General
- Spastic cerebral palsy is one of the commonest conditions seen in children’s orthopaedic practice.
Muscle
- Initially the muscles are functionally short because of spasm or contraction but with time the muscle/ tendon unit becomes structurally short from contracture.
Joints
- Muscle in spasm → joint has restricted movements → joint capsule becomes contracted → abnormal, usually dysfunctional, postures such as fixed knee flexion.
- Joint instability culminating in dislocation is relatively common in children with spastic cerebral palsy, for instance grossly overpronated (flat) feet and hip subluxation and dislocation
Management
- Treatments during the precontracture phase
- Antispasticity management
- Physiotherapy
- Treatments during contracture phase
- Orthopaedic surgery
- Aim to restore more normal anatomy and, hopefully, function.
- For children who cannot walk
- Aim to
- Prevention of hip dislocation
- Maintaining feet in a position to wear shoes comfortably
- Maintaining a comfortable seating position.
- For children who can walk
- Aim to
- Maintain or restore standing and walking function.
- The role of orthopaedic surgery in walking children has changed following more widespread availability of SDR in the United Kingdom currently offered to those walkers with a GMFCS score of 2– 3.
- Multilevel soft tissue releases (MLSTR)
- Formerly was the mainstay of treatment in walking children when function was plateauing or declining as they grew taller and heavier.
- This would be for both contraction and contracture.
- Typically, the child would present with a crouch or jumper’s gait (hips adducted, hips and knees flexed, ankles in calcaneus or equinus), which is an energy- sapping way to stand and walk.
- Children would undergo orthopaedic surgery between the ages of about 7 and 13 years but management is highly individualized.
- Typically, hip flexors (sartorius and psoas), knee flexors (gracilis, semitendinosus, semimembranosus medially, and sometimes biceps femoris laterally), and ankle plantarflexors (gastrocnemius or Achilles tendon) are lengthened in one session.
- Minimal splintage (usually a lightweight below- knee cast for four weeks) is used and early intensive rehabilitation is fundamental.
- Children should be assessed in a multidisciplinary clinic and if SDR is done first the child has a further orthopaedic assessment afterwards.
- Often some areas of tightness will have improved so that any further orthopaedic surgery is less than would otherwise have been the case.
- The optimal timing of staged orthopaedic surgery is not defined except to say that if further surgery is required if it is best performed within a few months of SDR to facilitate rehabilitation.
- Although there is little written, selective percutaneous myofascial lengthening (‘percs’) is popular method of MLSTR in the United States having advantages of smaller skin incisions and more rapid rehabilitation as well as causing less muscle scarring.
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