See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/51737382

Assessment of the hand in cerebral palsy

Article in Indian Journal of Plastic Surgery · May 2011

DOI: 10.4103/0970-0358.85356 · Source: PubMed

CITATIONS READS
13 11,684

2 authors:

Praveen Bhardwaj Raja Sabapathy

Ganga Medical Centre & Hospitals Pvt. Ltd. Ganga Medical Centre & Hospitals Pvt. Ltd.
94 PUBLICATIONS 654 CITATIONS 254 PUBLICATIONS 1,848 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Raja Sabapathy on 05 December 2015.

The user has requested enhancement of the downloaded file.

[Downloaded free from http://www.ijps.org on Saturday, July 28, 2012, IP: 122.178.186.125] || Click here to download free Android application for this journal

Review Article

Assessment of the hand in cerebral palsy

Praveen Bhardwaj, S. Raja Sabapathy

Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns Ganga Hospital, 313, Mettupalayam
Road, Coimbatore, India

Address for correspondence: Dr. S. Raja Sabapathy, Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns,
Ganga Hospital, 313 Mettupalayam Road, Coimbatore– 641 043, India. E-mail: rajahand@vsnl.com

ABSTRACT
Cerebral palsy is the musculoskeletal manifestation of a nonprogressive central nervous system
lesion that usually occurs due to a perinatal insult to the brain. Though the cerebral insult is static
the musculoskeletal pathology is progressive. Some patients with cerebral palsy whose hands are
affected can be made better by surgery. The surgical procedures as such are not very technically
demanding but the assessment, decision-making, and selecting the procedures for the given
patient make this field challenging. When done well, the results are rewarding not only in terms
of improvement in hand function but also in appearance and personal hygiene, which leads to
better self-image and permits better acceptance in the society. This article focuses on the clinical
examination, patient selection, and decision-making while managing these patients.

KEY WORDS
Assessment, cerebral palsy, decision-making, examination, spastic hand

ASSESSMENT OF THE HAND IN CEREBRAL mild spasticity of the hand to a completely wheelchair
PALSY bound child who is unable to communicate and totally
ignores his involved upper limb. But all patients have

C
erebral palsy is the musculoskeletal manifestation these common features:[2]
of a nonprogressive central nervous system • Cerebral palsy is the result of a brain lesion. Therefore,
lesion that usually occurs due to a perinatal insult the spinal cord and muscles are structurally and
to the brain. Though the cerebral insult is static the biochemically normal.
musculoskeletal pathology is progressive. Spasticity leads • The brain lesion must be fixed and nonprogressive.
to shortening of musculoskeletal units, which in turn Thus, all of the progressive neurodegenerative
causes fixed contractures and eventually leads to torsional disorders are excluded from the definition.
abnormalities of long bones, joint instability, deformity, • The abnormality of the brain results in motor
and degenerative arthritis.[1] The clinical manifestation impairment.
may vary widely ranging from an intelligent child with

Access this article online The complexity of the spastic hand is due to the fact that
Quick Response Code: the spastic muscles cannot be used as tendon transfers
Website:
with the same efficiency as done in reconstructive surgery
www.ijps.org
of the hand with flaccid paralysis.[3] The deformity is
DOI:
basically a dynamic deformity and hence the surgeon
10.4103/0970-0358.85356 must have a definite plan before embarking on the
procedure. After anesthesia, the deformities disappear
Indian Journal of Plastic Surgery May-August 2011 Vol 44 Issue 2 348
[Downloaded free from http://www.ijps.org on Saturday, July 28, 2012, IP: 122.178.186.125] || Click here to download free Android application for this journal

