1Hand & Microsurgery Unit, Department of Orthopaedic & Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
2Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
Correspondence: Hyun Sik Gong Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea. Tel: +82-31-787-7198 Fax: +82-31-787-4056 E-mail: hsgong@snu.ac.kr
• Received: December 29, 2024 • Revised: July 19, 2025 • Accepted: September 9, 2025
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Management of upper limb deformities in patients with cerebral palsy is crucial, given its impact on activities of daily living, social interaction, and self-esteem. While medical management and rehabilitative therapy—including the use of assistive devices—remain the foundation of treatment, significant advancements have been made in surgical reconstruction techniques aimed at enhancing functional outcomes. Despite this, many eligible patients may miss the opportunity for surgical intervention due to limited awareness of appropriate indications, candidate selection criteria, and the availability of specialized expertise. This article provides an overview intended to guide pediatric rehabilitation physicians in recognizing common upper limb presentations in cerebral palsy, conducting appropriate assessments, selecting candidates, and understanding available surgical reconstructive options.
Cerebral palsy is a group of permanent, non-progressive disorders of the development of movement and posture, due to disturbances that happens in the developmental fetal or infant brain [1]. It can be associated with many other neurological disorders including seizure, cognitive disorder, vision, hearing and speech problems [2]. Although the disease by itself is non progressive, the consequences of increase in tone and spasticity may result in deformity with growth [3].
The prevalence of cerebral palsy in South Korea is 2.6 per 1,000 children and the number is comparable to other countries, while the lifetime medical cost for a cerebral palsy patient is estimated to be 26,383 dollars which is 1.8 times more than the basic lifetime medical cost for the general population [4]. In South Korea, majority of the cerebral palsy patients are of the spastic type (87.3%), followed by dyskinetic (5.2%) and ataxic type (1.8%) [5]. Based on Korean database on the distribution of cerebral palsy patients using the Global Motor Function Classification (GMFCS), majority of the patients are in Level I (26.8%) and Level II (24.7%), while for their upper limb function using the Manual Ability Classification System (MACS), majority are in Level II (30.9%) and level I (26.4%) [5].
The classical upper limb deformities of cerebral palsy are internal rotation and adduction of the shoulder, flexion of the elbow, pronation of the forearm, flexion and ulnar deviation of the wrist, flexion of the fingers, and thumb-in-palm deformity (Fig. 1). The deformity occurs due to the imbalance between the paretic and spastic muscles that acts on the joints [3].
The upper limbs are important in performing daily functional activities. The psychological impact of the upper limb appearance on a patient’s self-esteem, and social interactions should be acknowledged [6,7]. Therefore, a clearer understanding of the management of upper limb deformities in cerebral palsy is essential—particularly regarding the assessment and selection of appropriate surgical candidates, as well as the available reconstructive options. This understanding should extend beyond surgeons to include pediatric rehabilitation physicians, physiotherapists, occupational therapists, and other healthcare professionals involved in the care of individuals with cerebral palsy. Multidisciplinary team involvement is critical, and decisions should be made collaboratively by the patient, family, caregivers, and the entire healthcare team [6].
This article aims to provide an overview and serve as a practical guide for pediatric rehabilitation physicians on the common upper limb presentations in patients with cerebral palsy, including approaches to assessment, candidate selection, and available surgical reconstructive options.
WHO IS AN IDEAL CANDIDATE FOR UPPER EXTREMITY RECONSTRUCTION?
While Tonkin suggested that an ideal candidate for surgery is a cooperative 6-year-old child, with stable family support, hemiplegia or monoplegia with predominantly spastic upper limb deformity, and good hand sensibility without significant general neurological defects [3], there is no single guideline that can determine all as each individual patients are different [8]. The assessment and decision of surgery should be made by an experienced surgeon after consideration of multiple factors mentioned in the assessment section below. As for the age, the authors believe that there is no age limit because adolescents and even adult patients also benefit from the surgery and can be more satisfied from the improved appearance of the hand and elbow. Sabella et al. [8] reported a median surgical age of 14.2 years, noting that optimal timing should balance rehabilitation compliance with the need to intervene before severe contractures develop. In Heest’s series, patients with high motivation and fair to good motor control showed an average improvement of +2.6 levels on the House functional score, regardless of preoperative mentation, sensibility, or type of cerebral palsy [9]. However, surgery is not recommended for patients with abnormal movements due to dystonia, and those with relatively good function (House score≥5) often do not require surgical intervention [10]. In our experiences, patients with severe flexion posture of the elbow and flexion deformity of the wrist are most satisfied with surgical outcomes.
