Cerebral palsy. Management of the upper extremity.
Although only a small number of children with cerebral palsy have indications for surgical treatment of dynamic or structural upper-extremity deformities, orthopedic surgery does improve function and appearance of the involved hand, particularly in spastic hemiplegia. For further assessment of the patient after careful physical examination, myoneural nerve blocks and dynamic electromyography are useful. Physical and occupational therapists have an important role as crucial links among parents, patients, and physicians. Surgeons can try to prevent deformity with splints; however, their use in prevention of deformities of the hand has not been validated by scientific studies. Shoulder deformities can be managed with myotomies, tendon transfers, and (if fixed) osteotomies; rarely is arthrodesis used. Elbow flexion and dynamic or fixed deformities greater than 60 degrees are treated by lengthening of the muscles and tendons. Pronation deformities of the forearm are managed by myotomies, lengthenings, and tendon transfers. Wrist flexion deformities can be corrected with tendon lengthenings and transfers. The best results have been obtained with transfer of the flexor carpi ulnaris to the extensor digitorum communis. Finger flexion deformities can be managed satisfactorily with Z-lengthenings of the flexor digitorum superficialis in the forearm; rarely is it necessary to lengthen the flexor digitorum profundus. For adduction deformity of the thumb, division of the proximal or distal insertions of the adductor pollicis and release of the first dorsal interosseus muscle from the first and second metacarpals are preferred.