Cerebral Palsy Hand Deformity

Understanding Cerebral Palsy (CP)

Cerebral palsy (CP) is a developmental disorder caused by brain injury before or after birth during a child’s developmental years. It is commonly associated with low-birth-weight babies, prematurity, jaundice, genetic disorders, maternal infections, and intracranial bleeding.

Involvement of Hands and Feet

CP can affect one or both hands and/or lower limbs, leading to spasticity, muscle tightness, stiff joints, limited mobility, an abnormal gait, toe-walking, and contractures.

Diagnosis of Hand Deformity in CP

Hand deformities often result from spasticity and can hinder a child’s daily activities. They are typically diagnosed if a child has:

• Thumb in the palm beyond the age of one and a half years.
• Neglected and shortened arms with spasticity.
• Hand contracture depending on the location of brain damage.

Importance of Early Detection

Early detection of hand deformities is crucial for better management. However, these deformities are challenging to recognize in the initial years due to delayed developmental milestones. Diagnosis typically occurs around the age of five.

Associated Disabilities in CP

Children with CP may also have associated disabilities, such as communication impairments, vision and hearing issues, and mental impairments, along with a history of seizures. All these aspects need to be considered when assessing a child with a spastic hand.

Treatment Goals

The goal of treating a spastic hand in children with CP is to develop and maintain hand manipulation skills, coordination, and basic hand functions. This includes holding objects for feeding and play. In older children, the focus extends to skills like writing, manipulation, activities of daily living, and social interactions.

Management of Spastic Hand

Treating a spastic hand is a team effort that involves parents, surgeons, physiotherapists, pediatricians, occupational therapists, nurses, and psychologists.

Treatment in Younger Children (Under 4 Years)

• In children under four, a combination of physical therapy, occupational therapy, and splinting should be attempted to improve functional activities, flexibility, and joint suppleness. Physical therapy focuses on a range of motion exercises and stretching to improve motor function.
• Occupational therapy aims to enhance the child’s ability to perform daily activities at home and school, focusing on strength improvement and bilateral hand coordination. Splints may be used for better hand positioning.

Treatment in Older Children (Over 4 Years)

For older children, an intensive therapy program is developed, incorporating physical and occupational therapy along with splints. Botox injections may be administered to relax spastic and contracted muscles, making them more amenable to physical therapy.

Surgery for Spastic Hand

If hand deformities persist or do not improve after Botox injections, surgery is considered. The ideal age for surgery in children with CP is typically between 8 to 12 years, although it can be performed in adults as well. Surgery can lead to significant improvements in hand function and the quality of life for both children and their parents.

Prerequisites for Surgery

For children with CP to be eligible for surgery, they should meet certain prerequisites:

• Sufficient intelligence to understand and cooperate in post-operative re-education.
• Strong family support.
• Continued use of the hand.
• Preservation of basic sensations of touch and pain, as well as the ability to recognize physical characteristics of touched objects.

Surgical Planning

Surgical planning for children with CP depends on the child’s intellectual capacity, hand usage, and sensations:

• Children with low IQ (<50) and reduced hand use may undergo surgery for cosmetic correction of contractures.
• Children with IQ >50, good hand control, and sensations aim for functional improvement.
• Surgeries are performed in multiple stages, with hand deformities corrected before lower limb issues to prepare for mobility aids.

Types of Surgery

Various surgical procedures are performed to address hand deformities in children with CP:

• Muscle Lengthening: Surgical lengthening of muscles aims to relieve tightness in the hands and fingers, improving wrist and hand movements.
• Tendon Lengthening: Reduces hand contractures, with joint-oriented physiotherapy necessary post-surgery.
• Tendon Transfer: Enhances hand and wrist function by rerouting a functional tendon to provide movement to non-functional areas.
• Tenotomy/Myotomy: Cutting tendons or muscles can improve muscle function and control, increasing upper limb abilities.
• Osteotomy: Bone alignment is corrected to improve posture and function.
• Arthrodesis: Severe cases of spastic hand may require wrist arthrodesis in a functional position to enhance daily activity performance.

Properly planned and performed surgeries significantly enhance the quality of life for children with CP, enabling them to lead more independent lives.