WHAT KIND OF ASSESSMENTS ARE DONE FOR SURGICAL CONSULTATION?
The evaluation of cerebral palsy patients is often complex and requires expertise and experience in managing these. Before deciding for surgical options, the patients’ general neurological condition must be taken into consideration including whether the problem is predominantly spastic, athetoid or dystonic or mixed patterns. The number of limbs affected, hand sensibility, specific joint position and degree of joint instability is also part of the assessment. The muscles need to be tested on whether they are having good or poor voluntary control which are important factor when considering tendon transfer [3,7]. In general, preoperative voluntary muscle control is the most important predictor of surgical success, and a greater degree of spasticity is associated with a higher likelihood of favorable outcomes [3,7]. For purely athetoid problems, soft tissue procedures alone is not effective and arthrodesis can be necessary [3].
The clinical examinations should also be done serially and repeatedly, for at least two or three times, both in clinic settings and in a child’s usual environment. Limited sensory capability is a relative contraindication for complex procedures but is not an absolute contraindication [7]. One should not also neglect to understand the patient’s developmental stage, capacity, motivation, goals and expectations, which will all require multiple assessment and observation [6].
The preoperative functional level is also a key predictor of surgical outcomes. MACS is used to grade the patient’s bimanual performance in daily activities rather than on the maximum capacity of the affected upper limb. It was found that individuals with higher MACS levels had better surgical outcomes according to House functional scale and also overall patients’ satisfaction [11]. Objective outcome measures are used in comparing the surgical outcomes and range of movement (ROM) is most commonly recorded and used [8]. Other outcome measures include Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS) to compare the task competency and performance satisfaction in pre and post operation [8]. GMFCS is also used to predict outcomes, where patients with a high level of motor impairment was found to have a less improvement in surgical outcomes [8].
WHAT KIND OF INVESTIGATIONS ARE NECESSARY?
Plain radiographs of the involved joints are necessary for evaluating joint congruity, and sometimes computed tomography can be helpful to identify any joint subluxation and dislocation or three-dimensional deformity of joints [7].
Dynamic electromyography can provide a qualitative and quantitative measurement of voluntary motor control and the type of motor activity of the muscles being considered for transfer [12].
Video recording evaluations are a valuable tool for understanding the functional capacity of the affected upper limb during real-world task performance, enabling more accurate diagnosis and improved surgical planning (Appendix 1). A study found that often there is a change to the initial presurgical plan after the videotaped evaluation [13].
WHAT ARE NON-SURGICAL INTERVENTIONS?
Non-surgical treatment should be started as early as possible, as its benefits have been well demonstrated [14].
Stretching exercises work by moving the joints through a full range of motion and perform stretching at the end range of motion and help to prevent contracture and improve overall range of motion [6]. Splinting or serial casting is another option available for prolonged periods of gentle stretch and increased joint range of motion [6].
Occupation therapy works on maximizing the patient’s ability to complete activities of daily living (ADLs) by increasing executive cortical function and selective motor control [6]. Besides, the beneficial effects of constraint-induced movement therapy for upper limb have been reported, where the use of the less-affected upper limb is restricted, hence encouraging the use of the more-affected upper limbs [6,15]. Hand-arm intensive bimanual therapy is also used to focus on structured training of functional activities that require bimanual hand use [15].