Bhardwaj and Sabapathy: Hand in cerebral palsy

and the hand may appear normal. The senior author thumb to the index finger but a child with cerebral palsy
would always say that “In cerebral palsy the consultant does not reach this milestone, although they may develop
cannot operate based on the findings of the registrar. One a more primitive key pinch (thumb to side of index
needs to know the extent of release required, tension finger).[4] When the child is older, sensory defects,
adjustment in tendon transfer, stability of the joints the abnormal intelligence, and poor voluntary control of
proposed tendon transfers would cross, the spasticity various muscle groups become obvious. If the child was
and voluntary control of the muscles selected for the born full term, if there were no perinatal medical problems,
transfer and moreover the child’s use of the hand during and especially if the child began to develop normally and
the bimanual activities.” The surgical procedures as such then regressed, prompt neurologic consultation should
are not very technically demanding but the assessment, be sought. The neurologist will differentiate cerebral
decision-making, and selecting a procedure for the given palsy from brain and spinal cord tumors and progressive
patient make this field challenging. When done well, the neurodegenerative diseases.[2]
results are rewarding not only in terms of improvement
in hand function but also in appearance and personal OUTCOME OF SURGERY FOR UPPER
hygiene, which leads to better self-image and permits EXTREMITY IN CEREBRAL PALSY
better acceptance in the society.
Outcome of surgery in the upper limb cerebral palsy is not
The goals of surgical intervention are set depending on as good as in lower limbs because children preferentially
the preoperative functional status. When the child has a use the good limb for most activities and it is difficult to
good voluntary motor control the goals are to improve train a limb suffering from “learned non-use.” Retraining
function and appearance. In cases of severe involvement, the upper limb is more difficult because it lacks repetitive
surgery is a reasonable option if it facilitates the nursing motor tasks, like walking. Higher incidence of dystonia,
care by the parents or the care giver. weakness, sensory impairment, and poor selective
motor control coexist with spasticity in the upper limb.
DIAGNOSING CEREBRAL PALSY Compared with lower limb, upper limb tasks are more
sophisticated and require high level of coordination and
Delay in milestones is an important indicator of cerebral control.
palsy. So a surgeon should be familiar with the normal
infant milestones. On average head control in an infant CLINICAL ASSESSMENT
is attained at 3-4 months, sitting by 6 months, crawling
by 9 months, standing by 10-12 months, and walking The examination of a child with cerebral palsy requires
by 12-18 months. The diagnosis should be suspected if patience. An examination of the motor, sensory, and
there is paucity of spontaneous movements during the intellectual function is done. Multiple visits may be
first few months of life, or if the motion of both upper needed. Symptoms may vary with the child’s emotional
limbs is not symmetric. Preferential use of one hand is state and fatigue level. Lengthy examinations should be
an important signal toward impaired neurologic status fragmented. Video recording is helpful.
of the other limb. Normally the hand dominance starts
developing at about 2-3 years and is fully developed by The child and family are asked to describe precisely
6 years. Early handedness, particularly apparent left- how the hand is used in activities of daily living, such as
handedness in small infants, is often a clue that the dressing, self-care, and eating. Parents are usually able to
neurologic status of the other extremity is abnormal, state the functional and cosmetic disability the child has.
and that spastic hemiplegia may be present.[2] Infantile
reflexes like Moro’s reflex, parachute reflex, tonic neck The motor examination of the upper limb should be
reflex are normal in a neonate but disappear by 3--6 aimed to address these six points:
months as the motor cortex matures and overrides • The dominant and deforming spastic muscles, their
them.[2] These reflexes are retained in children with strength, and voluntary control.
cerebral palsy. Identification of upper limb dysfunction • The status of the weak or nonfunctioning antagonists.
is usually noted by 1 year of age. Normally at 1 year an • Potential donors to substitute the weak muscles.
infant develops a refined pinch with opposition of the • Global motor control of the upper limb.
349 Indian Journal of Plastic Surgery May-August 2011 Vol 44 Issue 2
[Downloaded free from http://www.ijps.org on Saturday, July 28, 2012, IP: 122.178.186.125] || Click here to download free Android application for this journal

