Management of the Upper Limb in Children with Cerebral Palsy Prof P McArthur FRCS(Plast) PhD Consultant in Congenital Hand and Upper Limb Surgery Department of Plastic Surgery Royal Liverpool Children's Hospital Alder Hey Liverpool Introduction Why Upper limb? Which Botulinum Toxin? Why Ultrasound? Technique Sonography guided injection of Botulinum toxin Multilevel, multisite Dose range per child used 4 to 20 units/Kg Visualization of muscle groups? Visualization of muscle groups PL FCR PT The Multidisciplinary Team Hospital Physiotherapist Specialist Children's Hospital Hospital Occupational Therapists The Family and Child Community Physiotherapists Community Occupational Therapists Consultant Paediatric Neurologist Consultant Upper Limb Surgeon Consultant Lower Limb Surgeon Post Injection Management Physiotherapy – Stretch Physiotherapy – Strengthen Agonists Splintage Why the controversy? Very little level 1 evidence Variation in post injection regimes Inherently heterogeneous patient group Difficulty in establishing treatment goals Our Experience 41 patients 2004 – 2008 M:F ratio, 15:26 Mean age at first injection 11 years (range 3 – 16 yrs) 9 Bilateral Upper Limb injections Treatment Patterns 14/41 Required 2 Treatments Mean time to reinjection 8 months (range 3-16 months) 3/41 Required 3 Treatments Mean time to reinjection 10 months (range 5-15 months) Outcomes More reliable targeting of treatment due to toxin used and method of disposition “Soft” outcome measures: Better posture Better hygiene Better function Functional Ability ABILHAND-Kids questionnaire 21 tasks Bimanual ability assessment Discriminators of difficulty Base line assessment of function Goal Attainment Individualized outcome markers Functionally relevant Goal Attainment Scaling Summary Ultrasound guided treatment allows precise disposition of toxin to desired site Botox is the preparation of choice A multi disciplinary approach is required to maximize gains High level supporting evidence is elusive Individual goals for each child should be identified Surgical Strategies Indications Pain Failure of Toxin Therapy Established Contractures Hygiene / Dressing / Transfer Indications FUNCTION Principles Lengthen Tendon vs Shorten Skeleton Surgical Options Tendon Transfer Lengthening Release Tightening Skin Procedures Bone / Joint Osteotomy Excision Arthroplasty Arthrodesis Tendon Transfer Principles Subtle Joints Stable Joints Active Excursion Healthy Soft Tissue One Tendon One Joint One Action Synergy Tendon Principles and Aims Differ Internal Splinting Which Procedure? Divide / Lengthen / Transfer Depends on which Musculotendinous unit Requirements Bone / Joint Arthrodesis Thumb CMCJ Excision Arthroplasty Proximal Row Carpectomy + Tendon Surgery Osteotomy Post Op Care Casting Splinting Therapy Questions?