Management of muscle tone should also be considered, with treatment options including both systemic and localized approaches. While oral medications and intrathecal baclofen are commonly used as the mainstay of systemic spasticity management, botulinum toxin offers a selective and temporary reduction in muscle tone at targeted sites. In the upper limb, commonly treated muscles include the pronators, elbow, wrist, and finger flexors, as well as various intrinsic hand muscles. The strengthening of the antagonist muscles is important after injection, focusing on supination, wrist, finger and thumb extension [6,15].
Non-surgical approaches have several limitations. For botulinum toxin, one drawback is the need for repeated injections, as its effects typically wear off after a few months. Morever, injections are most effective when initiated early—ideally around 2 to 3 years of age—before contractures and deformities develop [10].
Surgical intervention is considered when non-surgical approaches fail to yield functional improvement, and when progressive joint contractures and deformities begin to impair ADLs [9].
WHAT ARE THE CONCEPTS OF SURGICAL TREATMENT?
The current strategy favors a single-event multilevel surgery approach, in which multiple procedures are performed during a single operative session [6]. The outcomes of surgical reconstruction have been well documented in the literature, generally showing improvements in patients’ functional levels following surgery [9,11,16,17]. Surgical procedures can be classified into tendon procedures (release, transfer, rerouting), bony procedures (arthrodesis, corrective osteotomy) and nerve procedures (selective neurectomy).
Tendon release surgery is a procedure that aims to lengthen the affected muscle-tendon unit to improve the range of motion. It can be either a fractional lengthening where the lengthening is done at the musculotendinous junction, or z lengthening where partial cut of tendon is performed at 2 sites and the ends are sutured to one another to increase the overall tendon length. Tendon transfer is the procedure where an expendable tendon is detached, mobilized and transferred to another non-functioning muscle-tendon unit. For example, in cases of wrist flexion deformity, the overactive flexor carpi ulnaris (FCU) tendon can be transferred to the weaker extensor carpi radialis brevis (ECRB) tendon to restore wrist extension. Tendon rerouting works by changing the original path where the tendon acts, like in the case of forearm pronation deformity, where pronator teres tendon is rerouted, to change its action from being a forearm pronator to become a forearm supinator.
Bony procedures are usually performed in severe deformity where soft tissue procedures are not effective. Arthrodesis or joint fusion fix the affected joint in a functional position to allow better function. Meanwhile, corrective osteotomy works by making cuts on the affected bones and correct them to the desired position before placing fixative devices such as plate, screws or pins.
Nerve procedures focuses on the nerve that is controlling the muscle functions of the affected limb. Hyperselective neurectomy involves cutting selected nerve branches at their entry points into the muscle, with the aim of reducing motor input and sensory feedback from the muscle spindle, thereby decreasing spasticity.
HOW TO CORRECT SHOULDER DEFORMITIES?
The common deformity is internally rotated and adducted shoulder. This happens due to muscle imbalance and spasticity of the internal rotator muscles of the glenohumeral joint (pectoralis major, latissimus dorsi, subscapularis, and teres major) [7, 16]. Soft tissue imbalances may lead to contracture of muscles, capsule and glenohumeral joint, and eventually result in subluxation or dislocation of the humeral head [16].
Surgical options include soft tissue releases, tendon transfers and/or humeral osteotomy [16]. To correct the internal rotation and adduction deformity, fractional lengthening and release of pectoralis muscle, subscapularis muscle can be performed (Fig. 2). Augmentation of external rotation can be achieved by transfer of the latissimus dorsi and teres major to the rotator cuff [3,6,7,16]. If the soft tissue procedures failed to address the issue, a proximal or distal humeral external rotation osteotomy may be helpful [3,7,16].
HOW TO CORRECT ELBOW DEFORMITY OR FLEXION POSTURE?
Elbow flexion contracture impairs upper limb function by limiting multidirectional reaching and restricting effective hand placement in space [7,18]. Moreover, patients are often unhappy with the abnormal elbow posture during ambulation, primarily due to its cosmetic appearance and the negative impact on self-image [7,18].
