cerebral palsy coass
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CEREBRAL PALSY
COASS
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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
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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
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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
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Postnatal
• Infection : Meningitis, Abses
• Head injury
• Hipoxia-iskemia
•
Etiology
( . ’ , .Canale ST Campbell s Operative Orhopaedics vol 2 10th . )Ed 2003
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Classification
According to the the type of motor dysfunction
(Minear 1956)
Spasticity Athetosis
Rigidity Ataxia Tremor Mixed
•
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According to the topographicaldistribution (Minear 1956)
Monoplegia. Hemiplegia.
Paraplegia. Diplegia.
Tetraplegia.•
Classification
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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)
•
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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
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Classification
3. Rigidity
• Severe form of
spasticity• Usually quadriplegic
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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;
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The lession in the brain
• Cerebral cortex : spastisity
• Midbrain or base of the brain :athetosis
• Cerebelum : ataxia
• Widespread brain involvement :
mixed
Four areas
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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)
•
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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
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• 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.
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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
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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
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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.
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Gait
• Hemiplegic :
asymmetric flexedknee toe walking
• Spastic diplegia : hipflexed, adducted
(scissors gait),trunk leandsforward, knee bent,feet equinus
• Narrow walking
•
Assessment
Over 1 year
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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
•
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team of health care professionals
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Treatment
Priorities
1.Communication
2.Activities of daily living
3.Mobility in the environment
4.Walking /ambulations
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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
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Strategy
•
• 0-3 yrs - physiotherapy
•4-6 yrs - surgery
• 7-18 yrs - schooling and psychosocialdevelopment
• 18 yrs + - work•
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Treatment of CerebralPalsy
• Psycological Consideration
• Therapeutik Drugs
• Phsysical and Occupational Therapy
• Speech Therapy
• Orthopaedic Appliances
• Surgical Manipulation
• Orthopaedic Operation• Rehabilitaion
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NON OPERATIVENON PHARMACOLOGIST
• Physiotherapy
• Orthosis & Splints
• Neuromuscular ElectricalStimulations (NEMS)
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Orthosis / Splints
Goals for orthotic intervention:
•
• prevention of deformity
•
• correction of soft tissue deformity
•• Control muscle tone
•
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Orthosis & Splints
KAFO
Short-leg brace
Articulating AFOAFO
AbductionOrthosis
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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
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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
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Hoke Procedure
Heel cordlengthening
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FOOT AND ANKLE DEFORMITIES
• Varus Deformities Split Posterior Tibial Tendon Transfer
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FOOT AND ANKLE DEFORMITIES
Anterior advancement of tendo achilles for correction of spasticequinus deformity (Murphy Technique)
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Hip Deformities
Internal RotationDeformities
• Excessive medialfemoral torsion(increasedfemoral
anteversion) isvery common inspastic CP.
• Subtrochanteric
Derotation
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FOOT & ANKLE
DEFORMITIESVarus Deformities Calcaneal osteotomy (lat displacement
or dwyer)
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FOOT & ANKLE
DEFORMITIESValgus deformities Calcaneal osteotomy (med displacement )
A h i
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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.