Bhardwaj and Sabapathy: Hand in cerebral palsy

• Voluntary control of various muscle groups. the contralateral knee. The speed and precision of the
• Existing function and functional needs of the hand for movement are recorded.
that particular patient.
Volitional use of the hand is the best predictor of
The examination begins with observing the position of functional improvement after a change in position of the
the rest of the extremity. The position of the limb should hand. Each muscle or a group of muscles are evaluated
also be assessed in walking and running which represents for voluntary motor control.
the actual cosmetic and functional disability.
Grasp and release
Resting position provides information on the amount of The child is asked to pick up the blocks of different size
spasticity. Spasticity of the muscle can be detected by and shape. This test evaluates not only the prehensile
performing the passive opposite movement and feeling capacity of the hand but also the contribution of the
for the abnormal contraction of the muscles. Spasticity of whole limb to that function. Quantitative measurements
finger extrinsic muscles can be tested by tapping briefly can be made if one introduces the time factor.
on the pulps of the fingers (for flexors), on the nails (for
extensors), which produces an exaggerated response of Bimanual activities
the tested muscles.[5] Spasticity of the intrinsic muscles of This gives accurate information of the spastic upper
the hand is extremely difficult to evaluate because of the limb’s actual functional ability.
associated deformities. Generally a swan-neck deformity
with the associated flexion of the metacarpophalangeal
GRADING OF HAND FUNCTION
(MCP) joint indicates intrinsic spasticity. The spastic
muscle is usually active, but their voluntary movements
McConnell and colleagues[6] reviewed 18 classification
are often impaired by cocontractions, e.g., cocontraction
systems for the upper limb in children with cerebral
of the wrist flexors with the attempted finger flexion.
palsy, and found House classification reliable and
clinically useful. House’s[7] classification contains nine
An attempt is made to grade the power of the spastic
subgroups and gives detailed functional levels. It makes
muscle though it is not always accurate. Passive as well as
identification of small functional improvement possible
active range of motion of all joints should be measured. It
[Table 1]. A simpler but equally useful classification of
is important to differentiate muscle spasticity from muscle
practical use in clinical practice is the system of Green
and joint contracture. Muscle spasticity can be overcome
and Banks,[8] modified by Samilson and Morris,[9] which
by the application of gentle sustained resistance to the
contains four subgroups:
spastic force, whereas muscle contracture cannot. Muscle
• Poor: Use of the hand only as a paperweight, poor or
spasticity, with relaxation, allows a full range of motions
absent grasp and release, and poor control
of the joint.
• Fair: Use of the hand as a helping hand but no effectual
use of the hand in dressing, moderate grasp and
The nonfunctioning or the weak muscles are identified
release, and fair control
and the strength of all potential donor muscles for
transfer should be measured. In some cases the muscle • Good: Use of the hand as a help in dressing and eating
may be present but made ineffective by the spastic and general activities, effectual grasp and release,
antagonist or by the elongation caused by a severe excellent control
deformity. Careful palpation of the muscle belly during • Excellent: Good use of the hand in dressing and eating,
attempted active motion may confirm that the muscle is effectual grasp and release, and good control
not paralyzed but cannot give information of its actual
strength. Asking patients to perform activities with both CRITERIA FOR PATIENT SELECTION FOR
extremities simultaneously can ensure that the patient SURGICAL INTERVENTION
comprehends instructions.
Age for surgery
Global motor control can be evaluated by standard The ideal age for the surgery is debatable. Four to six
tests, such as head-to-knee test, in which the patient is years is recommended because at this age adequate
asked to place his hand on his head and then move it to maturation of the nervous system has occurred.[10] At 4
Indian Journal of Plastic Surgery May-August 2011 Vol 44 Issue 2 350
[Downloaded free from http://www.ijps.org on Saturday, July 28, 2012, IP: 122.178.186.125] || Click here to download free Android application for this journal

Bhardwaj and Sabapathy: Hand in cerebral palsy

Table 1: House’s[7] functional classification system

Class Designation Activity level
0 Does not use Does not use
1 Poor passive assist Uses as stabilizing weight only
2 Fair passive assist Can hold onto object placed in hand
3 Good passive assist Can hold onto object and stabilize it for use by other hand
4 Poor active assist Can actively grasp object and hold it weakly
5 Fair active assist Can actively grasp object and stabilize it well
6 Good active assist Can actively grasp object and then manipulate it against other hand
7 Spontaneous use Can perform bimanual activities easily and occasionally uses the hand spontaneously
8 Spontaneous use Uses hand completely independently without reference to the other hand

years the deformities are easily detected and the child • Patients with IQ greater than 50 but poor placement
is usually mature and motivated enough to participate and sensibility should also be considered for
in the rehabilitation program. Miller[10] feels that 7-- procedures to improve the contracted appearance of
12 years is appropriate as children are cooperative for the limb.
occupational therapy and enough skeletal growth has • Patients with IQ greater than 50, hand placement
occurred to prevent recurrence due to increasing muscle less than 5 seconds, and good sensibility are ideal
tightness secondary to growth. As the child gets older, candidates for functional improvement of the
the contractures become more severe and this may extremity with reconstructive surgery.
hamper the results of tendon transfer.
Type and extent of neurological involvement
Only patients with pure spastic type of involvement are
Even though surgery is recommended at an early age,
amenable for surgical correction. One has to rule out the
older age is not a contraindication as long as the patient
presence of dystonia or athetosis as the patients with
tries to use and has voluntary control of the hand.[11]
these types of movement disorders do not get better
However adults should be evaluated cautiously before
with surgical intervention. The results are unpredictable
surgical planning, because the patients have adapted to
and some may even get worse after the operation.
the handicap, and surgery must not downgrade function.

