Cerebral Palsy Surgical Techniques – Upper Extremity

Dr. Dibyendunarayan BidSenior LecturerSarvajanik College of Physiotherapy, Rampura, Surat -395003.

Upper Extremity Procedures

1. Shoulder Adductor, Extension, and External Rotator Lengthening

Indication The indications for shoulder adductor

lengthening are usually in a child with a quadriplegic pattern involvement who has a severe shoulder adduction contracture making axillary care and dressing difficult.

The primary contracture is usually with internal rotation and adduction coming from the pectoralis.

Some children develop shoulder abduction extension and elbow extension during ambulation or while sitting in a wheelchair.

Improved cosmesis and fewer problems with injury of the hand can occur with lengthening of the triceps and external rotators.

Procedure 1. An incision is made over the anterior

deltopectoral groove. The inferior border of the pectoralis major is identified (Figure S1.1.1).

2. The superior and inferior borders of the pectoralis minor and major are identified and a hemostat is passed underneath these two muscles.

3. Cautery is used and the muscles are transected completely. Abduction then should increase 20° to 30°, sufficient to allow easy access to the axillary region (Figure S1.1.2).

4. If the latissimus dorsi and teres minor are very contracted, a separate posterior incision can be made (Figure S1.1.3) and these can be released as well (Figure S1.1.4).

5. The teres major and minor can also be transected medial to the long head of the triceps. Care has to be taken to avoid injury of the axillary nerve coming up through the quadrilateral space (Figure 1.1.5).

6. The long head of the triceps is then identified distal to the axillary nerve and transected (Figure 1.1.6).

7. The lateral head of the triceps is next defined and transected (Figure 1.1.7).

8. The wounds are closed and no immobilization is utilized.

Postoperative Care Immediate passive range of motion is

started postoperatively.

2. Humeral Derotation Osteotomy

Indication The indication is usually severe external

humeral rotation or severe internal rotation.

The most common patterns are children with severe abduction external rotation contractures, which make seating difficult, or the high-functioning child with hemiplegia who has a severe internal rotation contracture.

Procedure 1. Incision is made along the anterior

border of the deltoid and carried down to the midarm (Figure S1.2.1).

The interval is opened to the humerus with subperiosteal dissection distally but not with elevation of the deltoid insertion into the humerus.

2. An osteotomy with an oscillating saw is made at the level just proximal to the humeral insertion of the deltoid (Figure S1.2.2).

If the humerus is to be rotated externally, the plate is placed on the medial surface with a minimum of two holes proximally and three holes distally and, if possible, a six-hole plate should be utilized (Figure S1.2.3).

Good compression of the osteotomy is performed (Figure S1.2.4).

Postoperative Care Immediate postoperative passive range of

motion is allowed; however, when the limb is not being ranged, it should be immobilized in a sling for 4 weeks to allow healing to begin.

3. Elbow Flexion Contracture Release

Indication Elbow flexion contractures are common in both children

with hemiplegia and those with quadriplegia. For the child with hemiplegia and a mild contracture,

only the bicep is released. If the child has a very functional upper extremity, a Z-lengthening of the biceps tendon may be performed.

For the quadriplegic child with a severe contracture, complete transection of the biceps and brachialis is performed with some myofascial lengthening of the brachioradialis.

Procedure 1. Incision is made anterior transverse just

proximal to the elbow crease (purple line, Figure S1.3.1).

It is carried down to the subcutaneous tissue with spreading and retraction of the subcutaneous veins.

If more proximal or distal exposure is needed the incision can be extended in Z-plasty fashion (Figure S1.3.1, blue lines).

2. The tendon of the biceps is palpated and extensively cleaned. Retractors are placed on each side and the tendon is transected (Figure S1.3.2, purple lines).

At this point, if it is felt that the arm is extremely functional requiring heavy strength, a Z-lengthening of the tendon can be performed (Figure S1.3.2, green line).

3. For the quadriplegic child with a severe contracture, complete release of the biceps and the majority of the brachialis fascia beneath the biceps is performed as well (Figure S1.3.3).