Due to the increase in muscle tone of elbow flexors (biceps brachii, brachialis and brachioradialis), dynamic motor imbalance occurs around the elbow joint. The secondary fixed contracture of the capsule and flexor-pronator muscle and/or subluxation/dislocation of the radial head due to hyper pronation of the forearm contribute to elbow deformity. Severe cases may even have secondary dysplasia of the radial head [7].
Surgery is usually indicated when active extension loss is more than 30° or when flexion posture is more than 50° with activities [7,19]. For contractures less than 45°, fractional lengthening of brachialis and fractional or z-lengthening of biceps can be performed [6]. In more severe contractures, procedures such as z-lengthening of the biceps, distal myotomy of the brachialis, brachioradialis release, and anterior capsular release of the elbow may be beneficial. Gong et al. [19] reported favorable clinical outcomes following anterior elbow release combined with partial biceps tendon lengthening, resulting in improved elbow flexion posture and active elbow extension (Fig. 3). Based on the authors’ experience, this procedure yields an average improvement of 45 degrees in elbow flexion posture [19].
HOW TO CORRECT FOREARM PRONATION DEFORMITY?
Pronated forearm is part of the classic deformity of cerebral palsy, where the hypertonicity of the pronator teres and pronator quadratus are the main cause [7]. The decision of surgical option depends on the active and passive range of supination. In cases where there is a discrepancy between active and passive supination, pronator teres rerouting is preferred. In contrast, when both active and passive supination are limited, pronator release is typically performed—either proximally as part of a flexor pronator slide or distally at the midshaft of the radius [6]. In severe cases where a fixed pronation deformity is present, corrective osteotomy of the forearm bones may be an option [7] (Fig. 4).
HOW TO CORRECT WRIST AND FINGER FLEXION DEFORMITIES?
Flexion deformity of the wrist may affect the grasp-and-release function of the hand, due to hypertonicity of wrist flexors and/or weak wrist extensors. Surgical procedures may involve soft tissue release, bony correction, or a combination of both [7]. In cases of passively correctable deformities, the procedure involves release of the wrist flexors, such as flexor carpi radialis (FCR), palmaris longus, and FCU, or transfer of a wrist flexor (e.g., FCU) to the weak wrist extensors such as ECRB [6,7,18]. The FCU to ECRB transfer can improve wrist position to a neutral or slightly extended posture and provide active wrist extension. This procedure is the most effective and rewarding procedure for patients indicated [9].
In fixed wrist deformities, flexor tendon release together with wrist fusion and/or proximal row carpectomy will be a better option [6,7] (Fig. 5).
For finger flexion deformities, fractional lengthening at musculocutaneous junction can be performed for mild contracture. In more severe tightness, z-lengthening may be performed. In severe cases, flexor superficialis to profundus tendon transfers or a flexor pronator slide/origin release may be required [6,7,18].
In swan neck deformity of the fingers, patients experience difficulty in finger flexion due to hyperextension of the proximal interphalangeal (PIP) joint. This could be addressed by central slip tenotomy, lateral band transfer, or PIP tenodesis [3,7] (Fig. 6).
HOW TO CORRECT THUMB-IN-PALM DEFORMITY?
Thumb-in-palm deformity affects the grasp-and-release function of the hand. This deformity could be static (due to contracture) or dynamic (due to spasticity and shortening of adductor pollicis, first dorsal interosseous, and flexor pollicis longus muscle) [3,7]. In addition, due to prolonged abnormal thumb and wrist position, the muscles involved in active extension and abduction of thumb may be overstretched and weakened. The combination of this may results in instability of the metacarpophalangeal joint and fixed contracture of the first web space [7].
The first webspace can be widened with 2 flap or 4 flap z-plasty (Fig. 7). The adductor pollicis can be released either from its origin on the third metacarpal or from its insertion on the first metacarpal, allowing for proximal transfer [6,7].
For the thumb extrinsic muscles, the flexor pollicis longus is usually fractionally or z-lengthened. If the extensor pollicis brevis is weak, a brachioradialis transfer can be performed. The extensor pollicis longus is rerouted from the 3rd extensor compartment to a radial pass, to function as an extensor and abductor of the thumb (Fig. 8).
