Management of spastic hand

Management of hand deformities in children with cerebral palsy is done to develop and maintain hand manipulation skills, coordination and simple hand functions such as holding different objects for feeding and playing. In older children- writing skills, manipulation skills, activities of daily living skills and social skills have to be developed.

Management of such a deformity is a team effort involving parents, surgeons, physiotherapist, pediatricians, occupational therapist, nurses, and psychologists.

A) If the child is less than 4 years of age, then physical therapy, occupational therapy and positioning with splints should be tried so that their functional activities are made better

1. Physical therapy :
   • This is first line of treatment offered for spastic hand.
   • This treatment is oriented to give as much as possible flexibility and suppleness to joints
   • It includes range of motion exercises and stretching exercises.
   • Improvement in Motor function is targeted
2. Occupational therapy :
   • The only goal of occupational therapy to enhance child's ability to perform day to day activities in home and school
   • It focuses on strength improvement and bilateral hand coordination

B) If the child is more than 4 years of age, then evaluation should be done by all the members of the team and intensive therapy program should be chalked out for the child which involves physical and occupational therapy and splints. Botox can be given to the spastic and contracted muscles to loosen them so that they are amenable for physical therapy.

C) If the deformity has already set in or the contractor does not improve even after injection of Botox, then Surgery should be planned. The ideal age for surgery in children with cerebral palsy for treatment of hand deformity is between 8 to 12 years of age but surgery can be done even in adults.

The results of surgery in such patients are very gratifying and tremendously reduces the burden of parents who are immensely satisfied after the surgery of their child.

Types of surgery in children with cerebral palsy

Aim of surgery in children with hand deformities in cerebral palsy is to give a life to patient which is not dependent on some other individual. The different types of surgeries include-

1. Muscle lengthening: Surgical lengthening of muscles is done to relieve tightness in the hands and fingers. This will improve wrist and hand movements with improvement in motor skills of hand.
2. Tendon lengthening: This reduces contractures of hand. It requires joint oriented physiotherapy after surgery.
3. Tendon transfer: This improves the functional outcome of hand and wrist. In this, a functional tendon is oriented to give movement to non-functional motion at hand or wrist. If power of functioning tendon is not adequate, power of that tendon increased with physical therapy then tendon transfer is performed.
4. Tenotomy/ myotomy: Cutting of tendon or cutting of muscle may improve muscle function and increase control of the upper limbs and enhance ability to grasp objects with hands.
5. Osteotomy: Bones are aligned in correct position to improve posture and function
6. Arthrodesis: In severe cases of spastic hand, wrist arthrodesis done in functional position to improve the daily activities performance

Best plastic surgeon, Dr. Amit Agarwal is an American Board Certified, extensively trained, and best Plastic & Aesthetic surgeon in Lucknow. He is the Chief Plastic Surgeon heading the Department of Plastic, Microvascular, and Craniofacial surgery at Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, U.P, India. He maintains a busy practice at Avadh and Nishat Hospital and his own center - Kayakriti Plastic Surgery & Dental Center. He was formerly a Consultant in the Department of Plastic Surgery and Burns at the prestigious SGPGI, Lucknow.

MS, DNB (General Surgery) MCh, DNB (Plastic Surgery),
MNAMS, FACS, FICS, FRCS (Edinburgh, UK)

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