1. 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

2. Introduction  Why Upper limb?  Which Botulinum Toxin?  Why Ultrasound?

3. Technique  Sonography guided injection of Botulinum toxin  Multilevel, multisite  Dose range per child used 4 to 20 units/Kg

4. Visualization of muscle groups ?

5. Visualization of muscle groups PL FCR PT

6. The Multidisciplinary Team The Family and Child Hospital Physiotherapist Hospital Occupational Therapists Consultant Paediatric Neurologist Consultant Upper Limb Surgeon Consultant Lower Limb Surgeon Community Physiotherapists Community Occupational Therapists Specialist Children's Hospital

7. Post Injection Management  Physiotherapy – Stretch  Physiotherapy – Strengthen Agonists  Splintage

8. Why the controversy?  Very little level 1 evidence  Variation in post injection regimes  Inherently heterogeneous patient group  Difficulty in establishing treatment goals

9. 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

10. 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)

11. Outcomes  More reliable targeting of treatment due to toxin used and method of disposition  “Soft” outcome measures:  Better posture  Better hygiene  Better function

12. Functional Ability  ABILHAND-Kids questionnaire  21 tasks  Bimanual ability assessment  Discriminators of difficulty  Base line assessment of function

13. Goal Attainment  Individualized outcome markers  Functionally relevant  Goal Attainment Scaling

14. 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

15. Surgical Strategies

16. Indications  Pain  Failure of Toxin Therapy  Established Contractures  Hygiene / Dressing / Transfer

17. Indications  FUNCTION

18. Principles Lengthen Tendon vs Shorten Skeleton

19. Surgical Options  Tendon  Transfer  Lengthening  Release  Tightening  Skin Procedures  Bone / Joint  Osteotomy  Excision Arthroplasty  Arthrodesis

20. Tendon Transfer Principles  Subtle Joints  Stable Joints  Active Excursion  Healthy Soft Tissue  One Tendon One Joint  One Action  Synergy

21. Tendon  Principles and Aims Differ  Internal Splinting  Which Procedure?  Divide / Lengthen / Transfer  Depends on which Musculotendinous unit  Requirements

22. Bone / Joint  Arthrodesis  Thumb CMCJ  Excision Arthroplasty  Proximal Row Carpectomy + Tendon Surgery  Osteotomy

23. Post Op Care  Casting  Splinting  Therapy

24. Questions?