Demographics:

• Hemiplegic UL involvement

1. 80% motor
2. 90% sensory

• 69% loss of control of movement
• 36% fixed contracture
• 3 cause most functional problems = functional contracture

1. wrist flexion
2. thumb in palm
3. elbow flexion

• 19% hand/nail hygiene
• 8% pain/spasticity

MACS (manual ability classification system)

Similar to GMFCS but for the hand. 

• Easy and successful
• Reduced speed
• Needs adaptations
• Poor despite adaptations
• Severe limitations

Abilhand

• Questionnaire based, strong correlation to MACS

AHA / SHUEE

• Video analysis of function

<12 yrs

Functional contracture

• early identification
• aggressive splinting
• Botox
• consider check rein procedure  (e.g. tendon lengthening)

Non-functional contracture

• less aggressive intervention
• occasional splinting
• Botox

Dystonia can be difficult to treat - risk of over-correction. Botox and occasionally check rein procedure.

> 12 yrs

Functional contracture

• consider re-balancing procedure e.g. tendon transfer, arthrodesis, PRC

Non-functional contracture

• Likely to cause concerns regarding appearance. Surgery may be indicated for

Dystonia has a high risk of over-correction and check rein procedures and arthrodesis may be indicated

Deformities are similar to that occurred in children with obstetric Erbs palsy which include:

• Adduction / internal rotation deformity
• GHJ dysplasia may lead to dislocation ± OA
• Unable to place hand in functional position
• Surgery rarely indicated

Surgical treatment

• IR/add contracture

1. Pectoralis major lengthening
2. Subscapularis lengthening

• Increased ER power

1. Teres major transfer
2. Latismus dorsi transfer

• GHJ dysplasia

1. Open reduction / capsulodesis
2. Humeral ER osteotomy

• Refectory pain

1. GHJ fusion

Gershwind classification

• Active supination beyond neutral
• Active supination to neutral
• No active supination
• Tight passive supination

Surgical treatment

Pronator spasticity

• Release or z-lengthening
• Re-routing to cause supination

Fixed pronation contracture

• Radial derotation osteotomy
• Interosseous membrane release
• Anterior radio-ulnar ligament release

Wrist pronation contracture in CP.

[Image is courtesy of Paediatric Orthopaedics by Matthew Nixon Lulu publishing]

Unbalanced biceps, brachialis, CFO contracture lead to FFD.

Surgical treatment

• < 30° FFD, non-op as minimal functional impairment
• 30 - 60° FFD

1. Biceps Z lengthening
2. Elevation brachialis origin
3. Release BR from lat supracondylar ridge

Elbow flexion contracture in CP.

[Image is courtesy of Paediatric Orthopaedics by Matthew Nixon Lulu publishing]

Problem: long flexors stronger than long extensors

• Pronation, flexion, ulnar deviation flexed wrist à weak grasp + weak release
• Often interrelated with finger problems
• Often a combination of procedures used

Surgical treatment

FCU spasticity

• Transfer to ECRB/ECRL
• Transfer to EDC
• Prevents hyper-extension deformity
• Also strengthens long finger extensors

1-Swan-neck deformity

Caused by joint laxity± FDS spasticity± intrinsic tightness.

Swan neck deformity in CP

[Image is courtesy of Paediatric Orthopaedics by Matthew Nixon Lulu publishing]

Surgical treatment options

• Extensor release
• Central slip release
• Lateral band translocation
• Volar plate tenodesis
• FDS tenodesis
• PIPJ fusion

3-Thumb deformity

Thumb FFD

• FPL lengthening
• +- BR reinforcement

Web space contracture

• four flap z-plasty
• AddPB and 1st DI release

Abductor weakness

• BR/PL/FCR to APL transfer
• EPL lateralisation from Lister tubercle
• EPL weakness
• BR/FDS transfer

MCP instability

• Volar plate capuslodesis
• Arthrodesis