The metacarpophalangeal joint hyperextension instability can be addressed by volar plate capsulodesis or sesamoid capsulodesis [7,20].
WHAT IS HYPERSELECTIVE NEURECTOMY?
Hyper selective neurectomy (HSN) is a relatively new procedure that excises some branches of the involved peripheral motor nerves (about 2/3 of the fibers), at the point of entry of each motor ramus into the target muscle. It reduces the motor stimulation to and sensation from the muscle spindle, hence reducing the spasticity. The ideal indication for HSN is isolated spasticity where preoperative botulinum toxin injection is used to identify target muscles. It can be used in combination with muscle lengthening procedure in severe cases of muscle contracture and spasticity to achieve a better long-term outcome. For elbow spasticity, HSN of musculocutaneous nerve with biceps brachii and brachialis lengthening can be done. For the wrist, HSN to motor branch of FCU (ulnar nerve) and/or FCR (median nerve) can be performed, together with lengthening of wrist and finger flexors. A contraindication for HSN is the presence of dystonia, as HSN is ineffective in reducing muscle tone in these patients [20,21].
OUTCOMES OF SURGICAL TREATMENT
Outcomes of each surgical treatment depend on the preoperative status of the patients, procedures and rehabilitation. In a large scale study over 25-year period analysing 718 procedures for upper extremity surgical treatment in cerebral palsy, surgical intervention showed an average of +2.6 levels of House’s functional score improvement, despite the level of mentation, 2-point discrimination, stereognosis function or the type of cerebral plasy. Patients with a good voluntary control showed +3.0 levels of improvement as compared to +2.3 levels in those with poor voluntary control [9].
POSTOPERATIVE REHABILITATION
A well-planned postoperative rehabilitation regimen is essential for achieving optimal surgical outcomes. Input from therapists and rehabilitation physicians regarding therapy protocols and splinting should be incorporated during the preoperative planning phase. In general, the first 3–4 weeks postoperatively are critical, as this period corresponds to the initial healing phase. During this time, the operative site is typically protected with splinting or casting, while adjacent joints should undergo active and passive ROM exercises to prevent stiffness. After the initial healing phase, active and passive ROM exercises are introduced, and splinting is applied as indicated, varying according to the specific procedure performed. By 6 to 10 weeks postoperatively, strengthening exercises can be initiated, followed by a structured home exercise program [7].
WHAT ARE CONSIDERED TO BE THE BARRIERS TO UPPER LIMB RECONSTRUCTION?
Loewenstein et al. [22]conducted a cross-sectional questionnaire study in the United States, involving 263 respondents from the American Society for Surgery of the Hand (ASSH), the Pediatric Orthopaedic Society of North America (POSNA), and the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM). Respondents were categorized into two groups: surgeons and non-surgeons. Both groups found that the greatest barriers for upper extremity reconstructive surgery is the knowledge of referring, outcomes of surgery, or knowing the suitable candidates. Other barriers include patient access to medical resources, access to trained surgeons, and the disease complexity itself. Both groups agreed that functional improvement is the greatest benefit from the surgical intervention. In that study, it was also found that although most surgeons believed the literature supports the efficacy of surgery and that the benefits outweigh the risks, the majority of non-surgeons did not share this view. The difference in these beliefs could be the contributing factor to limited referrals for surgical evaluation [22]. The lack of clear algorithm and consensus could also lead to underutilization of the surgical reconstruction [23].
Rehabilitation physicians play a vital role as bridges between the patient and the surgical team. By understanding the indications and available surgical options for correcting specific deformities, they can facilitate timely referrals for surgical evaluation.
CONCLUSION
Managing a cerebral palsy patient is complex and requires a multidisciplinary approach. Upper limb reconstructive procedures can significantly enhance overall function and outcomes when performed in carefully selected candidates. Improving elbow flexion posture and correction of wrist flexion deformity are the most rewarding procedures in the authors’ experiences (Appendix 1).
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.
FUNDING INFORMATION
This study was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (Ministry of Science and ICT) (Grant no. RS-2023-00209251).