Intelligence level Voluntary function

Assessment of IQ is difficult in a child with cerebral palsy Voluntary use of the hand is consistently reported as an
and may not be accurate.[9,12] Many surgeons believe important predictor of the outcome of operation.[3,14,15]
that reconstructive surgery should not be undertaken Samilson and Morris[9] wrote that “the patient who has
if the IQ is less than 70.[8,13] Van Heest and colleagues[14] already dissociated his upper limb from bodily functions
in their study involving 134 patients observed that is not a candidate for reconstruction.” The indication for
similar functional improvement (2 level on House scale) surgery is questionable when patients tend to neglect
can be achieved in the highly motivated patient with the affected arm -- “learned disuse.” Ideally, surgery to
fair to good motor control regardless of preoperative improve function is reserved for those children who
mentation, sensibility, and type of cerebral palsy. Leaving have impaired function, but are trying to use the limb.
the controversy aside most surgeons would agree that However, if the main indication for surgery is to improve
the patient must be intelligent enough to interpret what position, it can be done.
is proposed to him in the way of treatment and to co-
operate in postoperative reeducation. IQ is not important Sensation and sensibility
when considering patients for procedures which do not The usual sensory condition of these patients is the
require reeducation and training, e.g., wrist fusion. preservation of the basic sensations of touch and
pain, and also the ability to recognize the physical
Summary of the guidelines[4] characteristics of the touched object- consistency,
• Hygiene should be the primary goal in patients shape, size, and surface without the aid of sight. The
with IQ less than 50, hand placement greater than 5 principle sensory deficit is in proprioception and tactile
seconds, and poor sensibility. gnosis (two-point discrimination). These sensory deficits
351 Indian Journal of Plastic Surgery May-August 2011 Vol 44 Issue 2
[Downloaded free from http://www.ijps.org on Saturday, July 28, 2012, IP: 122.178.186.125] || Click here to download free Android application for this journal

Bhardwaj and Sabapathy: Hand in cerebral palsy

make the child not to use his affected upper limb hand in space.[15] Zancolli[3] is a proponent of single-stage
spontaneously unless he is compelled to do so. Thus correction of all the elbow, forearm, wrist, thumb, and
surgery may improve the function of the hand but does finger deformities.
not reintegrate independent function in majority of
the cases. The child will still prefer to use the normal We prefer addressing one deformity in one procedure,
hand, using the affected hand only when necessary for instead of doing several different operations at once.
bimanual activities. Severe sensory deficit with loss of This allows us to assess the result of the procedure
even the touch and pain sensation is very unusual but after rehabilitation and help in planning subsequent
makes any attempt at surgical functional restoration procedures. With safer anesthetic techniques, with most
ineffective. Although important, sensibility should not operations being done under regional block multiple
in itself be a contraindication to surgery. Many children operations are no more a concern.
effectively use hand eye coordination to compensate for
defect in steriognosis and proprioception, particularly if Assessment of specific deformities
they have good voluntary control. In the upper extremity the typical pattern of spastic
joint deformity includes shoulder internal rotation,
Sensory examination requires, besides the child’s
elbow flexion, forearm pronation, wrist flexion and
cooperation, a certain level of intellectual capacity and
ulnar deviation, thumb-in-palm, and finger swan-neck
language ability. It becomes practical only after 4--5 years
or clenched fist deformity. Separation into deformities
and more complicated tests like 2-PD are reliable only
is undoubtedly artificial, but can help to understand
after 6--7years of age. Stereognosis was found to be
and treat the problem more specifically. The following
the most sensitive discriminator of sensibility
session discusses the assessment and decision-making
impairment.[16] Carlson and Brooks[17] found that
for correction of pronation deformity at forearm, wrist
stereognosis may be affected by hand position and may
improve after surgery to improve hand position. Sensation flexion deformity, swan--neck deformity, and thumb
is considered satisfactory when the child identifies at deformities.
least three out of five objects, can recognize large figures
drawn in the palm, and has a two-point discrimination Pronation deformity at forearm
test of no greater than 5--10 mm (according to the child’s Extreme pronation deformity decreases the sight of the
age).[18] object being grasped and thus obstructs the visual stimulus
in these patients with compromised stereognosis.
Motivation and environment
Motivation and parental support are important. Van The ability to supinate the forearm to neutral position
Heest and colleagues[14] found motivation as the only improves overall dexterity and function. The hand can
other significant determinant of outcome other than then reach the mouth and hair. Simple activities such as
good motor control. clapping the hands and catching balls are possible.[20]

