This document provides information on cerebral palsy (CP), including its definition, classification, etiology, management, and common lower limb deformities seen in CP patients. Some key points: - CP is a non-progressive disorder of the brain resulting in impaired motor function and posture. It occurs due to an insult to the developing brain, most commonly during prenatal, perinatal, or postnatal periods. - Common classifications of CP include spastic, athetoid, ataxic, and mixed types based on the predominant motor symptoms. Lower limb deformities often seen include hip flexion contractures, knee flexion contractures, and foot equinus. - Management involves controlling spasticity

1.  Chairperson Dr. R. S. Jatti
 Presenter Dr. Srinath Gupta

2.  Brain grossly differentiates into cerebrum
and cerebellum during 1st Trimester of
embryonic life
 Neurons begin to develop in 2nd trimester
 By end of 2nd trimester all neurons are
formed and any damage occurring now is
irreversible
 Synaptic connections occur in 3rd
trimester

3.  First described in 1862, by William John
Little, an orthopedic surgeon who
observed that children with tone and
developmental abnormalities often
had prolonged labor, prematurity or
breech delivery
 Cerebral Palsy was known as Little’s
Disease for decades.
 The term cerebral Palsy originated with
William Osler and Sigmund Freud
 Static Encephalopathy has been used
interchangeably with cerebral palsy

4.  Definition
 Incidence
 Etiology
 Classification
 Management
 Lower Limb Deformities

5.  Static, non progressive disorder of CNS secondary
to an insult to immature brain, resulting in
varying degrees of motor milestone delay and
dysfunction
 CP is a disorder of tone, posture or movement
 It results in paralysis, weakness, in coordination
or abnormal movement

6.  2.4-2.7 for every 1000 live births

7.  Prenatal:
◦ Infection: TORCH Complex, HIV
◦ Cerebral malformation
◦ Obstetrical complication: pre-eclampsia,
eclampsia, abruptio placentae, placenta previa,
placental infarction
◦ Maternal diseases
◦ Abuse of drugs

8.  Perinatal:
◦ Prematurity
◦ Low birth weight
◦ Complicated delivery
◦ Asphyxia
◦ Cerebral trauma
◦ Hyperbilirubinemia
◦ Blood incompatibilities
◦ Infections: Herpes simplex, meningitis
◦ Severe hypoglycemia

9.  Post natal :
◦ Infections : Meningitis, encephalitis
◦ Head injury
◦ Cerebral anoxia
◦ Aspiration
◦ Asphyxia
◦ Seizures
◦ Near drowning
◦ Cardiac arrest
◦ Cerebrovascular accidents
◦ Sickle cell anaemia
◦ Vascular malformations

10.  Because of the wide variability in presentation and
types of cerebral palsy, there is no universally
accepted classification scheme.

11.  Monoplegia
 Hemiplegia
 Paraplegia
 Diplegia
 Quadriplegia
 Double Hemiplegia
 Total body

12.  Spastic
 Athetoid
 Choreiform
 Rigid
 Ataxic
 Hypotonic
 Mixed

13.  Spastic:
◦ Most common type
◦ Associated with injury to pyramidal tracts in immature
brain
 Athetoid:
◦ Associated with injury to extrapyramidal tracts
◦ Dyskinetic purposeless movements
◦ Dystonia or hypotonia can occur with athetoid cerebral
palsy
 Choreiform:
◦ Continual purposeless movements of wrists,fingers,toes
and ankles

14.  Rigid:
◦ Most hypertonic form
◦ Cogwheel or leadpipe rigidity
 Ataxic:
◦ Very rare
◦ Injury to developing cerebellum
◦ Disturbance of coordinated movement viz.
walking
◦ Characterized by weakness, in-coordination, a
wide based gait, and trouble with fine and rapid
movements.
 Hypotonic:
◦ Passing stage in spastic or ataxic cerebral palsy
 Mixed:
◦ Signs of pyramidal and extrapyramidal deficits

15. •Bilateral spasticity of legs
•1st noticed when infant begins to crawl-tends to drag the
legs behind more ( commando crawl)
•Severe spasticity –application of diaper is difficult due to
excess adduction of hips
•Brisk reflexes, ankle clonus
•Scissoring posture of lower extremity when suspended
by axilla
•Walking tiptoes, disuse atropy ,impaired
growth of lower extremity
•Intellectual development normal
•Minimal seizures
•CT/MRI-periventricular leukomalacia of
white matter mainly lower limb fibres
•All spastic types characterized by toe
walking, a crouched gait, and flexed
knee, scissoring