AUTHOR CONTRIBUTION
Conceptualization: Gong HS. Methodology: Gong HS. Formal analysis: Gong HS. Funding acquisition: Gong HS. Project administration: Gong HS. Visualization: Soh EZF. Writing – original draft: Soh EZF. Writing – review and editing: Gong HS. Approval of final manuscript: all authors.
Fig. 1.
An overview of common upper limb deformities in cerebral palsy and the surgical procedures. FCU, flexor carpi ulnaris; ECRB, extensor carpi radialis brevis; EPL, extensor pollicis longus.
Fig. 2.
Surgery for correction of adduction and internal rotation of the shoulder joint. The pectoralis muscle (A) and subscapularis muscle (B) are lengthened.
Fig. 3.
Surgery for correction of elbow flexion deformity. (A) Through a transverse incision on the elbow, the lacertus fibrosus (dashed line) is divided. (B) Fractional lengthening of brachialis muscle at two points (white arrows). (C) Stripping of adventitia of biceps tendon, and plan incision for lengthening (double hemisection lengthening) of biceps tendon: Golgi organs are present in the adventitia, so removal of them can decrease spasticity. (D) Double hemisection lengthening of biceps tendon: The biceps tendon was cut partially in two places to create a longer tendon, and the part between the cuts are sutured to prevent rupture (black arrow).
Fig. 4.
Surgery for correction of forearm pronation deformity. (A) Pronator teres lengthening and rerouting; in pronator teres lengthening, the tendon is lengthened in z-plasty. In pronator teres rerouting, the distal pronator teres tendon is rerouted posteriorly before suturing back to the proximal part of tendon. This converts the pronation force into a supination force. (B) Corrective osteotomy. Osteotomies are made at the radius and the ulna to rotate the bones into a supination position.
Fig. 5.
Surgery of wrist deformity correction. (A) Flexor carpi ulnaris (FCU) lengthening; the FCU is lengthened at its musculotendinous junction. (B) FCU to extensor carpi radialis brevis (ECRB) tendon transfer: the FCU is detached from its insertion and transferred to the ECRB to augment wrist extension. This FCU to ECRB transfer also helps forearm supination. (C) Wrist fusion (arthrodesis).
Fig. 6.
Surgery for swan neck deformity. (A) Swan neck deformity is a finger deformity with proximal interphalangeal joint (PIPJ) hyperextension and distal interphalangeal joint flexion. (B) Central slip tenotomy for correction of PIPJ hyperextension in swan neck deformity.
Fig. 7.
Z-plasty of the 1st web space. It creates two triangular flaps of equal dimension (at an angle of 60 degrees) that are then transposed to lengthened the tight web space.
Fig. 8.
Extensor pollicis longus (EPL) rerouting. The EPL normally acts as extensor and adductor of the thumb. It is rerouted from passing through the 3rd extensor compartment to a radial pass, which is stabilized by a slip of the abductor pollicis longus (APL) tendon. After rerouting, the EPL acts as an extensor and abductor of the thumb.
REFERENCES
1. Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl 2007;109:8-14.
3. Tonkin MA. Management of cerebral palsy in the upper limb. In: Bentley G, editor. European surgical orthopaedics and traumatology. Springer; 2014. p. 2033-50.
4. Park MS, Kim SJ, Chung CY, Kwon DG, Choi IH, Lee KM. Prevalence and lifetime healthcare cost of cerebral palsy in South Korea. Health Policy 2011;100:234-8.
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8. Sabella DL, Scheinberg AM, Johnstone BR, McCombe DB, Hasnat MJ. Characteristics and assessment of children undergoing upper limb surgery for management of cerebral palsy. Australas J Plast Surg 2021;4:35-47.
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12. Hoffer MM, Perry J, Melkonian GJ. Dynamic electromyography and decision-making for surgery in the upper extremity of patients with cerebral palsy. J Hand Surg Am 1979;4:424-31.
