Characteristics and assessment of children undergoing upper limb surgery for management of cerebral palsy

Main Article Content

Danielle Sabella
Adam Scheinberg
Bruce Johnstone
David McCombe
Monika Hasnat


cerebral palsy, upper extremity, paediatric hospital, muscle spasticity, patient selection


Background: Surgical intervention for improvement of upper limb function in children with cerebral palsy is reported to be of benefit where careful patient selection is taken into consideration. Currently there are no clinical guidelines to help determine selection of individuals best suited for operative management, nor does research exist that identifies characteristics of the patient cohort currently being selected as appropriate for surgery. The aim of this study is to determine the current trends in selection, assessment and management of patients with cerebral palsy undergoing upper limb surgery.

Methods: This retrospective study included data from 102 individuals with cerebral palsy who had undergone upper limb surgical management during a 10-year time period at the Royal Children’s Hospital, Melbourne, Australia. There were 138 separate surgical events involving 579 procedures during this period. Data regarding the characteristics of the individuals and their perioperative assessment was collected and analysed.
Results: The cohort was 56.9% male, the median age at time of surgery was 14.2 years old. Motor involvement was 51.0% bilateral and 49.0% unilateral and 96.0% of individuals had a spastic component. The most common surgical goal was position care (50.4% of cases), followed by activity and participation (47.9% of cases). Preoperative outcome measures were used in 69.6% of cases.
Conclusions: Currently, individuals are selected for surgery using variable preoperative assessment. Selection has great potential to differ between clinicians. These compounding issues provide rationale for initiating further research into understanding the characteristics of this patient group and promoting better standardisation of perioperative assessment.


