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Management of the Upper Limb in Children with Cerebral Palsy

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?

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Management of the Upper Limb in Children with Cerebral Palsy

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  1. 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

  2. Introduction • Why Upper limb? • Which Botulinum Toxin? • Why Ultrasound?

  3. Technique • Sonography guided injection of Botulinum toxin • Multilevel, multisite • Dose range per child used 4 to 20 units/Kg

  4. Visualization of muscle groups?

  5. Visualization of muscle groups PL FCR PT

  6. The Multidisciplinary Team Hospital Physiotherapist Hospital Occupational Therapists Community Physiotherapists Specialist Children's Hospital The Family and Child Community Occupational Therapists Consultant Paediatric Neurologist Consultant Lower Limb Surgeon Consultant Upper Limb Surgeon

  7. Post Injection Management • Physiotherapy – Stretch • Physiotherapy – Strengthen Agonists • Splintage

  8. Why the controversy? • Very little level 1 evidence • Variation in post injection regimes • Inherently heterogeneous patient group • Difficulty in establishing treatment goals

  9. 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

  10. 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)

  11. Outcomes • More reliable targeting of treatment due to toxin used and method of disposition • “Soft” outcome measures: • Better posture • Better hygiene • Better function

  12. Functional Ability • ABILHAND-Kids questionnaire • 21 tasks • Bimanual ability assessment • Discriminators of difficulty • Base line assessment of function

  13. Goal Attainment • Individualized outcome markers • Functionally relevant • Goal Attainment Scaling

  14. 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

  15. Surgical Strategies

  16. Indications • Pain • Failure of Toxin Therapy • Established Contractures • Hygiene / Dressing / Transfer

  17. Indications • FUNCTION

  18. Principles Lengthen Tendon vs Shorten Skeleton

  19. Surgical Options • Tendon • Transfer • Lengthening • Release • Tightening • Skin Procedures • Bone / Joint • Osteotomy • Excision Arthroplasty • Arthrodesis

  20. Tendon Transfer Principles • Subtle Joints • Stable Joints • Active Excursion • Healthy Soft Tissue • One Tendon One Joint • One Action • Synergy

  21. Tendon • Principles and Aims Differ • Internal Splinting • Which Procedure? • Divide / Lengthen / Transfer • Depends on which Musculotendinous unit • Requirements

  22. Bone / Joint • Arthrodesis • Thumb CMCJ • Excision Arthroplasty • Proximal Row Carpectomy + Tendon Surgery • Osteotomy

  23. Post Op Care • Casting • Splinting • Therapy

  24. Questions?

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