According to Tonkin,[19] “the ideal candidate is a Palpation of the pronator teres during passive supination
cooperative 6-years-old child, with stable family support, of the forearm can identify spasticity. Evaluation for active
who has predominantly spastic upper limb deformity, with supination and pronation should also be determined, as
satisfactory hand sensibility, hemiplegic or monoplegic well as the position of the forearm at rest.
and without significant neurological deficits.”
The classification described by Gschwind and Tonkin[20]
Finally one must perform a complete general examination provides a sound basis upon which to plan surgery, aimed
(preferably with the help of physician and anesthesiologist) at improving supination but maintaining pronation, and
to seek associated neurological disorders and any thus improving function of children with cerebral palsy
contraindication to surgery. [Table 2].

Staging of operation We use this classification with following modifications:

It is usually appropriate to start proximally as adequate we divide group 1 patients into two groups depending
shoulder and elbow function is required to position the on the side involved -- right/left. We feel that in a good
Indian Journal of Plastic Surgery May-August 2011 Vol 44 Issue 2 352
[Downloaded free from http://www.ijps.org on Saturday, July 28, 2012, IP: 122.178.186.125] || Click here to download free Android application for this journal

Bhardwaj and Sabapathy: Hand in cerebral palsy

Table 2: Classification of pronation deformity described by Gschwind and Tonkin[20]

Group Classification Recommended operative procedure
Group 1 Active supination beyond neutral position No specific treatment
Group 2 Active supination to less than, or to, neutral position Pronator quadratus release +/− flexor aponeurotic release
Group 3 No active supination Pronator teres transfer
Free passive supination
Group 4 No active supination Pronator quadratus release +/− flexor aponeurotic release
No passive supination

functional right hand lack of supination even beyond better muscular balance will allow obtaining extension
neutral can be considered a functional problem in Indian of the fingers with smaller flexion of the wrist and better
culture. Lack of supination beyond neutral makes it ability for grasping.
difficult to eat with the hand and also unable to take
the offerings in the temple or ceremonies (one of the In most spastic hands the possibility of flexing the wrist
most common complaints of the parents in our patient actively is fundamental for releasing the hand. This
population). Hence, we would consider them for surgery. implies that wrist fusion is not a very useful operation to
In the left hand the same deformity is acceptable. The improve the function and when the patient has no active
left hand is used for perineal care, and pronation is wrist flexion and the fingers remain permanently flexed
important and supination till or past neutral is acceptable reconstructive surgery is not effective.[3] For the same
both cosmetically and functionally. reason any decision to transfer a wrist flexor to obtain
wrist extension must consider the ability to retain wrist
In the patients with group 2 type of involvement, we flexion. The flexor carpi ulnaris to extensor carpi radialis
feel that if one is not sure that the deformity is more brevis transfer is well accepted. However, the ability to
because of spasticity of the pronators than because of contract the flexor carpi radialis muscle voluntarily must
lack of supinator one should do a pronator teres transfer. be assessed. If this is not possible, a wrist extension
Because once you have released the pronator quadratus deformity may result with a consequent inability to
transferring the pronator teres for supination may result extend the fingers.
in supination deformity. Pronator teres rerouting is a safe
option in this group as well. Pronator quadratus retains Swan-neck deformity
adequate pronation. The swan-neck deformity in cerebral palsy can be of two
types -- extrinsic and intrinsic.[21] In the extrinsic type
Wrist and hands the main cause is the overactivity of the long extensor
The flexion contracture of the wrist weakens and makes tendons, which is generally due to flexed position of the
grasping very difficult. This is due to the flexor muscle of wrist [21] Overpull of digital extensors causes stretching of
the wrist, particularly the flexor carpi ulnaris, remaining the volar plate and eventually hyperextension deformity
contractured during finger flexion (cocontraction). Also of the proximal interphalangeal joint without MCP
the flexion of the wrist slackens the long flexors and flexion. Once the volar plate is stretched even if the wrist
hence weakens the grip. This alters the normal pattern flexion is corrected, the swan-neck deformity persists
of grasping functions of the hand. With better wrist and can be severe.[22]
position after surgery the active finger flexion and the
grip usually improves. In the intrinsic type, the main cause is the increased
power of traction of the intrinsic muscles and is due to
Zancolli[3] classified the deformities in cerebral palsy as the spasticity of the intrinsic tendons.[21] The patient has
extrinsic and intrinsic based on the predominance of substantial MCP joint flexion deformity due to intrinsic
localization of the spasticity of the deformity. Part of spasticity with usually mild swan-neck deformity.[22]
his classification which relates to the correction of wrist
deformity is widely used [Table 3]. It is important to differentiate between these two types
of patients because the later requires intrinsic release
Group 2 patients represent the ideal case for procedures but the former will require procedures like
reconstructive surgery since reduction of spasticity and superficialis tenodesis[23] to prevent hyperextension
353 Indian Journal of Plastic Surgery May-August 2011 Vol 44 Issue 2
[Downloaded free from http://www.ijps.org on Saturday, July 28, 2012, IP: 122.178.186.125] || Click here to download free Android application for this journal

