Cerebral Palsy Orthopaedic Management
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Direct answer
Cerebral palsy orthopaedic management aims to preserve walking, sitting and hand function by treating the deformities that spasticity produces. Plans are shaped by the GMFCS level, with hip surveillance for non-ambulant children, botulinum toxin for focal dynamic spasticity, and tendon lengthening for fixed contractures such as equinus. Hip subluxation is the most important complication to detect early, because it causes pain and loss of sitting balance.
What you must remember
- GMFCS: the Gross Motor Function Classification System grades mobility from level I, walking independently, to level V, with severely limited mobility even with assistive technology.
- Hip displacement: spastic subluxation is most frequent in GMFCS levels IV and V, and a migration percentage above about 30 to 40 per cent warns of progression.
- Equinus: gastrocnemius or soleus tightness causes toe walking and, if prolonged, contributes to crouch gait.
- Crouch gait: a flexed-knee gait produced by hamstring and gastrocnemius tightness combined with weakness and poor motor control.
- Botulinum toxin: reduces focal dynamic spasticity in muscles such as the gastrocnemius, adductors and hamstrings, but its effect is temporary.
- Hip surgery: soft-tissue release of the adductors and psoas for early disease, with varus and pelvic osteotomies for established subluxation.
- Spine: neuromuscular scoliosis in non-ambulant children is usually treated with posterior spinal fusion extended to the pelvis.
- Neurosurgery: selective dorsal rhizotomy reduces spasticity in selected ambulant children, but it is a neurosurgical rather than orthopaedic procedure.
Matching the procedure to the deformity
A 7-year-old with spastic diplegia at GMFCS level III walks with hand-held devices, toe-walks on both sides, and has a right hip migrating on serial radiographs. The plan is matched to each deformity rather than to the child as a whole.
| Procedure | Target deformity | Typical setting and role |
|---|---|---|
| Botulinum toxin injection | Focal dynamic spasticity in gastrocnemius, adductors and hamstrings | Temporary effect for children with mobile joints; used before or alongside surgery and physiotherapy |
| Tendon lengthening or recession | Fixed equinus, hamstring or hip flexor contracture | Permanent release of a tight muscle-tendon unit when stretching and bracing have failed |
| Adductor and psoas release | Early hip subluxation and limited abduction | Soft-tissue procedure aimed at slowing migration in children with still-mobile hips |
| Proximal femoral varus osteotomy | Established subluxation with a high migration percentage | Bony realignment of the femur that improves coverage of the femoral head |
| Pelvic osteotomy | Dysplastic acetabulum with persistent subluxation | Reconstructs the acetabular roof to contain the femoral head |
Soft-tissue procedures suit young children with mobile joints, while bony procedures suit fixed or advanced deformity. Surgical choice depends on the GMFCS level, age and findings on gait analysis.
Where the exam tries to catch you
Examiners test whether you can match the treatment to the deformity and recognise the hip as the key complication.
- Trap: treating a migrating hip with botulinum toxin alone. Correct: toxin relaxes dynamic spasm but cannot reverse a bony subluxation, which needs surgical reconstruction.
- Trap: lengthening the Achilles tendon for every crouch gait. Correct: crouch gait has several causes, so hamstring, hip flexor and gastrocnemius contributions must be assessed on gait analysis first.
- Trap: assuming hip surveillance ends once walking begins. Correct: migration progresses through growth, so serial pelvic radiographs are continued, most often in GMFCS levels IV and V.
Frequently asked questions
What is the GMFCS and why is it used in cerebral palsy?
The Gross Motor Function Classification System grades mobility in children with cerebral palsy from level I to level V. It guides prognosis, hip surveillance and the choice between soft-tissue and bony surgery.
Which radiographic sign suggests progressive hip subluxation in cerebral palsy?
A rising migration percentage on serial pelvic radiographs, typically above about 30 to 40 per cent, signals progressive subluxation. Hip pain, adductor spasm and loss of sitting balance are the clinical accompaniments to watch for.
When is botulinum toxin used in cerebral palsy?
Botulinum toxin treats focal dynamic spasticity in muscles such as the gastrocnemius, adductors and hamstrings. Its effect is temporary, so it is used alongside physiotherapy, bracing or surgery rather than as a permanent correction.
How is equinus treated in cerebral palsy?
Equinus is treated by gastrocnemius recession or Achilles tendon lengthening, chosen according to whether the gastrocnemius or the soleus is the dominant tight muscle. Stretching and bracing are tried first in most children.
Why are non-ambulant children at higher risk of hip displacement?
Non-ambulant children have more severe spasticity and little weight-bearing through the hips, which together produce muscle imbalance and progressive migration. This explains why hip surveillance is emphasised in GMFCS levels IV and V.