If a significant lateral contracture of the flexor still remains, myofascial lengthening of the lateral mass also can be performed.

Postoperative Care Immediate active range of motion is begun if

there is no other indication for the utilization of a cast. If the child also undergoes forearm procedures, the elbow may be immobilized in a cast in approximately 70° to 80° of flexion.

Casting is utilized based on the requirements of other procedures, not the elbow tendon lengthening.

4. Pronator Release or Transfer

Indication Release or transfer of the pronator teres is

indicated if there is a significant pronator contracture, usually in the child with a hemiplegic upper extremity.

Some children with a quadriplegic pattern with functional forearms also may need a pronator release.

Procedure 1. The incision is made in the midforearm between

the brachioradialis and the extensor carpi radialis longus muscles (Figure S1.4.1). The incision is carried through the subcutaneous tissue and the interval between brachial radialis and extensor carpi radialis longus is opened.

2. The radius is identified and the fascia overlying the radius is opened.

3. The pronator teres tendon will be identified, and proximal dissection is extended until the full tendon of the pronator teres can be identified. The pronator teres has a very broad insertion onto the radius.

4. A right-angle clamp is placed around the pronator teres (Figure S1.4.2).

5. If a release is planned, especially for individuals with quadriplegia and for many children with hemiplegia, the tendon is transected and care is taken to make sure that no remnants of the tendon remain attached.

6. If a transfer is indicated, the tendon is released with its underlying periosteum to the distal third–middle third junction of the radius.

7. The tendon of the pronator teres then is passed through the interosseous membrane, wrapped around the radius distally in the opposite direction (Figure S1.4.3), and sutured into the periosteum or a single drillhole placed in the distal radius with a stay suture tied to a suture anchor (Figure S1.4.4).

8. Care should be taken to avoid major bicortical drillholes because of the risk of fracture.

Postoperative Care The forearm is immobilized in full

supination in a long-arm cast for 4 weeks.

Postoperative treatment includes range of motion after cast removal, which can occur as early as 2 weeks if no other procedures were performed.

5. Flexor Carpi Ulnaris Transfer for Wrist Flexion Deformity

Indication Wrist flexion, often combined with ulnar deviation, is a

common contracture. Flexion of the fingers may be present as well.

Transfer of the flexor carpi ulnaris is indicated when there is dynamic wrist flexion contracture and when there is a wrist flexion contracture with a fixed contracture on the ulnar side.

This procedure may be combined with lengthenings of the extensor carpi ulnaris if there is significant ulnar deviation, or lengthening of the flexor carpi radialis if there is significant fixed wrist flexion contracture after detachment.

Procedure 1. The incision is made across the wrist crease along the

flexor carpi ulnaris (Figure S1.5.1) and then may be extended across the forearm in a lazy S fashion, dependent on whether finger flexor lengthenings are indicated (Figure S1.5.2).

The tendon border of the flexor carpi ulnaris is identified and freed of its fascial and muscle attachments in the distal 6-cm segment. The tendon is detached as far distally as possible off the carpal bones, being careful to protect the ulnar nerve on the deep and thenar side of the tendon (Figure S1.5.3).

It is next stripped using a surgical finger or another instrument so its fascia is stripped at least to midforearm. A suture is place in the end of the tendon.

2. At this time, the wrist should easily dorsiflex passively to 20° or 30°, and if this is not possible, the flexor carpi radialis is identified and a myofascial or Z-lengthening is performed based on how much dorsiflexion is needed. Usually, a Z-lengthening is required because the muscle often is very short and the tendon very long.

Flexor carpi radialis lengthening is only required in wrists with severe flexion contractures (Figure S1.5.4).

3. An incision is made in the dorsum of the wrist from distal on the radial side to slightly proximal on the ulnar side (Figure S1.5.5).

4. If the goal is to transfer the tendon into the extensor carpi radialis longus or brevis, these tendons are exposed to their insertion distally, freeing the extensor hallucis longus.

If the goal is to transfer the FCU into the finger extensors, the finger extensors are identified at their common dorsal wrist compartment.