Bhardwaj and Sabapathy: Hand in cerebral palsy

Table 3: Zancolli’s[3] classification of wrist and finger deformity and treatment directions
Group Deformity Pathology Treatment guidelines
1 Full active finger extension possible with Spasticity localized to FCU Generally no treatment required.
wrist in almost or completely neutral Occasionally tenotomy of the FCU
extension
2 The fingers can be actively extended
fully but only with wrist flexed.
2a Active extension of the wrist possible Spasticity principally localized to the Aponeurotic release of the ventral
with fingers flexed (Volkmann test) finger flexors, FCU also may be spastic, muscle of the forearm or fractional
wrist extensors are active lengthening of the finger flexors,
tenotomy of the FCU if it is spastic
2b Active extension of the wrist not The wrist extensors are not active, Transfer of FCU to ECRB with fractional
possible even with fingers flexed spasticity of wrist and finger flexors lengthening of the finger flexors or
aponeurotic release
3 Active finger extension not possible Marked spasticity of wrist and finger Poor candidates for surgeries aimed to
even with maximal flexion of the wrist flexors and paralysis of the wrist improve function
extensors Can consider for operations aimed to
decrease spasticity or improve position

Table 4: The comprehensive classification of the thumb deformity in cerebral palsy

Type Description Defect Main component of treatment
Type I Simple metacarpal adduction AP spastic Release of the AP
Type II Metacarpal adduction with MCP flexion AP and FPB spastic Release of the AP and FPB
Type III Metacarpal adduction with MCP AP spastic Release of the AP + Stabilization of the
hyperextension deformity Plus unstable MCP joint MCP Joint
Type IV Metacarpal adduction with MCP and IP AP and FPB spastic with FPL spastic Release of the AP,FPB and FPL
flexion
Type V IP flexion with less marked metacarpal FPL spastic with weak EPL Release of FPL +/− augmentation of EPL
adduction
Type VI Weakness of extensors with less marked Weak extensors Augmentation of the thumb extension and
spasticity (with or without unstable MCP) abduction

of proximal interphalangeal (PIP) joint, lateral band Classification of the thumb deformities in
translocation[24] or central slip tenotomy[22] depending on cerebral palsy
the surgeon’s preference and the patient factors. The three commonly used classifications for the thumb
deformity in cerebral palsy are those described by House
Thumb and colleagues,[7] Sakellarides et al.,[25] and Tonkin.[26]
Thumb involvement is common in cerebral palsy and its
management is complex. The thumb held flexed inside We have observed that in clinical practice there does
the palm impairs grip and grasp and lack of abduction exist a paralytic type of involvement (weakness of the
and extension limits the size of the object the patient can abductors and extensors without much spasticity of the
grasp. The presence of thumb in the palm also obstructs flexor and adductors) which is not included in the House
the function of other fingers. It may even contribute to or Tonkin classification. Also cases of isolated spasticity
rejection of the hand and cause problems in hygiene.[25] of the flexor pollicis longus (Tonkin- Extrinsic type) which
There are four key things to examine when considering a does not form a part of House classification does exit. To
child with thumb deformity in cerebral palsy for surgical address these issues and to help decision-making we use
intervention.[4] the following “comprehensive classification” [Table 4].
• Spasticity of adductor and flexor muscles – adductor
pollicis (AP), flexor pollicis brevis (FPB), first dorsal We have found this classification helpful in assessment
interosseous (FDI), flexor pollicis longus (FPL) and decision-making. It is basically an extended House
• Flaccidity of the extensors and abductors. classification.[7] The first four types are the same as the
• Hypermobility of the metacarpophalangeal (MCP) House classification. Type V is akin to the Tonkin[26]
joint. extrinsic type with FPL spasticity being more marked
• Web space skin contracture. than the other muscles with weak EPL. These patients
Indian Journal of Plastic Surgery May-August 2011 Vol 44 Issue 2 354
[Downloaded free from http://www.ijps.org on Saturday, July 28, 2012, IP: 122.178.186.125] || Click here to download free Android application for this journal

