Child/adult transition of the walking Cerebral Palsy patient: the upper limb.
Seance of wednesday 06 december 2023 (l'ANC reçoit la SOFCOT : Table ronde Transition Enfant/Adulte du sujet Paralysé Cérébral marchant)
DOI number : 10.26299/dvd5-t869/emem.2023.35.06
Abstract
Surgery on the upper limb of adult Cerebral Palsy (CP) patients are not uncommon. Even if the principles and techniques of adult vascular or traumatic central paralysis are transferable, these patients have their own specificities.
Indeed, the walking PC subject combines motor deficits and spasticity predominantly in the flexors (elbow, wrist and fingers), but often also very good proximal control (shoulder/elbow) with possible holds. A vicious "rollover" attitude of the wrist is particularly frequent, and is a frequent reason for consultation in late adolescence for aesthetic reasons. Finally, the frequent and sometimes masked dystonia in this population is a trap for the surgeon.
In addition to neurological disorders, there are growth anomalies, joint retractions and, above all, functional extinction offset by significant compensatory mechanisms.
The surgeon must not destabilize an established situation, and has 4 main tools at his disposal: tendon lengthening to correct retractions and reduce spasticity, muscle denervation, tendon transfers and bone stabilization by arthrodesis.
In contrast to most paralyses, surgical strategies for these patients are not unambiguous, due to the fact that their clinical presentations have very different ambitions, whether functional or merely comfort-related.
Thanks to the INOM score, which integrates prognostic factors and parameters that can be cured surgically, it is possible to evaluate these patients and build a surgical strategy. The program is based on three key factors: proximal motor control of the shoulder and elbow, correction of vicious attitudes, and restoration of active finger extension. The program is validated by simulation of the various gestures envisaged, using anesthetic blocks, botulinum toxin injections and orthoses.
Indeed, the walking PC subject combines motor deficits and spasticity predominantly in the flexors (elbow, wrist and fingers), but often also very good proximal control (shoulder/elbow) with possible holds. A vicious "rollover" attitude of the wrist is particularly frequent, and is a frequent reason for consultation in late adolescence for aesthetic reasons. Finally, the frequent and sometimes masked dystonia in this population is a trap for the surgeon.
In addition to neurological disorders, there are growth anomalies, joint retractions and, above all, functional extinction offset by significant compensatory mechanisms.
The surgeon must not destabilize an established situation, and has 4 main tools at his disposal: tendon lengthening to correct retractions and reduce spasticity, muscle denervation, tendon transfers and bone stabilization by arthrodesis.
In contrast to most paralyses, surgical strategies for these patients are not unambiguous, due to the fact that their clinical presentations have very different ambitions, whether functional or merely comfort-related.
Thanks to the INOM score, which integrates prognostic factors and parameters that can be cured surgically, it is possible to evaluate these patients and build a surgical strategy. The program is based on three key factors: proximal motor control of the shoulder and elbow, correction of vicious attitudes, and restoration of active finger extension. The program is validated by simulation of the various gestures envisaged, using anesthetic blocks, botulinum toxin injections and orthoses.