5. A tendon passer is passed through the subcutaneous tissue from dorsal to volar, and the tendon is grasped and pulled into the dorsal wound, which should provide easy and sufficient tendon length.

Care should be taken to make sure that the muscle is pulled in a gentle curve and a sharp bend is not made in the subcutaneous tissue at midforearm (Figure S1.5.6).

Attention then is directed back to the volar area where further lengthenings are performed if indicated.

6. With the wrist in 20° to 30° of dorsiflexion, if there is full passive finger extension, no finger flexor lengthenings are indicated. If the fingers are unable to extend with the wrist in 20° of dorsiflexion, especially if they lack more than 40° or 50° coming to extension, lengthenings of the finger flexors should be performed.

7. Usually, the primary contracted finger flexor is the flexor digitorum superficialis, which then is exposed by extending the incision across the muscle belly in the midforearm, aiming toward the incision of the pronator release.

The flexor muscles are identified and, if good muscle mass is present and the finger flexion contractures are not severe, myofascial lengthenings are performed.

Myofascial lengthenings of all the flexor digitorum superficialis muscles usually are required (Figure S1.5.7).

8. If the finger flexion contractures are quite severe, then the tendons of the flexor digitorum superficialis are identified and the tendons of the index and long finger (Figure S1.5.8, group A) are sutured together as far distally as possible and proximally at the level of their muscle bellies.

The tendons of the ring finger and little finger (Figure S1.5.8, group B) similarly are sutured together.

The tendons then are transected, one distal and one proximal, which allows a Z-lengthening of the combined motor units to the index and long finger and the ring and little fingers. Sufficient lengthening is provided to allow finger extension (Figure S1.5.9).

9. Following flexor digitorum superficialis lengthening, if there is still significant contracture present, the flexor digitorum profundus tendon and muscle are identified and, for moderate contractures, a myofascial lengthening can be performed.

If a severe lengthening is required, a similar combined Z-lengthening is performed.

10. With the wrist extended 20°, the thumb should be extended, and if it is unable to fully extend at neutral abduction and the flexor pollicis longus is very tight, a myofascial lengthening of the flexor pollicis longus usually is sufficient and can be performed through the same incision.

For severe contractures in which the muscle belly is short, a Z-lengthening should be performed (Figure S1.5.10).

11. If additional procedures of the thumb or fingers are required, these next should be performed before the tendon transfer is completed.

However, the description of this procedure will presume that this has been done or is not needed. The volar wounds are all closed in the appropriate fashion.

Attention is directed to the dorsum, where the tendon has had a Kessler suture placed through its end and can be drawn into the wound (Figure S1.5.11).

The tendon is woven with a Pulvertaft weave through the tendon to which it is intended to be transferred (Figure S1.5.12).

The tension is increased until the wrist is at 20° to a maximum of 30° of extension and the tendons are sutured together (Figure S1.5.13).

Following a provisional fixation with one or two sutures, tension is relaxed and the wrist should stay in dorsiflexion of 10° to 30° when the wrist is not supported.

If the wrist drops into flexion, the tendon repair has to be taken down, the wrist further dorsiflexed, and the tension of the tendon transfer increased.

If the dorsiflexion is more than 30°, the tendon should be relaxed to prevent a hyperdorsiflexion deformity. Suturing of the tendon is completed. The wound is closed.

Postoperative Care A forearm cast is applied with the wrist in 30° of

dorsiflexion and the finger metacarpal phalangeal joints extended to neutral and interphalangeal joints flexed to 45°.

The fingers should be incorporated in the cast to the fingertips with the appropriate flexion as noted.

The thumb should be in abduction and slightly flexed, especially avoiding hyperextension of the metacarpal phalangeal joint of the thumb and fingers.

Four weeks of immobilization in a cast is required, then the cast is removed and a dorsal or volar wrist extension splint is worn 24 hours per day for an additional 4 to 8 weeks, with the splint being removed for gentle active range of motion and bathing only.

Following this, the splint is gradually removed as strength is increased.

6. Proximal Row Carpectomy and/or Wrist Fusion

Indication The indication is primarily in individuals with

nonfunctional upper extremities and severe flexion deformities.

