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Surgical Treatment of the Hand in Cerebral Palsy: Correction of Thumb-in-Palm and Other Deformities: REPORT OF NINETEEN CASES.

KEATS, SIDNEY
Journal of Bone & Joint Surgery - American Volume: March 1965
Case Report

1. It has been demonstrated within recent years that certain carefully selected orthopaedic surgical procedures, skillfully performed and with proper postoperative care, can benefit the cerebral-palsied child in a way not possible with other therapies and in a shorter time than with any single conservative measure.

2. It should be borne in mind that the function of the hand is primarily reach, grasp, and release; surgical procedures on the cerebral-palsied hand do not provide the initiation of movement lost as a result of damage to cerebral control. Operative procedures should be reserved for patients with a predominantly spastic hand, rarely for the patient with pure athetosis, tremor, rigidity, and ataxia.

3. Careful screening of patients considered for surgical treatment of the hand should include such general factors as the age, cooperation, and mentality of the patient, brace tolerance, and motivation, as demonstrated by the occupational-therapy program. Screening should also consider the type of cerebral palsy, the degree of involvement and appearance of the hand, sensory appreciation and existing functional capacity of the hand, the degree of involvement of the other extremities, psychological attitudes of the parents and child, and the need for functional or cosmetic improvement.

4. Indications for operation depend on the ability of the hand to grasp and release, the degree of control of the wrist and fingers, the position of the hand in grasp and release, the degree of spasticity, and the evaluation of motor activity of the flexors and extensors of the wrist and the fingers.

5. The general plan of treatment should be clearly delineated, including preparatory treatment by stretching, splints, and braces and occupational therapy. Parents and child can be observed during this period for evaluation of motivation and ability to cooperate.

6. The specific surgical procedures must follow a systematic sequence. Selective tenotomies are performed first to eliminate deforming elements; then, carefully planned and executed tendon transfers are performed at the same procedure. Joint stabilization is reserved as the last procedure.

7. Postoperatively, the surgeon must check carefully the casts and braces as well as the program of occupational and physical therapy.

8. In my experience, three specific procedures have given successful results in properly selected handicapped hands: (1) transfer of the flexor carpi ulnaris tendon to the extensor carpi radialis brevis to improve dorsiflexion of the wrist; (2) arthrodesis of the wrist to correct deformity and stabilize the wrist; and (3) stripping of the first dorsal interosseus muscle from the metacarpal of the thumb, tenotomy of the adductor pollicis muscle, and transfer of the flexor carpi radialis tendon to the tendons of the long abductor and short extensor tendons of the thumb for correction of a thumb-in-palm deformity.

9. The results of twenty-nine procedures on nineteen patients operated on from 1958 to 1963 are described. They are encouraging and clearly indicate the expanding opportunities for the habilitation, by modern orthopaedic surgery, of children with cerebral palsy.

Copyright 1965 by The Journal of Bone and Joint Surgery, Incorporated

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