Bhardwaj and Sabapathy: Hand in cerebral palsy

only require fractional lengthening or z-lengthening of the • Within the spastic muscle group they help determine
FPL. Type VI patients have weak abductor and extensors which muscles are spastic and which are not.
(EPL, EPB, or APL) without any significant spasticity of
the flexors. This group represents type1 (weak EPL) and Role of preoperative therapy
type 3 (APL weakness) of Sakellarides classification.[25] Splints are a useful adjunct in planning surgical
These patients do not require any flexor release and only intervention. A patient with a chronically flexed wrist
augmentation of the thumb extension is enough. can “test” the functional effect of the wrist in a neutral
position by using a wrist splint. Similarly, potential
There are two important aspects of thumb in palm thumb-in-palm correction can be evaluated with a thumb
deformity which need to be addressed - the position abduction splint, and potential swan-neck deformity
of thumb in the palm during fisting and the inability to correction can be evaluated with an extension block
abduct the thumb when opening the hand. Former usually splint. Botulinum toxin may be helpful in predicting the
indicates the spasticity of the adductor and flexors and effect of muscle lengthening. Aggressive therapy after
the later the weakness of the abductor and extensors. The injection helps strengthen antagonist muscles.
key concept is to rebalance the forces by decreasing the
deforming force and augmenting the opposing muscles. Counseling the parents and patient has a unique role in
Unstable joints may need stabilization and an adequate the management of a cerebral palsy patient. A surgeon
web should be created. All elements should be addressed
should provide a clear picture of the child’s condition and
at the same sitting, as serial intervention has a high risk of
the expected functional status to the parents. The child
failure or recurrence of deformity.[27]
and parents have to know that the hand will not become
normal and whatever interventions we are planning are
In the patient with voluntary control of extensor pollicis
to improve the function and appearance of the hand. Also
longus and no fixed deformity of the interphalangeal
they should be told that we are not correcting the basic
joint rerouting of EPL is an effective procedure.[28] If the
problem, which is in the brain, but are only trying the
extensors are weak they will require augmentation. The
address the effects of the problem on the musculoskeletal
transfer of the functioning muscle can be done to abductor
system to have the best use of the existing functional
pollicis longus (APL), extensor pollicis brevis (EPB) or
muscles. It is important to counsel parents and patient
extensor pollicis longus (EPL). Usually augmentation of
regarding this because they usually believe that the hand
EPB is preferred as it brings about the thumb abduction
will be normal after the operation. It is usually harsh for
and extension. EPL unless rerouted may still be adducting
the parents to hear this but the surgeon has to manage
the thumb and APL does not have any effect over the MCP
this by combining truth with sympathy. The discussion
joint.
should always end on a positive note since many children
Tendon transfer to augment thumb extension leads to can be made better with intervention either in form of
further metacarpal adduction and MCP joint hyperextension therapy or surgery.
if it is very lax. A hyperextension of more than 20°
warrants treatment.[29] Joint stabilization can be done by REFERENCES
capsulorrhaphy, sesamoid arthrodesis, or complete fusion
1. Graham HK, Selber P. Musculoskeletal aspects of cerebral palsy.
of joint. Before fusion a temporary stabilization with K-wire J Bone Joint Surg Br 2003;85:157-66.
can be useful to assess the consequences of an irreversible 2. Herring JA. Disorders of brain. In: Tachdjian’s Pediatric
procedure.[15] Orthopaedic. 4th ed. Philadelphia: Saunders; 2008. p. 1275-404.
3. Zancolli E. Structural and dynamic bases of hand surgery. 2nd ed.
Philadelphia: Lippincott; 1979. p. 263-83.
Role of motor blocks[5] 4. Carlson MG. Green’s operative hand surgery. In: Green DP,
• They differentiate spasticity from fibrous contracture Hotchkiss RN, Pederson WC, Wolfe SW, editors. Cerebral palsy.
in flexors, adductors, and pronator muscle groups. 5th ed. Philadelphia: Churchill Livingstone; 2005. p. 1197-234.
5. Leclercq C. General assessment of the upper limb. Hand Clin
Injection of spastic pronator teres can help recognize a 2003;19:557-64.
possible contracture of the interosseous membrane. 6. McConnell K, Johnston L, Kerr C. Upper limb function and
• They allow assessment of individual muscles after deformity in cerebral palsy: A review of classification systems.
Dev Med Child Neurol 2011;53:799-805.
removing spasticity of the antagonists or co-
7. House JH, Gwathmey FW, Fidler MO. A dynamic approach to the
contractions of adjacent muscles. thumb-in-palm deformity in cerebral palsy: Evaluation and results