Wrist fusion is to be avoided in any extremity with substantial function, especially in hemiplegics; however, wrist carpectomy or fusion should be considered only in older individuals or those with no function.

Postoperative Care After postoperative rehabilitation and cast

removal, little therapy is indicated as these are by definition nonfunctional upper extremities in which the operation was done for comfort care, improved ability for dressing, and personal hygiene.

Arthrodesis may or may not occur, but the fibrous arthrosis is stable if the finger flexors do not contract and claw the fingers into the palm.

7. Thumb Adductor LengtheningIndication Thumb adductor lengthening, by release

of the muscle in midsubstance, is indicated for mild to moderate thumb adduction contractures.

Postoperative Care Postoperative management is with the

thumb in abduction in the cast for 3 or 4 weeks.

Make sure the cast is not producing thumb hyperextension at the MTP joint.

After cast removal, thumb abduction splinting at nighttime is usually used for at least 3 weeks.

No other treatment is indicated.

8. Webspace Lengthening and Z-Plasty

Indication Webspace lengthening and Z-plasty are used for

severe adduction contractures of the thumb, especially those in which the goal is to get the thumb out of the palm and around large objects.

A thumb webspace lengthening with a more aggressive adductor lengthening is indicated.

Care has to be taken to avoid excessive lengthening because this will greatly improve thumb abduction at the expense of adduction.

If the thumb is abducted enough to hold a drinking glass, almost always lateral key pinch is lost.

The relative importance of these functions needs to be individually considered in each child.

Postoperative Care A soft bulky dressing is used for 3 weeks

until the wounds are well healed.

Therapy is then started, focusing on the functional gains that the child hopes to attain.

9. Metacarpal Phalangeal Joint Fusion of the Thumb

Indication The indication for the metacarpal phalangeal joint

fusion is severe flexion of the metacarpal phalangeal joint or severe extension hypermobility.

The most common indication is a House type 4 thumb deformity, also known as a cortical thumb, in which the caretakers have difficulty in keeping the hand clean.

This posture leads to sweating in the hand and the development of a very foul odor.

Children with functional use of the thumb, but severe MTP hyperextension, are the other indication.

Postoperative Care Pin removal and cast removal can be

performed when the X-ray demonstrates some bridging callus.

No splinting or therapy is further required.

10. Extensor Pollicis Longus Rerouting

Indication Rerouting is indicated for active thumb

adduction contractures, or those in which there is a lack of thumb abduction and extension; rerouting of the extensor pollicis longus is indicated for moderate deformities.

Postoperative Care The thumb is held in an abduction cast

for 4 weeks and then is allowed to have full active range of motion.

11. Palmaris Longus or Brachioradialis Transfer to the Abductor Pollicis

Indication The indication to transfer the palmaris

longus or brachioradialis to the abductor pollicis is to augment thumb abduction due to inactive power of a moderate to severe degree.

Postoperative Care The hand is immobilized in a thumb

spica with maximum thumb abduction but avoiding MSP hyperextension.

The cast is removed after 4 weeks, and a thumb abduction splint is worn at nighttime for an additional 2 to 4 months.

12. Volar Plate Advancement and Sublimis Slip Reinforcement for Swan Neck Deformity

Indication Contracted finger flexors with wrist flexion

deformity and contracted intrinsic muscles result in hyperextension of the proximal interphalangeal (PIP) joint and flexion of the distal interphalangeal joint to cause a stretching out of the volar capsule at the proximal interphalangeal joint.

When the deformities are severe, finger PIP joints get locked in extension and surgical treatment may be indicated.

Pain from hyperextension or inability to flex the PIP joint causing functional limitation is the typical direct indication for surgical treatment.

Postoperative Care At 4 weeks postoperatively the pins are

removed.

A splint is made to prevent dorsiflexion and should be worn for another 2 to 4 weeks.

Once the splint is removed, there should be no attempt at forceful extension stretching; however, range of motion into PIP joint flexion of the fingers is encouraged.

End of Part - I