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

Introduction

Why Upper limb?

Which Botulinum Toxin?

Why Ultrasound?

Technique

Sonography guided

injection of Botulinum

toxin

Multilevel, multisite

Dose range per child

used 4 to 20 units/Kg

Visualization of muscle groups?

Visualization of muscle groups

P

LFCR

PT

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

Post Injection Management

Physiotherapy – Stretch

Physiotherapy – Strengthen Agonists

Splintage

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

Goal Attainment

Individualized outcome markers

Functionally relevant

Goal Attainment Scaling

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 Strategies

Indications

Pain

Failure of Toxin Therapy

Established Contractures

Hygiene / Dressing / Transfer

Indications

FUNCTION

Principles

Lengthen Tendon

vs

Shorten Skeleton

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

Post Op Care

Casting

Splinting

Therapy

Questions?