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18. Maskill L. Upper extremity surgery for patients with cerebral palsy. In: Nowicki P, editor. Orthopedic care of patients with cerebral palsy: A clinical guide to evaluation and management across the lifespan. Springer; 2020. p. 213-9.
19. Gong HS, Cho HE, Chung CY, Park MS, Lee HJ, Baek GH. Early results of anterior elbow release with and without biceps lengthening in patients with cerebral palsy. J Hand Surg Am 2014;39:902-9.
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Pre- and postoperative video recordings of a 14-year-old girl with spastic left hemiplegia. In the preoperative video, she cannot take out a bill from the wallet due to severe wrist flexion deformity.
The procedures included anterior elbow release to improve elbow flexion posture, pronator teres rerouting to improve forearm supination, FCU to ECRB transfer to improve wrist extension, and the procedures for thumb-in-palm deformity (the 1st web space z-plasty, adductor pollicis release, EPL rerouting, and brachioradialis to EPB transfer).
The postoperative video shows that she can perform multiple tasks with a better wrist position and excellent finger grasping and opening.
A consent was obtained from the patient, concerning that the data and videos would be submitted for publication.
Surgical Reconstruction of the Upper Extremity in Patients With Cerebral Palsy: Indication, Techniques, and Rehabilitation Considerations
Fig. 1. An overview of common upper limb deformities in cerebral palsy and the surgical procedures. FCU, flexor carpi ulnaris; ECRB, extensor carpi radialis brevis; EPL, extensor pollicis longus.
Fig. 2. Surgery for correction of adduction and internal rotation of the shoulder joint. The pectoralis muscle (A) and subscapularis muscle (B) are lengthened.
Fig. 3. Surgery for correction of elbow flexion deformity. (A) Through a transverse incision on the elbow, the lacertus fibrosus (dashed line) is divided. (B) Fractional lengthening of brachialis muscle at two points (white arrows). (C) Stripping of adventitia of biceps tendon, and plan incision for lengthening (double hemisection lengthening) of biceps tendon: Golgi organs are present in the adventitia, so removal of them can decrease spasticity. (D) Double hemisection lengthening of biceps tendon: The biceps tendon was cut partially in two places to create a longer tendon, and the part between the cuts are sutured to prevent rupture (black arrow).
Fig. 4. Surgery for correction of forearm pronation deformity. (A) Pronator teres lengthening and rerouting; in pronator teres lengthening, the tendon is lengthened in z-plasty. In pronator teres rerouting, the distal pronator teres tendon is rerouted posteriorly before suturing back to the proximal part of tendon. This converts the pronation force into a supination force. (B) Corrective osteotomy. Osteotomies are made at the radius and the ulna to rotate the bones into a supination position.
Fig. 5. Surgery of wrist deformity correction. (A) Flexor carpi ulnaris (FCU) lengthening; the FCU is lengthened at its musculotendinous junction. (B) FCU to extensor carpi radialis brevis (ECRB) tendon transfer: the FCU is detached from its insertion and transferred to the ECRB to augment wrist extension. This FCU to ECRB transfer also helps forearm supination. (C) Wrist fusion (arthrodesis).
Fig. 6. Surgery for swan neck deformity. (A) Swan neck deformity is a finger deformity with proximal interphalangeal joint (PIPJ) hyperextension and distal interphalangeal joint flexion. (B) Central slip tenotomy for correction of PIPJ hyperextension in swan neck deformity.
Fig. 7. Z-plasty of the 1st web space. It creates two triangular flaps of equal dimension (at an angle of 60 degrees) that are then transposed to lengthened the tight web space.
Fig. 8. Extensor pollicis longus (EPL) rerouting. The EPL normally acts as extensor and adductor of the thumb. It is rerouted from passing through the 3rd extensor compartment to a radial pass, which is stabilized by a slip of the abductor pollicis longus (APL) tendon. After rerouting, the EPL acts as an extensor and abductor of the thumb.
Graphical abstract
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Graphical abstract
Surgical Reconstruction of the Upper Extremity in Patients With Cerebral Palsy: Indication, Techniques, and Rehabilitation Considerations