16. •Arms often more involved than leg-difficulty in
hand manipulation is obvious by 1 yr
•Delayed walking -18-24 months
•Equinovarus deformity of foot, walks on tip
toes because of increased tone
•Affected upper limb has dystonic posture when
child runs
•Deep tendon reflexes increased, ankle clonus,
Babinski sign +
•1/3rd have seizure disorder
•25% have MR
•CT/MRI- atrophic cerebral hemisphere with
dilated lateral ventricle contralateral to the
affected side

17. •Most severe form ,most
common
•All extremities severely
impaired
•High association with MR
and seizures
•Flexion Contractures of
knees and elbows

18.  After age 1yr –athetoid movements
become evident
 Speech is affected (slurred, voice
modulation impaired) due to
involvement of oropharyngeal muscles
 Upper motor neuron signs –not
present
 Seizure uncommon
 Intellect –preserved
 Characterized by an exaggerated step,
hip and knee hyperextension, a
backwards lean, and shoulder girdle
and trunk extension.

19.  I Has nearly normal gross motor function
 II Walks independently, but has limitations with
running and jumping
 III Uses assistive devices to walk and wheelchair
for long distances
 IV Has ability to stand for transfers, but minimal
walking ability; depends on wheelchair for
mobility
 V Lacks head control, can’t sit independently, is
dependent for all aspects of care

20.  Mental Retardation
 Communication
Disorders
 Behavioral disorder
 Seizures
 Vision Disorders
 Hearing loss
 Somatosensation (skin
sensation, body
awareness)
 Temperature instability
 Nutrition
 Drooling
 Dentition problems
 Neurogenic bladder
 Neurogenic bowel
 Gastroesophageal reflux
 Dysphagia
 Autonomic dysfunction

21.  Gait in cerebral palsy
◦ Idiopathic toe walking
◦ Spastic knee gait
◦ Crouch gait

22.  Determine grades of muscle strength and selective
control.
 Evaluate muscle tone and determine type.
 Evaluate degree of deformity / contracture at each
joint.
 Assess linear, angular and torsional deformities of
spine, long bones, hands and feet.
 Appraise balance, equilibrium and standing / walking
posture.

23.  History
 Examination
 X-ray skull-intracranial calcification
 EEG
 CT/MRI
 Test of hearing ,vision
 IQ test

24. Achievable goals should be set
The child with CP becomes the adult with CP
Goals based on needs of adults
 Communication : verbal / nonverbal
 Mobility
 Walking
 Activity of daily living (ADL)
feeding, dressing, toileting, bathing
 Turn focus of parents from the disease to the
goal-oriented approach

25.  Control of spasticity
 Physical therapy
 Orthotics
 Orthopedic surgery

26.  Spasticity is present in most patients with CP (65 % )
 When it is reduced patients may :
- perform integrated muscle
movement
- develop muscle strength
- function at a higher level
 Approaches :
• Selective dorsal rhizotomy
• Intrathecal baclofen
• Botulinum-A toxin

27.  Other oral medicines used in Cerebral Palsy:
◦ Dantrolene
◦ Flexeril
◦ Antiepileptic drugs such as Phenytoin, Sodium Valproate,
Carbamazepine, etc.

28.  Conventional PT :
◦ Works on muscles, tendons, and ligaments
 Active exercises
 Passive ROM exercises
 Passive stretching
 Bracing

29. Involve parents as much as possible
(even if they resist)
Do not raise false hopes
which could increase frustration

30. Casting..
Short leg casts are applied with extended toe plates, careful
molding of the heel and metatarsal head control.
For a period of time varies but usually a minimum of 6 weeks.
and is followed by the use of orthoses.
There is a limited role for casting in patients with cerebral
palsy.
Orthoses..
Can be helpful in improving gait in ambulatory patient with
cerebral palsy.
Ankle-foot orthoses are most commonly prescribed to assist
the child with positioning of the ankle and foot during gait.

31. Ankle Foot Orthoses (AFO)

32.  m

33. Primary deformity : needs treatment
Compensatory deformity : can improve without intervention
Surgery
 Prevent structural changes - usually early
 Improve function - usually later
Distinguish between

34.  Type : spastic
 Extent : hemiplegics / diplegics : good results
quadriplegics : minimal improvement
 Age : 3- 12 years
 IQ : good
 Good upper limb function : for walking
 Underlying muscle power : not weak
 Walker / non-walker :
surgery hardly changes state but improves gait

