Wrist Arthrodesis in Children with Cerebral Palsy

Author(s): Alexander RD, Davids JR, Peace LC, Gidewall MA

Source: Journal of Pediatric Orthopedics

Summary:

The authors present a retrospective review of 18 children (19 extremities) treated with total wrist arthrodesis at a mean follow-up of approximately 5 years. The underlying premise is that wrist arthrodesis enhanced function, cosmesis, and hygiene in children with spasticity. Although the title indicates cerebral palsy, 5 of the 12 patients had traumatic brain injury. All children were within 2 years of skeletal maturity at the time of fusion. Preoperative and postoperative function was graded according to the House classification, which ranges from no use (level 0) to complete use (level 8). Surgery frequently included proximal row carpectomy along with additional bone and soft tissue procedures, which are confounding factors. Nonetheless, successful primary arthrodesis was obtained in 18 of 19 extremities. The mean improvement in the House score was almost 2 levels (1.4 to 3.2). Four patients did not improve, although their preoperative level was ³ 4 (i.e., fairly functional). Perceived subjective satisfaction was clearly evident cosmetically (94%) and less apparent functionally (72%).

The vast majority of mild to moderate spastic cerebral palsy patients are candidates for tendon transfers to restore wrist extension. However, severe spasticity or the absence of available motors requires alternative methods of management. Wrist fusion has been delegated as a “salvage” surgery in the treatment of cerebral palsy, although considerable functional, hygienic, and cosmetic benefit can be obtained. The amount of active finger extension should be assessed in different wrist positions, as digital extension is often better in a neutral wrist position. This finding requires deviation from the standard slightly extended position of wrist fusion. A functional hand that cannot extend the digits when the wrist is positioned into neutral or slight extension is not a candidate for fusion without concomitant tendon transfers to restore finger extension (e.g., FCU to EDC). A “nonfunctional” hand with severe dyskinesia may also benefit from wrist fusion, although primarily performed for hygiene and appearance. In the older child approaching skeletal maturity, plate fixation is preferred. Kirschner wire fixation is reserved for the skeletally immature child that requires chondrodesis for preservation of the physis.

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