Deformities related to cerebral palsy and their orthotic

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1. deformities related to cerebral palsy and their orthotic treatment Rabia Mustafa King Edward Medical University

2. In Bone and joint changes cer ebral palsy result from muscle spasticity and contracture. The spine and the joints of the lower extremity are most commonly affected. Scoliosis may progress rapidly and may continue after skeletal maturity. Increased thoracic hypnosis and lumbar lordosis, spondylolisthesis, spondylolysis, and pelvic obliquity may accompany the scoliosis. Progressive hip flexion and adduction lead to windswept deformity, increased femoral anteversion, apparent coxa valga, subluxation, deformity of the femoral head, hip dislocation, and formation of a pseudoacetabulum.

3. In the knee, flexion contracture,, and patellar fragmentation are the most commonly seen abnormalities. Recurvatum deformity can also develop in the knee secondary to contracture of the rectus femoris muscle. Progressive equinovalgus and equinovarus of the foot and ankle are associated with rocker-bottom deformity and subluxation of the talonavicular joint.

4. Specific deformities Hip – flexion / adduction Knee- flexion / recurvatum Foot- equionovarus elbow-flexion/pronation Hand-wrist flexion-pronation Spine - scoliosis

5. Spasticity Spasticity is increase in tonic reflexes Exaggerated tendon jerks Spasticity is one part of the upper motor neuron syndrome, but it is a widespread problem in cerebral palsy; it is debilitating, affects function and can lead to musculoskeletal complications. Significant advances have occurred in antispasticity management (and related musculoskeletal problems) in children with cerebral palsy during the past 5-10 years the potential for combination treatment with other modalities. There is a role of biomechanical assessment and providing mobility aids/casting/orthoses and motor training/stretching exercises

6. Thoracolumbar spine The prevalence of scoliosis in patients with spastic cerebral palsy ranges from 15% to 61% .Males are more commonly affected .This is in contrast to idiopathic scoliosis, which has an 8:1 female predominance. Curves are typically less than 40° but can range from 10° to 146°. The incidence of scoliosis increases with age and decreased ambulation. Most scoliotic curves progress from postural to fixed deformities . Body braces showed benefit in a randomised controlled trial. The Milwaukee brace is one particular body brace that is often used. Modern CAD / CAM braces are used in Europe

7. Treatment Treatment is primarily aimed at improving sitting balance and halting curve progression. Severe deformities may be prevented by external bracing if scoliosis is detected early . The patients' wheelchair needs to be assessed and modified in order to accommodate for their corrected spinal posture and seating balance after surgery. A reclining wheelchair can be used initially to provide better sitting comfort during the immediate postoperative period and while a patient who has been fused distally to the sacrum and the pelvis has difficulties to sit to 90°.

8. hip Hip subluxation and dislocation are the second most common deformities in patients with spastic cerebral palsy, with a reported prevalence of up to 28%. The spastic adductors and iliopsoas muscles overpower the weaker hip abductors and extensors . This may result in scissor gait (bilateral adduction hip contracture) or windswept deformity. Windswept deformity (adduction contracture of one hip and abduction contracture of the other hip) occurs in up to 23% of patients . Impaired ambulation and sitting balance, greater trochanteric decubiti, and pain may also be present

9. treatment Treatment is aimed at preventing adduction and flexion deformity and progression to subluxation or dislocation . Nonsurgical management involves stretching the spastic agonist muscles and strengthening the weaker antagonist muscles. Abduction splinting may also be used . Hkfo is recommended in case of hip deformity Since 1992 following orthosis has been used for thousands of CP children in many countries

10. knee Knee flexion deformity (crouch knee) is the most common knee abnormality in spastic cerebral palsy . This deformity is associated with hip and ankle flexion contractures and is due to spasticity of the hamstrings . As flexion progresses, more force is placed on the quadriceps muscles, leading to overstretching of the quadriceps muscle fibers and the infrapatellar tendon, causing patella alta, patellar fragmentation, chondromalacia, joint instability, muscle weakness, and pain.

11. treatment Treatment of knee flexion deformity is aimed at progression ground reaction ankle foot orthosis (GRAFO) is use . GRAFO locks ankle and resist ankle dorsi flexion Help to correct crouch from plantar flexion KAFO is used to correct the deformity

12. Foot Equinus deformity (plantar-flexed calcaneus) is the most common musculoskeletal abnormality in patients with spastic cerebral palsy . A fixed or spastic contracture of the gastrocnemius and soleus causes the characteristic tiptoe or toe-heel gait with an inability to keep the heel in the shoe. Equinus is commonly associated with knee flexion and valgus or varus deformity of the hind foot and forefoot.

13. treatment The goal of treatment is to prevent and correct deformities to increase function. braces attempt to stretch shortened muscles Floor reaction orthosis Ankle foot orthosis is given in case of foot deformity

14. Orthoses in cp Splintage Cp strollers Cp chairs Elbow crutches Hand splintage Spinal orthoses Neck supports Floor reaction orthosis

15. Gait disorders Stiff knee gait characterized by limited knee flexion in swing phase due to rectus femoris firing out of phase Crouch gait hamstring contracture - most common cause(results in a combination of hip flexion, knee flexion, and ankle equinus ) Toe-walking gait common in hemiplegics Treatment: Ankle foot orthosis

16. Upper extremity deformities Most pts w/ hemiplegic cerebral palsy have functionless hand marked by: - flexion of the elbow with pronation of the forearm - flexion of the wrist and fingers: spasticity, weakness, flexion deformity of the wrist & fingers - thumb in palm deformity - loss of sensation and proprioception .

17. Deformities in upper extrimty Shoulder internal rotational contracture Fore arm pronation Wrist flexion deformity Thumb in palm deformity Finger flexion deformity

18. Conclusion Cerebral palsy is a central nervous system disorder characterized by muscle spasticity and contracture. Scoliosis and flexion deformities of the hips, knees, and feet occur. Early recognition of progressive deformity allows timely treatment and prevention of irreversible change.