بسم الله الرحمن الرحيم بسم الله الرحمن الرحيم CEREBRAL PALSY

a group of disorders that result from non-progressive brain damage during early development and are characterized by abnormalities of movement and posture

causal factors are maternal toxaemia, prematurity, perinatal anoxia, kernicterus and postnatal brain infections birth injury, though often blamed, is a distinctly unusual cause.

Classification . when the child is frightened. It is caused by damage Spasticity , is the commonest muscle movement disorder and is associated with damage to the pyramidal system in the CNS. Hypotonia , is usually a phase, lasting several years during early childhood before the features of spasticity become obvious Athetosis. manifests as continuous, involuntary, writhing movements which may be exacerbated when the child is frightened. It is caused by damage to the extrapyramidal systems of the CNS. .

Mixed palsy, appears as a combination of spasticity and athetosis Dystonia, There is a more generalized increase in muscle tone and abnormal positions induced by activity. Ataxia. appears in the form of muscular incoordination during voluntary movements. It is usually due to cerebellar damage. Mixed palsy, appears as a combination of spasticity and athetosis

TOPOGRAPHIC DISTRIBUTION Hemiplegia is the commonest. This usually appears as a spastic palsy on one side of the body.

Diplegia involves both sides of the body, with the lower limbs always most severely affected

Total body involvement describes a general and often more severe disorder affecting all four limbs

Monoplegia occasionally appears in an upper limb

Diagnosis in infancy A history of prenatal toxaemia, haemorrhage, premature birth, difficult labour, foetal distress or kernicterus should arouse suspicion

Early symptoms include difficulty in sucking and swallowing, with dribbling at the mouth. The mother may notice that the baby feels stiff or wriggles awkwardly.

Diagnosis in later childhood Most children presenting to the orthopaedic surgeon have already had the diagnosis made. Occasionally, for example with a mild hemiplegia or a symmetrical mild diplegia, the diagnosis has not been made and the child is simply referred for advice about their gait or their tendency to trip and fall

Tests for diagnosis in children over 1 year The primitive neck-righting reflex, asymmetrical and symmetrical tonic neck reflexes, the Moro reflex and the extensor thrust response should all have disappeared at 1 year of age. .

Children who retain more than two primitive reflexes after that age, cannot sit unsupported by 4 years and cannot walk unaided by 8 years are unlikely ever to walk independently

Ideally the child should be reviewed by a multidisciplinary team so that speech, hearing, visual acuity, intelligence and motivation can also be assessed.

Management Medical treatment Baclofen, acts by inhibiting reflex activity Dantrolene. produces weakness without much reduction in spasticity Analgesic medication , for the reduction of pain associated with musculoskeletal problems

Botulinum toxin, This potent neurotoxin is produced by Clostridium botulinum; it acts by blocking acetyl choline release at the neuromuscular junction. The preparation is injected into the ‘spastic’ muscle

Physical therapy

Manipulation and serial casting

Operative treatment The indications for surgery are: (1) a spastic deformity which cannot be controlled by conservative measures; (2) fixed deformity that interferes with function; and (3) secondary complications such as bony deformities, dislocation of the hip and joint instability.

Surgery Splintage Deformity Lengthen tendo Achillis and transfer lateral half of tibialis anterior to cuboid Spring-loaded dorsiflexion Bracing in eversion and Equinus Equino varus Foot Hamstring release Long caliper flexion Knee Obturator neurectomy Adductor muscle release Adduction Hip – Release elbow flexor Flexion Elbow Lengthen or release wrist flexors; may need fusion or carpectomy splint Flexion wrist Wrist Lenghten or release flexor Fingers –

POLIOMYELITIS Poliomyelitis is an acute infectious viral disease, Spread by the oropharyngeal route, that passes through several distinct phases.

Clinical features Poliomyelitis typically passes through several clinical phases, from an acute illness resembling meningitis to paralysis, then slow recovery or convalescence and finally the long period of residual paralysis. The disease strikes at any age but most commonly in children

The acute illness Early symptoms are fever and Headache. in about one-third of cases the patient gives a history of a minor illness with sore throat, mild headache and slight pyrexia 5–7 days before

Paralysis Soon muscle weakness appears; it reaches a peak in the course of 2–3 days and may give rise to difficulty with breathing and swallowing.

Recovery and convalescence A return of muscle power is most noticeable within the first 6 months, but there may be continuing improvement for up to 2 years.

Post polio syndrome

Treatment Depending on the stage . Stage of onset. Greatest paralysis. Recovery. Residual deformity.

Early treatment . During the acute phase the patient is isolated and kept at complete rest, with symptomatic treatment for pain and muscle spasm. Active movement is avoided but gentle passive stretching helps to prevent contractures.

Late treatment

Passively correctible deformity Residual paralysis Fixed deformity Flail joint Shortening Vascular dysfunction Sensation is intact but the paralyzed limb is often cold and blue

operative treatment Two main group of operations Arthrodesis of joints. Muscle or tendon transfers.