Cerebral Palsy: Orthopaedic Aspects

CP Basics - Brainy Beginnings

• Cerebral Palsy (CP): Permanent, non-progressive group of disorders affecting movement & posture.
• Etiology: Brain injury or malformation; prenatal, perinatal, or early postnatal (up to age 2-3 years).
• Key: Brain lesion is static; musculoskeletal manifestations can progress or change over time.
• Motor Types:
  • Spastic (~75%): Most common; UMN lesion, velocity-dependent ↑tone.
  • Dyskinetic (Athetoid, Dystonic): Involuntary movements; basal ganglia damage.
  • Ataxic: ↓Balance & coordination; cerebellar lesion.
  • Mixed patterns.
• GMFCS (Gross Motor Function Classification System): Levels I (most able) to V (severely limited).

  ⭐ Spastic diplegia is the most common pattern in premature infants, often linked to periventricular leukomalacia (PVL).

Ortho Manifestations - Twisted Troubles

• Spasticity & Dystonia: Primary motor disorders causing muscle imbalance, abnormal posture.
• Contractures: Fixed joint limitations. Common:
  • Hip: Flexion, adduction (scissoring)
  • Knee: Flexion
  • Ankle: Equinus (toe-walking)
• Torsional Deformities: Rotational bone issues.
  • Femur: ↑Anteversion (in-toeing)
  • Tibia: External/Internal torsion
• Hip Dysplasia/Dislocation: Progressive. Risk ↑ with GMFCS level; ~50% in GMFCS V.
• Spinal Deformities: Scoliosis (most common), kyphosis, lordosis.
• Foot Deformities: Equinovarus, planovalgus common.
• Gait Patterns: Characteristic - Scissoring, crouch, equinus.

⭐ Hip subluxation/dislocation is common, especially in non-ambulatory children (GMFCS IV-V).

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Gait Parade - Wobbly Walks

• Gait Analysis: Key for diagnosis, prognosis, guiding interventions (orthotics, surgery, therapy). OGA standard; 3D IGA for complex cases.
• Common Patterns:
  • Spastic Diplegia:
    • Scissoring: Hip adduction/internal rotation.
    • Equinus: Toe-walking due to calf spasticity.
    • Crouch Gait: ↑ hip/knee flexion, ankle dorsiflexion. From hamstring/psoas spasticity, weak extensors.
  • Spastic Hemiplegia:
    • Circumduction: Stiff leg swings outward.
    • Equinovarus/Equinovalgus foot.
  • Ataxic CP: Wide-based, unsteady, staggering.
  • Dyskinetic CP: Variable, involuntary movements.

⭐ Equinus is the most common deformity in spastic CP, often addressed by Achilles tendon lengthening.

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Joint Hit List - Problem Hotspots

• Hip (Most Critical):
  • Progressive subluxation/dislocation, common in spastic quadriplegia/diplegia.
  • Key contractures: Adduction, flexion, internal rotation.
  • Associated: Coxa valga, increased femoral anteversion.

  ⭐ Reimer's Migration Percentage (MP) > 30% signals hip instability; >40% often warrants surgical intervention.

• Knee:
  • Flexion deformity (hamstring spasticity) → crouch gait.
  • Patella alta is common. Genu valgum may occur.
• Foot & Ankle:
  • Equinus (most frequent; gastrocnemius/soleus spasticity).
  • Equinovarus (spastic tibialis posterior).
  • Equinovalgus (peroneal spasticity, tight Achilles tendon).
• Spine:
  • Neuromuscular scoliosis: Often progressive, long C-shaped curves, with pelvic obliquity.
  • Increased kyphosis or lumbar lordosis.
• Upper Limb:
  • Shoulder: Adduction, internal rotation. Elbow: Flexion. Forearm: Pronation. Wrist/Fingers: Flexion, thumb-in-palm.

Fix-It Strategies - Untangling Limbs

• Goals: Maximize function, improve gait, correct deformities, manage pain.
• Approach: Multidisciplinary team; individualized treatment plan.

Non-Operative Management:

• Physiotherapy: Essential for stretching, strengthening, gait training.
• Orthotics: Ankle-Foot Orthoses (AFOs) for equinus; splints.
• Medications:
  • Botulinum Toxin A: For dynamic spasticity (e.g., calf, adductors); effect lasts 3-6 months.
  • Baclofen (Oral/Intrathecal pump): For generalized spasticity.

Operative Management:

• Key Procedures: Tendon lengthening (Achilles, hamstrings), osteotomies (femoral, pelvic), SDR.

⭐ SEMLS addresses multiple deformities in one session, reducing anesthesia exposure & rehab time.

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High‑Yield Points - ⚡ Biggest Takeaways

• Cerebral Palsy (CP) is the most common childhood motor disability.
• Spasticity is the predominant motor disorder; spastic diplegia is the most frequent type.
• Hip displacement (subluxation/dislocation) is a major concern, especially in non-ambulatory patients.
• Common gait issues include equinus deformity and crouch gait; managed with Botox, orthoses, or tendon lengthening.
• Scoliosis is prevalent, particularly in quadriplegic CP.
• Management involves a multidisciplinary team; GMFCS classifies motor function_._