Surgery for the Pronated Forearm and Flexed Wrist in Children with Cerebral Palsy

Area of Science:

• Orthopedic Surgery
• Pediatric Rehabilitation
• Cerebral Palsy Management

Background:

• Wrist flexion and forearm pronation deformities are common challenges in children with cerebral palsy (CP).
• Current management strategies lack a standardized consensus, leading to varied treatment approaches.
• Effective surgical interventions are crucial for improving upper limb function in pediatric CP.

Purpose of the Study:

• To develop a treatment algorithm for the surgical management of wrist flexion and forearm pronation deformities in children with CP.
• To provide a structured approach for surgeons dealing with these complex upper limb deformities.

Main Methods:

• Retrospective review of 13 children with CP who underwent upper limb surgery between 2009 and 2016.
• Data collected included pre- and post-operative movement analysis and Shriners Hospital Upper Extremity Evaluation (SHUEE).
• Surgical procedures primarily involved flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB) transfer, with optional pronator teres (PT) re-routing and flexor releases.

Main Results:

• Significant improvements observed in active supination (mean increase 40.8°) and wrist extension (mean increase 28.9°).
• The SHUEE dynamic positional analysis showed a mean improvement of 25.4%, attributed to enhanced wrist and forearm function.
• No significant loss of wrist flexion was noted post-operatively, with a mean follow-up of 14 months.

Conclusions:

• A treatment algorithm is proposed, favoring FCU to ECRB transfer for pronation and flexion deformities.
• The algorithm stratifies treatment based on active supination range: isolated FCU to ECRB transfer for neutral or better supination, and FCU to ECRB with PT release/re-routing for limited supination.
• This approach aims to optimize functional outcomes for children with CP experiencing these specific upper limb deformities.