Ambulatory Children: CP

The goal here is to improve walking, though the spine and hips must still be monitored as in the non
ambulatory child. Typically the children are ambulating but with some issue such as toe walking, a poor
stride length, scissoring (hips crossing over while walking), or crouching (the knees bent while walking). At
times the feet may not be aligned with the way that the child is walking and there may be toeing in or
toeing out. Instrumented three dimensional gait analysis may be helpful in identifying which muscles are
contributing to the abnormalities, and examination can determine if there are twists in the bones that need
to be addressed. Scissoring may be caused by tight adductor muscles of the hips, or flexion at the knees
and internal rotation at the hips. A crouch gait may be related to simple weakness, or balance issues, or
can be due to contractures of the hips and / or knees. For the ankle level the issues are tightness or
weakness of the triceps surae, or both. In the past heel cords were released as necessary, but now we
recognize that the gastrocnemius may be tight without the soleus being involved. The latter is important in
lifting the heel at the end of stance (‘push off’) so that when possible it must be preserved. Otherwise, there
is a risk of further crouching at the ankle as the child ages. The exception is for hemiplegic individuals,
where toe walking may be treated (after conservative measures such as casting and or botulinum toxin) by
tendon achilles lengthening without concern for later crouching which is a risk only for diplegic children with
both lower extremities involved.
Nonambulatory:
The goal is to promote ease of care by preventing contractures, the development of significant scoliosis, and
progressive hip subluxation,. This is done to promote useful sitting and tranfers, if possible, and to prevent
pain and pressure difficulties which may eventually accompany poor sitting postures, and subluxed hips.. In
order to ensure good sitting height and lung development, scoliosis surgery is postponed to as late as
possible by sitting modification and at times bracing. Likewise, hip abduction bracing or chair ‘pom pom’
modifications may be useful to control hip subluxations. Both of these area are monitored by x-rays. Spinal
fusion may be offered for curves in older children that exceed 50 degrees when sitting. The mere presence
of hip and knee contractures in wheelchair dependent individuals are not in itself an indication for surgery.
For progressive hip subluxation, iliopsoas release and adductor tendon lengthenin may stabilize the
situation, but when there is bony deformity of the hip joint itself, or when spasticity is particularly severe,
proximal femoral varus osteotomy (cutting and redirecting the thigh bone) and /or acetabuloplasty
(deepening or reorientation of the socket) may be necessary. For foot deformities, the goal to perform
procedures to allow the child to wear comfortable shoes and to be able to place them properly in a
wheelchair foot platform. This may require tendon lengthening, particularly the triceps surae (heelcord) and
the posterior tibialis muscles (responsible for inverting or turning the foot in), but may require bony
realignments and fusions in more severe cases.