35.  For structural changes : Early
e.g. Hip subluxation , usually <5 years
 To improve function ( gait ) :
defer until walking ( independently / with aids )
until gait pattern develops and can be assessed
walking : 18 – 21 months in hemiplegia
3 – 4 years in spastic diplegia
 Optimum time of lower extremity surgery
5 – 7 years: can analyze and observe gait pattern

36. Surgery should not be unduly staged one by
one
( with each birthday )
?ETA ? Hams ? Psoas ? Rectus Femoris
Equinus Crouch Flexion Stiff Knee Ok

37.  Hip
◦ Flexion contracture
◦ Increased hip addduction/ scissoring
◦ Subluxating or dislocating hip
 Rotational deformities of femur and tibia
 Knee
 Foot
◦ Equinus
◦ Equinovarus
◦ Pes valgus
◦ Ankle valgus
◦ Hallux valgus
◦ Dorsal Bunion

38.  Adduction and flexion deformity
 Hip at risk
 Hip subluxation
 Hip dislocation

39. Hip flexion contractures are found most commonly
in patients with spastic diplegia and spastic
quadriplegia.
Flexion contracture is due to increased tone in the
hip flexors (primarily the iliopsoas) and relative
weakness of the hip extensors (such as the gluteal
muscles)
The contracture is identified during the physical
examination by performing the Thomas and
Staheli maneuvers.

40. Thomas test
Staheli test

41. Ely / Rectus Femoris
Test

42.  Flexion internal rotation deformity should be
differentiated from True Adduction deformity.
 Increased femoral anteversion when combined with
crouch at the knee can produce the appearance of
scissoring which termed as pseudo adduction
 Adductor surgery will be ineffective in improving the
child’s ability to walk when the narrow base of gait is
secondary to pseudo adduction.

43.  Single-stage multilevel procedures are preferable to
staged single-level procedures because hospitalization,
immobilization, and rehabilitation time and the number
of anesthetic exposures are decreased
 Hip flexion contractures from 15 to 30 degrees usually
are treated with psoas lengthening
 Contractures of more than 30 degrees may require more
extensive releases of the rectus femoris, sartorius, and
tensor fasciae latae and the anterior fibers of the gluteus
minimus and medius, in addition to the iliopsoas

44.  Iliopsoas recession (Skaggs et al technique)

45.  Iliopsoas release at the Lesser trochanter(Miller
technique)

46. Iliopsoas tenotomy / lengthening /
recession
 Tenotomy : Should not be done in
ambulatory patients
 Recession : Doesn’t cause excessive hip
flexion weakness
 Lengthening (z plasty) : best / easy
/satisfactory in ambulating patients no
risk of too much weakening of flexion
power

47.  Most common deformity
 Spasticity in the adductor muscles in cerebral palsy results
in a narrow base of gait and scissoring, hip subluxation,
and, in severely affected children, difficulty with perineal
hygiene

48.  Adductor tenotomy and release
◦ Resection of tendon of adductor longus and anterior half of
addductor brevis and gracilis ,if required
◦ Avoid neurectomy of ant. branch of obturator nerve

49.  Deformities of the hip in patients with cerebral
palsy range from mild painless subluxation to
complete dislocation with joint destruction, pain,
and impaired mobility
 In most patients, the hip is normal at birth, and
radiographic changes typically become apparent
between 2 and 4 years of age.

50.  Hip subluxation in patients with cerebral palsy can
be difficult to detect clinically
 Routine clinical and radiographic examinations
should be done every 6 months
 A practical radiographic method for quantifying the
amount of hip subluxation present, which was
described by Reimers as the “migration percentage.”

51. Hip subluxation ( partially out)
Hilgenreiner line
Dislocated Subluxated
50 %
Reimer’s migration
index

52. Hip subluxation ( partially out )
( > 30 % uncoverage / broken Shenton’s line )

53. Because early intervention can be very effective in
preventing or delaying the development of dislocation,
considerable work has been done to identify hips at
risk

54. Hip at Risk Hip subluxation
At 2.5 years At 7 years

55.  Varus Derotational Osteotomy, usually combined
with soft-tissue releases, is indicated for patients
with excessive anteversion and valgus deformity of
the proximal femur and a hip that is either
subluxated or dislocated

57.  Combined One-Stage Correction of Spastic
Dislocated Hip (San Diego Procedure)
◦ medial approach (soft-tissue release)
◦ anterior approach (open reduction)
◦ lateral approach (femoral osteotomy)
◦ anterior approach (pericapsular pelvic osteotomy)

58.  Proximal Femoral Resection
Painful dislocated
> 1 year
Surgical resection

59.  Hip Arthrodesis
The ideal candidate is a patient with unilateral
disease and no spinal involvement. Hip arthrodesis
may be preferable in ambulatory patients because it
allows weight bearing, in contrast to proximal
femoral resections.

