Early Motion Regimen Following Surgical Treatment of Cerebral Palsy Affecting The Upper

Extremity. The Leeds ProtocolMr J Wiper1, Mr K G Chan2, Mr W Saeed1, Mrs J Burdon1, Miss M Dolan1

1St James’s University Hospital, Leeds, United Kingdom2RIPAS Hospital, BSB, Brunei

SummaryThe Leeds Cerebral Palsy Clinic over a 5.5 year period provides surgical treatment through specialist multidisciplinary team approach to 46 patients, the majority suffering from cerebral palsy. These patients underwent surgical treatment of elbow, wrist, finger and thumb contractures and deformities. All transfers with the exception of biceps lengthening were started on an early motion protocol on the first postoperative day. Out of 110 transfers in 46 patients there was one case of tendon rupture remote from the site of tenorraphy as a result of non-compliance. Early mobilisation did not result in permanent complications and is safe for the procedures used in this series.

Introduction Post operative therapy is vital to the successful outcome of reconstructive surgery to the musculoskeletal system. In the Leeds Cerebral Palsy Clinic, surgical treatment to the upper limb deformity is provided through specialist multidisciplinary approach and the whole process is summarised below:

Method and Material

• Prospective review of all procedures carried out by the senior author for the treatment of upper extremity deformities.

Results

47 patients, 121 transfers. 2 pronator teres re-routing immobilised as stand-alone procedures excluded. One patient, 2 separate surgical procedures (30/06/99 & 14/08/00), 4 transfers (FCU to EPL, PL to EPB, FDS3 to EDC, FDS4 to ECRB) immobilized post op (? prior to start of Mr Saeed’s practice) and excluded, 4 transfers (2 transfers each in 2 patients) were redo of the same transfers and excluded.

46 patients, 111 transfers, 13 complications (8 patients) (Table 1)

Most common complication is a sequalae of FDS harvest which is swan neck deformity in the respective finger

One rupture of EDC following FDS4 to EDC transfer with matev weave of EDC one month following surgery

References1. Krotoski & Tomancik (1987) The repeatability of testing with Semmes- Weinstein monofilaments. The Journal of Hand Surgery Vol 12A. No. 1:155-161.2. Dellon (1981) Evaluation of sensibility and re-education of sensation in the hand. Williams & Wilkins. Baltimore.3. House et al (1981) A dynamic approach to the thumb in palm deformity in cerebral palsy. The Journal of Bone and Joint Surgery Vol. 63 – A, No. 2:216 – 225. 4. Pinzur M.S. (1991) Flexor origin release and functional prehension in adult spastic hand deformity. The journal of Hand Surgery Vol. 16B. No.2:133-136.5. Germann G. (2001) Early dynamic motion versus postoperative immobilisation in patients with extensor indicis propius transfer to restore thumb extension: A prospective randomised study. The

Journal of Hand Surgery Vol 26A. No. 6:1111 – 11156. Brüner S. (2003) Dynamic splinting after extensor tendon repair in zones V to VII. Journal of Hand Surgery. Vol 28B No. 3:224-7

Discussion• Early mobilisation in our series resulted in only one post op rupture in our series. The patient is a male adult with mild

severity of cerebral palsy who has good power and moderate voluntary control prior to surgery.• This low incidence may be attributed to:

1. CP as a group has weaker muscles and poorer motor control2. Pulvertaft tendon weave is strong and no rupture was reported in a series of 10 patients undergoing extensor indicis propius tranfer for thumb

extension with early dynamic motion5

3. Simultaneous release of flexors (weakened extrinsic flexion force) and transferred flexors to power extensors (weakened intrinsic flexion), likely to result in synergistic weakening of forces acting to disrupt the tendon weave.

• Advantages of early mobilisation following tendon repair are well validated5,6 and our patients also benefit from:1. Earlier commencement of rehabilitation and relearning of new function thus shortening of rehabilitation time2. Reduce potential risk of tendon adhesions to surrounding tissues and hence reduce need of tenolysis

Follow up as per individual needs

Farication of Thermoplastic splint

Leeds protocol for early motion post tendon transfer performed at the wrist, fingers or thumb:

1st day Post Op Commence

•passive/active exercises

•Wrist extension / flexionDigit extension / flexion concentrating on MCP joints +/- Thumb

•1st Web Stretches

•Opposition to neutral

Inpatient DischargeDecided by MDT, dependent on:•Pain Control•Wound condition•Pt / parent or carer independent with splint and exercise regime•Compliance•Distance from home to hospital

Splint modifications when required (usually removed by six

weeks post op)

Physio weekly (up to 3 times per week) as assessed by therapist

Full functional assessment at one year post op

Post op Therapy Aims•Gain maximum compliance from patient / parent or carer•Maintain full passive range of movement as achieved in theatre•Initiate normal movement patterns

Pre Op Therapy Aims

Identification of patient expectation Awareness of psychosocial needs Assessment of current functional ability

Full functional assessment to include: •Summary of functional abilities including: social/work/education/hobbies

•Patient goals including hygiene/cosmetic/function

•Resting position of arm/hand

•Active ROM/ability to hold when placed passively into a position

•Sensation1

•Stereognosis

•Grip/pinch

•Dexterity2

•Pattern of hand use

•Validated grading systems used:•Hand placement4

•Thumb in palm deformity3

•Volunatary Motor Capacity4

Clinic consultation with patient / parent / consultant / therapist to plan future management

O.T Pre Op assessment carried out

Assess for provision of splint

Prioritised referral from consultant for Pre Op assessment

Inclusion Criteria

• Primary operations consisting of all kinds of tendon transfers and re-routing of Pronator Teres tendon

Exclusion Criteria

• Patients who has contractures as a result of cerebrovascular stroke are excluded

• Patients who did not undergo early mobilisation following surgery for whatever reason

ConclusionEarly mobilisation is safe for procedures and in this group is not associated with high rupture rate or permanent complication.

Procedure Number Complication

Pronator Teres Re-routing 18  

FDS3 to EDC 212 swan neck, 1* over correction with wrist in fixed extension of 60 degrees, 1 redo ? Why

FCR to ECRB 17 1 over correction, 1 weak post op due to poor physio compliance

FCU to ECRB 121* over correction with wrist in fixed extension of 60 degrees, 1 redo ? Why

FDS4 to EDC 8 1 adhesion with poor pull through, 1 rupture of tendon

FDS3 to ECRB 5  

FDS4 to ECRB 3 1 swan neck

FDS2 to ECRL 2  

FDS3 to ECRL 2  

FDS3 to opponens plasty 2  

FDS4 to EPL 2  

PL to EPB 1  

ECRL to ECU 1  

ECU to ECRL 1  

FCR to EDC 1  

FCU to ECRL&B 1  

FCU to ECRL 1  

FDS2 to APL 1 Re route ? Why

FDS3 to ECRL&B 1  

FDS3 to FPL 1  

FDS4 to EI & EDC 1  

FDS4 to EPB 1  

FDS4&5 to APL 1  

FDS5 to EPB 1 Re route ? Why

FDS2 to ECRL&B 1 1 swan neck

FDS2 to EDC 1  

FDS4 to APL 1  

Pl to APL 1  

PL to EPL, EPB & APL 1  

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