The spectrum of hemiplegic cerebral palsy severity is broad. Sometimes a child is seen for intoeing or clumsiness and found to have mild hemiplegia or hemiparesis. The family may not have been aware of any underlying neurologic problem.
Contractures are most severe distal in the hands and feet. Typical deformities include equinus and varus or valgus feet, and flexed elbow, wrist, fingers, and adducted thumb. Proximal joints have less consistent involvement. Scoliosis is uncommon. Limb shortening is mild and proportional to severity. Function is generally fair and proportional to severity. Walking is slightly delayed. The involved hand disability is proportional to overall severity. Learning disability, seizures, and social problems are common. Sensory deficits are more significant than deformity in limiting hand function.
Treatment of hemiplegic cerebral palsy
Tailor management based on the severity of the disability. Mainstream children when possible. It has been said that children function as well as their best side. These children function well; their major problems are often cosmetic with a significant hand deformity and limp.
Lower limb First, classify the type of hemiplegia. Several classifications are available.
Winter classification Four deformity patterns have been described by Winter and colleagues. Bracing may be useful for all groups. Group II is managed by heel-cord lengthening. Groups III and IV are more complex and require multilevel procedures. Evaluation by gait analysis is recommended for hemiplegia.
Equinus deformity Equinovarus deformity is common. Manage by bracing or operative heel-cord lengthening for fixed deformity. Add intramuscular lengthening of the posterior tibialis if a significant varus component is present. Overlengthening is uncommon.
Limb shortening Shortening is progressive throughout growth and proportional to the palcy severity. Most shortening occurs in the tibia. Usually overall shortening is about 1 cm for mild, 2 cm for moderate, and 3 cm for severe involvement. Some shortening may be useful to allow toe clearance. Left uncorrected, limb shortening does not cause spine or other problems and overtreatment is common. Avoid shoe lifts. If operative correction is considered necessary, correct by an epiphysiodesis at the end of growth to achieve a correction of about 2 cm.
Intoeing Assess a rotational profile. Often a component is dynamic, which may not be apparent in the static evaluation. Often a major component of the intoeing is due to a spastic posterior tibialis.
Upper limb Because hand function requires sensation and fine motor function, disability is most severe. Encourage use of hands early. Sensibility testing will often demonstrate loss of two point discrimination, stereognosis, graphesthesia, rough/smooth differentiation, and proprioception. These losses in sensation limit potential for functional improvement. Sometimes constraint-induced therapy is prescribed that involves placing the good hand and arm in a cast for 3 weeks along with an occupational therapy program.
The value of early stretching, splinting, and casting is controversial. Base operative indications on level of discriminatory sensibility, intelligence, motivation, and overall function. When possible, delay operative correction until mid or late childhood. By waiting, patient cooperation, functional needs, motivation, and disability can better be determined.
Dynamic stage before contractures become fixed, consider injecting multiple sites with botulinum toxin to reduce deformity and improve function. Repeated injections at 3–6-month intervals are typically necessary.
Fixed deformity stage requires correction by one-stage multilevel correction to improve function.
Transfer muscle under voluntary control to improve finger, thumb, or wrist extension.
Fuse joints for stability.
Lengthen fixed contractures and correct imbalance by tendon transfers.
The objectives include improvement in motor function of grasp, release, and pinch by restoring muscle balance and stabilizing joints. Improved appearance is often significant and may be the principal benefit.