common (70-80% of cases)

• Most amenable to surgery• Characterized by increased muscle tone and

hyperreflexia.

• Spasticity is characterized by increased muscle activitywith increasingly rapid stretch

• Increase deep tendon reflex.

• As the chlid grows muscle become shorter (contracture)

•




Athetosis Dyskinetic

• 10-20% of cases• The limb Involuntary purposeless movement. Contorted

• Two subtype : a.nontension mov describe as rotary(rotation & twisting the

limb), dystonik or chorea/spontaneous jerking motion at fingers or toe

b.tension muscle very tense so contorted motions are blocked affected muscle of face & tongue

grimacing & drooling




Classification

3. Rigidity

• Severe form of

spasticity• Usually quadriplegic




Classification

4. Ataxic • 5-10% of cases

• Involvement of the cerebellum or its pathways

• Lack of balance sensation,position sense &uncoordinated mov

Such children walk as if sailors on the rolling ship at seaWide based gait

• Poorly amenable to surgical correction;




The lession in the brain

• Cerebral cortex : spastisity

• Midbrain or base of the brain :athetosis

• Cerebelum : ataxia

• Widespread brain involvement :

mixed

Four areas




DIAGNOSIS

History

• Abnormal birth history ,looking carefully at the infant'smedical history

•

• Prematurity•

• Abnormal Developmental milestones :• Head control -3 mths (6 mths)

• Sitting independently - 6 mths (9 mths)

• Crawling - 8 mths

• Pulling to stand - 9 mths (12 mths)

• Walking -12 mths (18 mths)

•




Primitive reflexes Predictors of Walking (from 1 year of age): (Bleck 1987)

• The primitive Neck righting reflex• The asymmetrical tonic neck reflex• The symetrical tonic neck reflex

• Moro reflex• Extensor thrust• Parachute reflex• Foot placement reaction

Poor diagnosis score 2 or more (95 % accuracy)Inability sit alone after 4 y.o poor prognostic “nonwalker”

•

Assessment



• Asymmetrical tonic neck reflex—as headis turned to one side, contralateral

arm and knee flex.• B, Moro reflex—as neck is suddenly

extended, upper limbs extend awayfrom body and come together inembracing pattern.

• C, Extensor thrust reflex—as infant isheld upright under armpits, lower

extremities stiffen out straight.

• D, Neck-righting reflex—as head isturned, shoulders, trunk, pelvis, andlower extremities follow turned head.

• E, Parachute reaction—as infant issuspended at waist and suddenly

lowered forward toward table, armsand hands extend to table inprotective manner.

• F, Symmetrical tonic neck reflex—as neckis flexed, arms flex and legs extend.Opposite occurs as neck is extended.

• G, Foot placement reaction—when top of foot is stroked by underside of flatsurface infant laces foot on surface.



PRIMITIVE REFLEX• Grasp reflex elicited by

introducing the clinician’sfinger into the infant palmfrom the ulnar side flexionand grasp firmly.

•

• Moro reflex elicited by gently

lifting the infant with theclinician’s right hand under theupper thoracic spine and theleft hand under the head

drop the hand, allow suddenneck extension abduct the

upper limbs, with spreading ofthe finger, follow by an



ØAsymmetric tonic neck

reflex elicited byturning the head to

the side

extension the upper

and lower limb on

the side toward

which the head is

turned, flexion the

PRIMITIVE REFLEXPRIMITIVE REFLEX



POSTURAL REFLEX

Ø The foot-placement reaction

elicited by holding the infantunder the arms, then gentlylifting, the dorsum of thefoot or anterior surface ofthe tibia comes up against theunder side of the table.

Ø Positive picks up the

extremity as if to step uponto the table.

ØThe parachute reflex elicited byThe parachute reflex elicited by

holding the infant in the air in theholding the infant in the air in theprone position, then suddenlyprone position, then suddenlylowering.lowering.

ØPositive extend the upperPositive extend the upper

extremities and places the hands onextremities and places the hands ontable top.table top.




Gait

• Hemiplegic :

asymmetric flexedknee toe walking

• Spastic diplegia : hipflexed, adducted

(scissors gait),trunk leandsforward, knee bent,feet equinus

• Narrow walking

•

Assessment

Over 1 year




CEREBRAL PALSY Treatment

Cerebral palsy can not be cured•

•• The Goals :

- Increase the patient’s physical independence - cognitive & speech abilities - Improve a child's capabilities & quality of life

work with a team of health care professionals first toidentify a child's unique needs and impairmentsplan treatment

•




team of health care professionals




Treatment

Priorities

1.Communication

2.Activities of daily living

3.Mobility in the environment

4.Walking /ambulations




Objectives

• Maintain straight spine and levelpelvis

• Maintain located, mobile, painless

hips• Maintain mobile knees for sitting and

bracing for transfer

• Maintain plantigrade feet• Provide appropriate adaptive

equipment, incl. Wheelchairs

• Recognise and treat medicalproblems




Strategy

•

• 0-3 yrs - physiotherapy

•4-6 yrs - surgery

• 7-18 yrs - schooling and psychosocialdevelopment

• 18 yrs + - work•




Treatment of CerebralPalsy

• Psycological Consideration

• Therapeutik Drugs

• Phsysical and Occupational Therapy

• Speech Therapy

• Orthopaedic Appliances

• Surgical Manipulation

• Orthopaedic Operation• Rehabilitaion



NON OPERATIVENON PHARMACOLOGIST

• Physiotherapy

• Orthosis & Splints

• Neuromuscular ElectricalStimulations (NEMS)



Orthosis / Splints

Goals for orthotic intervention:

•

• prevention of deformity

•

• correction of soft tissue deformity

•• Control muscle tone

•



Orthosis & Splints

KAFO

Short-leg brace

Articulating AFOAFO

AbductionOrthosis




Surgery Treatment

Indication for Orthopaedic Surgery

• Inability to control a spastic deformity

• Correct fixed deformity• Correct secondary bony deformities,hip

dislocations or joint instability

( . ’ ,Solomom L et al Apley s System of Orthopaedics and Fravtures 8th




Surgery Treatment

Types of surgery include :

• Tight muscle Release• Weaks muscles Tendon

transfer

• Fixed deformities

Osteotomies or arthrodesis

( . ’Solomom L et al Apley s System of Orthopaedics and

,Fravtures 8th ,)Ed




Hoke Procedure

Heel cordlengthening




FOOT AND ANKLE DEFORMITIES

• Varus Deformities Split Posterior Tibial Tendon Transfer




FOOT AND ANKLE DEFORMITIES

Anterior advancement of tendo achilles for correction of spasticequinus deformity (Murphy Technique)



Hip Deformities

Internal RotationDeformities

• Excessive medialfemoral torsion(increasedfemoral

anteversion) isvery common inspastic CP.

• Subtrochanteric

Derotation



FOOT & ANKLE

DEFORMITIESVarus Deformities Calcaneal osteotomy (lat displacement

or dwyer)



FOOT & ANKLE

DEFORMITIESValgus deformities Calcaneal osteotomy (med displacement )

A h i




Aphorisms

• After you operate, the patient still hascerebral palsy.

• If unsure, wait.

• Avoid tying up adolescents with marginalprocedures.

• A little equinus better than calcaneus.

• A little valgus better than varus.• A little varus better than a lot of valgus.

• A little knee flexion better thanrecurvatum.

Cerebral Palsy Coass

Documents

Transcript of Cerebral Palsy Coass