Management of the Upper Limb in Children with Cerebral Palsy Prof P McArthur FRCS(Plast) PhD Consultant in Congenital Hand and Upper Limb Surgery Department of Plastic Surgery Royal Liverpool Children's Hospital Alder Hey Liverpool
Management of the Upper Limb
in Children with Cerebral Palsy
Prof P McArthur FRCS(Plast) PhD
Consultant in Congenital Hand and Upper Limb Surgery
Department of Plastic Surgery
Royal Liverpool Children's Hospital
Alder Hey
Liverpool
Technique
Sonography guided
injection of Botulinum
toxin
Multilevel, multisite
Dose range per child
used 4 to 20 units/Kg
The Multidisciplinary Team
The Family and
Child
Hospital
PhysiotherapistHospital Occupational
Therapists
Consultant Paediatric
Neurologist
Consultant Upper Limb
Surgeon
Consultant
Lower Limb
Surgeon
Community
Physiotherapists
Community
Occupational
Therapists
Specialist Children's
Hospital
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 Treatments
Mean 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
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 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