Indications for Surgery
Upper limb surgery is mainly in spastic hemiplegia
- many of the CP' s have sensory neglect for affected limbs
- won't use limb post surgery anyway
Surgical indications
- a reasonable level of IQ (>70)
- spastic not athetoid
- voluntary grasp and release
- intact sensation / stereogenesis
- good motivation
- hygiene
Options
1. Tendon lengthening / division
2. Tendon transfer
3. Tenodesis / arthrodesis
Principles
1. Lengthening is more predictable than transfer
2. Tendon transfers alone can never overcome rigid osseous deformity
3. Joints which are not under voluntary control should be tenodesed or arthrodesed before tendon transfer
4. Agonist-antagonist tenodesis (spastic coupling) is a good approach because it is symmetrical & balanced
Typical Posture
Shoulder - adducted and internally rotated
Elbow - flexed + pronated
Wrist - flexed + pronated
Fingers - swan-neck +/- flexed
Thumb - in palm
Shoulder
Soft tissue
- lengthening / release of P major and subscapularis
Bony
- external rotation osteotomy humerus
Elbow
Indication
- contracture > 45o
Options
Mild
- lengthen biceps / lacertus fibrosis / brachialis
Severe
- release CFO (Steindler)
- distal release of brachioradialis and pronator teres + anterior capsulotomy
Pronation
- release of pronator teres +/- transfer to radius (makes it a supinator of the forearm)
- if severe osteotomy of radius putting it in neutral rotation
Wrist
Flexion deformity
Class 1 (mild)
- fingers can be extended with only 20o or less of wrist flexion
- Release FCU or CFO slide (Steindler)
Class 2 (moderate)
- full flexion only possible with > 20o wrist flexion
- A: extensor power present
- B: no extensor power
- CFO release
- transfer FCU to ECRB if no extensor power
- +/- FDS to ECRB transfer
Class 3 (severe)
- great wrist & finger flexion deformity without extensor motors
- no functional gain is expected
- surgery here is to improve cosmetic appearance only
- multiple releases +/- wrist arthrodesis
Fingers
Swan neck deformity
Aetiology
- over pull of extrinsic extensors / central slip shortening / intrinsic spasticity
- final common pathway is volar plate incompetence with hyperextension at the PIPJ
Management
- FDS tenodesis through a volar Brunner incision
Thumb
Most crippling upper extremity deformity
- can be a significant hygiene problem in severely affected
- may need surgery despite not fitting criteria set out above
- in practice surgery is directed at what the pathology is
Type 1
- weak EPL
- reroute EPL + reinforce with PL or FCR or brachioradialis
Type 2
- intrinsic contracture & first dorsal interosseous tightness
- release webspace +/- Z plasty
Type 3
- weak APL & EPB
- APL tenodesis reinforced with PL, FCR or brachioradialis
Type 4
- spasticity of FPL
- Z lengthening of FPL