60.  Deformities of the knee rarely occur in isolation
 The hip and the knee are tightly coupled because of
the muscles that cross both joints, the “two-joint
muscles.”

61.  Flexion Deformity
 Recurvatum of the Knee
 Knee Valgus
 Patella Alta

62.  Most common knee deformity in patients with
cerebral palsy and frequently occurs in ambulatory
children
 Crouching gait.

63.  Straight leg raising
◦ Angle< 70 … Indication
 The Hamstring Test
◦ Holt’s method
◦ Popliteal Angle< 135 - Indication

64.  Fractional Lengthening
of Hamstring Tendons

65.  Distal Transfer of Rectus Femoris

66.  Combined Hamstring Lengthening and
Quadriceps Shortening along with posterior
capsule release

67. Hip flexion Deformity
increases after
hamstring release
Better to transfer
hamstring insertion
to keep hip extended

68.  Caused by Quadriceps spasticity or long standing
Knee FFD.
 Can lead to repeated to micro trauma to patellar
tendon and quadriceps tendon and stress fractures
of patella and tibial tubercle.
 Usually painless, so intervention is not required.
 Correction of FFD of knee with hamstring
lengthening causes improvement.

69.  DEFORMITIES
◦ Equinus Deformity
◦ Varus or Valgus Deformity
 Equinovarus Deformity
 Equinovalgus Deformity
◦ Calcaneus Deformity
◦ Cavus Deformity
◦ Forefoot Adduction Deformity
◦ Hallux Valgus Deformity
◦ Claw Toes

70.  Most common foot
deformity in patients
with cerebral palsy
 It is an increased plantar
flexion due to a plantar
flexion contracture or
dynamic plantar flexion
due to over activity of
the gastrocsoleus during
gait

71.  Toe-walking patients must be considered as two
different groups:
◦ equinus patients
◦ as a consequence of crouch at the hip and knee with
natural ankle.
 Cerebral palsy must be differentiated from:
 Idiopathic toe walking as a congenital short Achilles
tendon
 Muscular dystrophy (as Duchenne’s)produces toe
walking.

72.  Clinical examination..
Inability to fully dorsiflex the ankle
 The Silverskiold test:
If the ankle can be passively dorsiflexed with the knee
bent to 90 degree but cannot be dorsiflexed with the
knee extended it is believed that the gastrocnemius is
tight, but the soleus is not contracted
 This test is used to determine which type of surgical
lengthening to perform

73. The Silfverskiold test

74.  Dynamic :
Treat by :
Bracing
Spasticity reduction
Surgery
 Fixed :
Treat by :
Serial casting
Surgery

75.  Open Lengthening of the
Achilles Tendon

76.  Z-Plasty Lengthening of the Achilles Tendon

77.  Percutaneous Lengthening of the Achilles Tendon

78. Vulpius technique.. Strayer procedure

79. Baker technique
(tongue-in-groove)

80.  Diplegic patients typically have internally rotated
and adducted hips, flexed knees, and external
rotation deformity of the tibia. This combination of
deformities causes the foot to assume a valgus
position.
 In hemiplegic patients, the internally rotated thigh
with the knee coming to full extension in stance
phase causes the foot to internally rotate and
produce a varus deformity

81.  Muscle imbalance in which
the invertors of the foot over
power the evertors, most
commonly Tibialis post.
 Gastrocnemius contributing
equinus
 Surgery is indicated to
1. Improve foot contact.
2. Relieve pain.
3. Relieve skin changes

82. The confusion test:
The patient flexes the hip against
resistance
If supination of the forefoot is seen, then
anterior tibialis is contributing to
equinovarus deformity .When
dorsiflexion is seen without supination,
the deformity is less likely to respond to
surgery on the anterior tibialis

83.  It also is important to determine whether or not the
deformity is flexible and correctable or rigid because
patients with flexible deformities are more likely to be
successfully treated nonoperatively with orthotics and
shoe modifications and operatively with soft-tissue
procedures such as tendon lengthenings, releases, or
transfers (usually of the abnormally active muscle)
 Patients with rigid varus deformities generally require
bone procedures, such as calcaneal osteotomy.

84.  Lengthening of the Posterior Tibial Tendon
◦ Z-Plasty Lengthening of the Posterior Tibial Tendon
◦ Step-Cut Lengthening of the Posterior Tibial Tendon
◦ Intramuscular lengthening of the Posterior Tibial Tendon

85.  Split Tendon
Transfers
◦ Split posterior tibial
tendon transfer
It is one of the most common
procedures for equinovarus
deformity treatment.
The posterior one-half of the
posterior tibialis tendon is
rerouted posterior to tibia and
woven into the peroneus brevis
tendon.