355 Indian Journal of Plastic Surgery May-August 2011 Vol 44 Issue 2

[Downloaded free from http://www.ijps.org on Saturday, July 28, 2012, IP: 122.178.186.125] || Click here to download free Android application for this journal

Bhardwaj and Sabapathy: Hand in cerebral palsy

in fifty-six patients. J Bone Joint Surg Am 1981;63:216-25. 21. Zancolli E. Structural and dynamic bases of hand surgery.
8. Green WT, Banks HH. Flexor carpi ulnaris transplant and its use Pathology of the extensor apparatus of the finger: 2nd ed.
in cerebral palsy. J Bone Joint Surg Am 1962;44:1343-52. Philadelphia: Lippincott; 1979. p. 64-104.
9. Samilson RL, Morris JM. Surgical improvement of the cerebral- 22. Carlson MG, Gallagher K, Spirtos M. Surgical treatment of swan
palsied upper limb: Electromyographic studies and results of 128 neck deformity in hemiplegic cerebral palsy. J Hand Surg Am
operations. J Bone Joint Surg Am 1964;46:1203-16. 2007;32:1418-22.
10. Miller F. Cerebral palsy. 1st ed. Wilmington (USA): Springer 23. Swanson AB. Surgery of the hand in cerebral palsy and swan
Publishers; 2005. neck deformity. J Bone Joint Surg Am 1960;42:951-64.
11. Manske PR. Cerebral palsy of the upper extremity. Hand Clin 24. Tonkin MA, Hughes J, Smith KL. Lateral band translocation for
1990;6:697-709. swan neck deformity. J Hand Surg Am 1992;17:260-7.
12. Samilson RL. Principles of assessment of the upper limb in 25. Sakellarides HT, Mital MA, Matza RA, Dimakopoulos P.
cerebral palsy. Clin Orthop Relat Res 1966;47:105-25. Classification and surgical treatment of the thumb-in-palm
13. Goldner JL. Upper extremity surgical procedures for patients with deformity in cerebral palsy and spastic paralysis. J Hand Surg
cerebral palsy. Instr Course Lect 1979;28:37-66. Am 1995;20:428-31.
14. Van Heest AE, House JH, Cariello C. Upper extremity surgical 26. Tonkin MA. Surgery for Cerebral palsy part 3: Classification
treatment of cerebral palsy. J Hand Surg Am 1999;24:323-30. and operative procedures for thumb deformity. J Hand Surg Br
15. Tonkin MA. The growing hand. In: Gupta A, Kay SPJ, Scheker 2001;26:465-70.
LR, editors. The upper limb in cerebral palsy. London: Mosby; 27. Goldner JL. Upper extremity tendon transfers in cerebral palsy.
2000. p. 447-59. Orthop Clin N Am 1974;5:389-414.
16. Van Heest EA, House J, Putnam M. Sensibility deficiencies in 28. Manske PR. Redirecting of extensor pollicis longus in the
the hands of children with spastic hemiplegia. J Hand Surg Am treatment of spastic thumb-in-palm deformity. J Hand Surg Am
1993;18:278-81. 1985;10:553-60.
17. Carlson MG, Brooks C. The effect of altered hand position and 29. Zancolli EA, Zancolli E Jr. Surgical rehabilitation of the spastic
motor skills on stereognosis. J Hand Surg Am 2009;34:896-9. upper limb in cerebral palsy. In: Lamb DW, editor. The paralyzed
18. Hoffer MM. The upper extremity in cerebral palsy. AAOS hand. Edinburgh: Churchill Livingstone; 1987. p. 153-68.
Instructional Course Lecture. St Louis: Mosby; 1979. p. 133-7.
19. Tonkin M. The upper limb in cerebral palsy. Curr Orthop
1995;9:149-55.
How to cite this article: Bhardwaj P, Sabapathy SR. Assessment
20. Gschwind C, Tonkin M. Surgery for cerebral palsy: Part 1:
of the hand in cerebral palsy. Indian J Plast Surg 2011;44:348-56.
Classification and operative procedures for pronation deformity.
Source of Support: Nil, Conflict of Interest: None declared.
J Hand Surg Br 1992;17:391-5.

Indian Journal of Plastic Surgery May-August 2011 Vol 44 Issue 2 356

View publication stats