Get the Facts about the Orthopaedic Considerations for Children with Cerebral Palsy

Cerebral palsy (CP) is the most common motor disability during childhood. It is a life-long condition that affects the communication between the brain and the muscles and the condition can cause a variety of motor disabilities and issues. Disability resulting from cerebral palsy can be very mild, with the child appearing to be a little clumsy, to more severe, where the child may be unable to walk. Despite the difficulty with motor control/movement, many children with cerebral palsy have normal intelligence.

Common Symptoms of Cerebral Palsy include:

The signs and symptoms of cerebral palsy vary depending on the type of cerebral palsy, degree of disability, and how each child experiences these symptoms.

• Muscle weakness
• Difficulty controlling the arms or legs
• Shaking of the arms or legs (called spasticity)
• Muscle stiffness in the legs
• Clenched fists

Causes of Cerebral Palsy 
The cause of cerebral palsy is often unknown, but there are some links to premature birth, severe jaundice after birth, and an injury to the brain. If you have any concerns about your child’s development, talk to your pediatrician at your routine visit.

Unfortunately there is no cure for cerebral palsy right now. The best course of action is to manage the symptoms with a team of specialists including an orthopedic surgeon. At Emory Orthopaedics and Spine Center, when it comes to pediatric patients coping with cerebral palsy, we focus on preventing or minimizing deformities.

Orthopaedic Considerations & Risks From Cerebral Palsy:

Limb Shortening 
As a child develops, some children will develop a shortening of the leg and arm on only one side of the body. The difference between the legs can be up to two inches. If the parent notices a shortening, please contact a pediatric orthopedic surgeon who will be able to help determine the degree of difference between the legs and recommend appropriate treatment options. The surgeon may recommend a heel lift that is to be worn in the child’s shoes. A heel lift may also help prevent problems in the hip and spine. A leg length difference left untreated could eventually lead to a curvature of the spine called scoliosis.

Scoliosis is a curvature of the spine and is very common in children with cerebral palsy. One in five children with CP will have scoliosis so it is very important to see a pediatric orthopaedic surgeon to help monitor it. Scoliosis is usually mild and will not need anything more than regular observation by your doctor. Occasionally scoliosis can worsen and require more extensive treatments.

At the Emory Orthopaedics and Spine Center, we typically use non-operative treatments such as modification of a wheelchair, bracing or casting to minimize the worsening of scoliosis before we consider surgical treatments. Surgery is typically reserved for more severe cases of scoliosis. Emory pediatric orthopaedists Dr. Robert Bruce, Jr. and Dr. Nicholas Fletcher have extensive experience with growing rod and Vertical Expandable Prosthetic Titanium Rib (VEPTR) for the management of severe scoliosis in young patients. These techniques allow for continued growth of the spine in younger children to allow normal development and function. Some older children may need true spinal fusion surgery in order to stop the spine from curving.

Joint Problems
In children with cerebral palsy, it is often difficult to prevent “contracture,” an extreme stiffening of the joints caused by the unequal pull of one muscle over the other. The child will usually work with his or her care team to learn how to stretch the muscles to try to help prevent the joints from stiffening. The orthopaedic surgeon may also recommend braces, casting, or medication to improve mobility in the child’s muscles and joints. Occasionally contractures may begin to cause significant problems in the joints such as an inability to straighten out the leg and stand or a hip which may slide out of the socket. These are problems best managed by a surgeon with lengthening of tendons or perhaps a joint realignment surgery.

Foot Problems
Children with cerebral palsy will often also have difficulties with their feet due to the unequal pull of one muscle over another. These can result in problems with things as basic as getting a shoe on to walking or running. Most patients can be managed with physical therapy or possibly a special brace to hold the foot in a better position. Problems that are more severe may require surgery to rebalance the muscles in the foot or realign the foot so that it functions better.

If you have additional questions about Cerebral Palsy and its implications for pediatric patients, please leave them for us in the comments below.

About the Authors

About Robert Bruce, Jr., MD
Dr. Bruce has been a fixture in the Atlanta community for 17 years having started practicing at Emory in 1995. He is the director of the Children’s Healthcare of Atlanta (CHOA) cerebral palsy program and has a tremendous experience caring for all types of orthopaedic conditions in children with cerebral palsy from the spine to the hips to the feet. Dr. Bruce is also specialty trained in Ilizarov and the treatment of leg length differences and angular deformities. Outside of his clinical duties, Dr. Bruce serves on the CHOA medical board, is the past medical director of Egleston campus, and is currently the head of the orthopaedic team at Egleston hospital.

About Nick Fletcher, MD
Dr. Fletcher has been practicing at Emory since 2010 and cares for all forms of pediatric spinal problems including adolescent scoliosis, neuromuscular scoliosis, congenital scoliosis, early onset scoliosis, kyphosis, and spondylolisthesis. 
He also has spoken locally, nationally, and internationally on his research in scoliosis. His work on adolescent scoliosis has been presented as far away as Japan and he has published multiple studies on early onset and adolescent scoliosis. He also received the 2010 T. Boone Pickens Award for Spinal research for his research in Adolescent Idiopathic Scoliosis. Dr. Fletcher is a current member of the Pediatric Orthopaedic Society of North America’s (POSNA) evidenced based medicine committee and the Children’s Healthcare of Atlanta spinal infection prevention taskforce. His current research on post operative care following spinal surgery will be presented at this year’s POSNA annual meeting in Toronto, Canada.

Dr. Fletcher also specializes in pediatric and young adult hip conditions including hip dysplasia, femoroacetabular impingement (FAI), perthes disease, avascular necrosis, and slipped capital femoral epiphysis. He is one of only a handful of surgeons in the southeast with expertise in the Ganz or periacetabular osteotomy (PAO) for hip dysplasia and the modified Dunn osteotomy for slipped capital femoral epiphysis. He takes care of children of all ages with hip conditions in addition to young adults with hip dysplasia and impingement. He also has extensive experience in hip reconstruction for children with cerebral palsy and hip conditions such as dysplasia, subluxation, or dislocation.

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