88. ◦ Split anterior tibial tendon transfer
The lateral one-half of anterior tibialis is detached from its
insertion.
Passed beneath the extensor retinaculum.
Inserted through a bone tunnel into the cuboid.
Foot is positioned in 5-10 deg. of dorsiflexion.
Known as the Rancho procedure when done in combination with
posterior tibialis lengthening.

89. Split transfer of tibialis anterior tendon

90.  Heel varus will respond to calcaneal osteotomy.
 If the deformity is severe, and with rigid
component of mid foot supination… Triple
arthrodesis should be performed.
 Even with bony procedures, muscle imbalance
must be corrected.

92.  Occurs in up to 25% of patients with cerebral palsy.
and most common in older diplegic or quadriplegic
patients.
 Can be caused by spastic peroneal muscles, weakness
of the p.tibialis and a tight gastrocsoleus.
 Radiographs should be obtained in standing position
for the foot and ankle.
 Conservative treatment should vigorously pursued..
shoe inserts and orthoses may be adequate to relive
pain and avoiding surgery.

94.  Bony surgery is the only predictable alternative
for full and lasting correction.
 Surgical options are…
I. The Grice extra- articular arthrodesis.
II. Lateral column (calcaneal neck) lengthening.
III. Calcaneal osteotomy.
IV. Triple arthrodesis.

95.  Modifications to the original procedure:
 Fibular graft was changed to iliac crest graft.
 Using internal fixation to keep the position of the subtalar joint in
combination with cancellous iliac crest graft.

96. Advantage: preserve
joint motion of sub
talar joint.
Results have been very
good.
Contraindications:
severe rigid valgus
deformity.

97.  Treatment of choice for rigid symptomatic Pes valgus in adolescent
with cerebral palsy.
 Resecting the subtalar, calcaneocuboid, talonavicular joints.
 Indications:
1. Pain
2. Skin ulceration over the talar head.
3. Deformity interfering with ambulation in child with deformity not
amenable to osteotomy.
 Satisfactory outcomes are found when deformity is well corrected.
 Degenerative changes have been documented in the ankle joint at
an average of 18yrs.following arthrodesis in 43% of the pediatric
population.

98. Triple arthrodesis for Pes valgus treatment

99.  It is a rare deformity.
 The first metatarsal head is elevated, but
the great toe is plantar flexed.
 Surgical rebalance depends on…
Transfer of the flexor tendon to the extensor.
Or flexor tenotomy.
Or by transferring of the flexor hallucis brevis
to the metatarsal neck
Or by all that in combination with closing
wedge plantar flexion osteotomy of first
metatarsal.

100.  Develops in cerebral palsy patients in response to a Equino valgus deformity of the
hind foot.
 There is a progressive eversion and abduction of foot because of peroneus longus is
spastic.
 The toe is pushed laterally as weight is borne by the everted foot.
 The big toe comes to lie beneath the second toe, and the first metatarsal head
becomes uncovered and painful bunion develops.
 When this deformity is mild, surgical treatment of Pes valgus will halt the
progression of toe deformity.
 Bleck& Goldner described soft tissue realignment including:
Release of the adductor hallucis t. and lateral capsulotomy of the first metatarsophalangeal
joint. combined with first metatarsal and proximal phalangeal osteotomy.
 McKeveer technique:
 First metatarsophalangeal fusion.
 That led to better results with less recurrence than soft tissue realignment.
 Preferred position for fusion is 15-25 deg. Of dorsiflexion and slight valgus.

101. Hallux valgus in 14 yrs. Old girl with cerebral palsy.
Treated with metatarsophalangeal fusion.

102.  Usually caused by femoral ante-
version
 Internal tibial torsion adds to Intoeing
 Not related to spasticity of internal
rotators
 If severe : Derotation osteotomy
Delay to late childhood if
possible
 Derotation osteotomy of femur might
cause tightening of medial hamstrings
( might need lengthening )

104.  Anteversion rotates Greater Trochanter
posteriorly
 On stance phase need Abductor power
 Abductor power optimized when Greater
Trochanter is lateral not posterior
 Internal rotation in stance phase brings
Greater Trochanter laterally

105.  Severe femoral anteversion, with loss of all
external rotation.
 Dynamic in-toeing causing gait abnormalities.
 Dynamic in-toeing causing secondary foot
deformity.
 Usually not before 8-10 years.

106. THANK YOU…!!