Metrics Loading ...
Abstract 366 | PDF Downloads 135 HTML Downloads 66


1. Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol. 2007 Jun;49(6):480
2. Clark SM, Ghulmiyyah LM, Hankins GD. Antenatal antecedents and the impact of obstetric care in the etiology of cerebral palsy. Clin Obst Gynecol. 2008;51(4):775–86. PMid:18981802
3. Jacobsson B, Hagberg G. Antenatal risk factors for cerebral palsy. Best Pract Res Clin Obstet Gynaecol. 2004;18(3):425–36. PMid:15183137
4. Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil. 2006;28(4):183–91. PMid:16467053 PMCid:PMC4010242
5. Zancolli EA. Surgical management of the hand in infantile spastic hemiplegia. Hand Clin. 2003;19(4):609–29.
6. Lomita CE, Ezaki M, Oishi S. Upper extremity surgery in children with cerebral palsy. J Am Acad Orthop Surg. 2010;18:160–68. PMid:20190106
7. Tonkin M, Freitas A, Koman A, Leclercq C, Van Heest A. The surgical management of thumb deformity in cerebral palsy. J Hand Surg Eur 2008;33(1):77–80. PMid:18332025
8. Makki D, Duodu J, Nixon M. Prevalence and pattern of upper limb involvement in cerebral palsy. J Child Orthop. 2014;8(3):215–19. PMid:24824566 PMCid:PMC4142879
9. Mackey AH, Walt SE, Stott NS. Deficits in upper-limb task performance in children with hemiplegic cerebral palsy as defined by 3-dimensional kinematics. Arch Phys Med Rehabil. 2006;87(2):207–15. PMid:16442974
10. World Health Organization. International Classification of Functioning, Disability and Health: ICF. Geneva: World Health Organization; 2001.
11. Koman LA, Sarlikiotis T, Smith BP. Surgery of the upper extremity in cerebral palsy. Orthop Clin North Am. 2010;41(4):519–29. PMid:20868882
12. Smitherman JA, Davids JR, Tanner S, Hardin JW, Wagner LV, Peace LC, Gidewall MA. Functional outcomes following single-event multilevel surgery of the upper extremity for children with hemiplegic cerebral palsy. J Bone Joint Surg Am. 2011;93(7):655–61. PMid:21471419
13. Van Heest AE, Bagley A, Molitor F, James MA. Tendon transfer surgery in upper-extremity cerebral palsy is more effective than botulinum toxin injections or regular, ongoing therapy. J Bone Joint Surg Am. 2015;97(7):529–36. PMid:25834076
14. Novak I, McIntyre S, Morgan C, Campbell L, Dark L, Morton N, Stumbles E, Wilson S-A, Goldsmith S. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol. 2013;55(10):885–910. PMid:23962350
15. Van Heest AEH, House JH, Cariello C. Upper extremity surgical treatment of cerebral palsy. J Hand Surg Am. 1999;24(2):323–30. PMid:10194018
16. Koman LA, Gelberman RH, Toby EB, Poehling GG. Cerebral palsy. Management of the upper extremity. Clin Orthop Relat Res. 1990(253):62–74.
17. Lawson RD, Tonkin MA. Surgical management of the thumb in cerebral palsy. Hand Clin. 2003;19(4):667–77.
18. Ozkan T, Tuncer S. Upper extremity surgery in spastic cerebral palsy. J Acad Res Med. 2012;2(2):20–31.
19. Davids JR, Sabesan VJ, Ortmann F, Wagner LV, Peace LC, Gidewall MA, Blackhurst DW. Surgical management of thumb deformity in children with hemiplegic-type cerebral palsy. J Pediatr Orthop. 2009;29(5):504–10. PMid:19568025
20. Boyd RN, Morris ME, Graham HK. Management of upper limb dysfunction in children with cerebral palsy: a systematic review. Eur J Neurol. 2001;8(Suppl. 5):150–66. PMid:11851744
21. Wesdock KA, Kott K, Sharps C. Pre- and postsurgical evaluation of hand function in hemiplegic cerebral palsy: exemplar cases. J Hand Ther. 2008;21(4):386–97. PMid:19006765
22. Malizos KN, Liantsis AK, Varitimidis SE, Dailiana ZH, Rigopoulos NS. Functional gains after surgical procedures in spastic upper extremity: a comparative study between children and adults. J Pediatr Orthop B. 2010;19(5):446–53. PMid:20634723
23. de Roode CP, James MA, Van Heest AE. Tendon transfers and releases for the forearm, wrist, and hand in spastic hemiplegic cerebral palsy. Tech Hand Up Extrem Surg. 2010;14(2):129–34. PMid:20526169
24. Ho JJ, Wang TM, Shieh JY, Wu KW, Huang SC, Kuo KN. Pronator teres transfer for forearm and wrist deformity in cerebral palsy children. J Pediatr Orthop. 2015;35(4):412–18. PMid:25075892
25. Thomason P, Graham HK. Rehabilitation of children with cerebral palsy after single-event multilevel surgery. In: Morris ME, Iansek R (eds). Rehabilitation in movement disorders. Cambridge: Cambridge University Press, 2013; pp. 203–16.
26. Eliasson A-C, Krumlinde-Sundholm L, Rösblad B, Beckung E, Arner M, Öhrvall A-M, Rosenbaum P. The Manual Ability Classification System (MACS) for children with cerebral palsy: scale development and evidence of validity and reliability. Dev Med Child Neurol. 2006;48(7):549–54. PMid:16780622
27. Morris C, Kurinczuk JJ, Fitzpatrick R, Rosenbaum PL. Reliability of the Manual Ability Classification System for children with cerebral palsy. Dev Med Child Neurol. 2006;48(12):950–53. PMid:17109781
28. Australian Cerebral Palsy Register (ACPR) Group. Australian cerebral palsy register report 2016. Sydney: ACPR Group; 2016.
29. Hansen AØ, Tromborg H. Increased use of the affected hand one and a half years after surgical correction for cerebral palsy and subsequent intensive hand therapy. Hand Ther. 2013;19(1):17–25.
30. Oishi S, Butler L. Technique of pronator teres rerouting in pediatric patients with spastic hemiparesis. J Hand Surg Am. 2016;41(10):e389–92. PMid:27546440
31. Miller F. Cerebral palsy. New York: Springer; 2005.
32. Alewijnse JV, Smeulders MJ, Kreulen M. Short-term and long-term clinical results of the surgical correction of thumb-in-palm deformity in patients with cerebral palsy. J Pediatr Orthop. 2015;35(8):825–30. PMid:25575357
33. Gong HS, Chung CY, Park MS, Shin HI, Chung MS, Baek GH. Functional outcomes after upper extremity surgery for cerebral palsy: comparison of high and low manual ability classification system levels. J Hand Surg Am. 2010;35(2):277–83, e1–3. PMid:20141898
34. Johnstone BR, Richardson PW, Coombs CJ, Duncan JA. Functional and cosmetic outcome of surgery for cerebral palsy in the upper limb. Hand Clin. 2003;19(4):679–86.
35. Ozkan T, Bicer A, Aydin HU, Tuncer S, Aydin A, Hosbay ZY. Brachialis muscle transfer to the forearm for the treatment of deformities in spastic cerebral palsy. J Hand Surg Eur Vol. 2013;38(1):14–21. PMid:22526513
36. Bunata RE. Pronator teres rerouting in children with cerebral palsy. J Hand Surg Am. 2006;31(3):474–82. PMid:16516745
37. van Munster JC, Maathuis KG, Haga N, Verheij NP, Nicolai JP, Hadders-Algra M. Does surgical management of the hand in children with spastic unilateral cerebral palsy affect functional outcome? Dev Med Child Neurol. 2007;49(5):385–89. PMid:17489815
38. Wagner LV, Davids JR. Assessment tools and classification systems used for the upper extremity in children with cerebral palsy. Clin Orthop Relat Res. 2012;470(5):1257–271. PMid:21932104 PMCid:PMC3314769