Management of the Upper Limb in Children with Cerebral Palsy

Prof P McArthur FRCS(Plast) PhDConsultant in Congenital Hand and Upper Limb SurgeryDepartment of Plastic SurgeryRoyal Liverpool Children's HospitalAlder HeyLiverpool

Introduction

Why Upper limb?

Which Botulinum Toxin?

Why Ultrasound?

Technique Sonography guided

injection of Botulinum toxin

Multilevel, multisite

Dose range per child used 4 to 20 units/Kg

Visualization of muscle groups?

Visualization of muscle groupsPL

FCRPT

The Multidisciplinary Team

The Family and Child

Hospital Physiotherapist

Hospital Occupational Therapists

Consultant Paediatric Neurologist

Consultant Upper Limb Surgeon

Consultant Lower Limb Surgeon

Community Physiotherapists

Community Occupational Therapists

Specialist Children's Hospital

Post Injection Management

Physiotherapy – Stretch

Physiotherapy – Strengthen Agonists

Splintage

Why the controversy?

Very little level 1 evidence Variation in post injection regimes

Inherently heterogeneous patient group

Difficulty in establishing treatment goals

Our Experience

41 patients 2004 – 2008

M:F ratio, 15:26

Mean age at first injection 11 years (range 3 – 16 yrs)

9 Bilateral Upper Limb injections

Treatment Patterns

14/41 Required 2 TreatmentsMean time to reinjection

8 months (range 3-16 months)

3/41 Required 3 Treatments

Mean time to reinjection 10 months (range 5-15 months)

Outcomes

More reliable targeting of treatment due to toxin used and method of disposition

“Soft” outcome measures: Better posture Better hygiene

Better function

Functional Ability

ABILHAND-Kids questionnaire 21 tasks Bimanual ability assessment Discriminators of difficulty

Base line assessment of function

Goal Attainment Individualized outcome markers

Functionally relevant

Goal Attainment Scaling

Summary

Ultrasound guided treatment allows precise disposition of toxin to desired site

Botox is the preparation of choice

A multi disciplinary approach is required to maximize gains

High level supporting evidence is elusive

Individual goals for each child should be identified

Surgical Strategies

Indications

Pain

Failure of Toxin Therapy

Established Contractures

Hygiene / Dressing / Transfer

Indications

FUNCTION

Principles

Lengthen Tendon

vs

Shorten Skeleton

Surgical Options

Tendon Transfer Lengthening Release Tightening

Skin Procedures

Bone / Joint Osteotomy Excision Arthroplasty Arthrodesis

Tendon Transfer Principles

Subtle Joints

Stable Joints

Active Excursion

Healthy Soft Tissue

One Tendon One Joint

One Action

Synergy

Tendon

Principles and Aims Differ

Internal Splinting

Which Procedure?

Divide / Lengthen / Transfer

Depends on which Musculotendinous unit

Requirements

Bone / Joint

Arthrodesis Thumb CMCJ

Excision Arthroplasty Proximal Row Carpectomy + Tendon Surgery

Osteotomy

Post Op Care

Casting

Splinting

Therapy

Questions?