Cerebral Palsy

Cerebral palsy (CP) is a group of permanent, non-progressive disorders of movement, muscle tone, and posture caused by a disturbance that occurred in the developing foetal or infant brain. It is the most common physical disability in childhood, affecting approximately 2–3 per 1,000 live births.

While the brain lesion itself is non-progressive, the musculoskeletal consequences — spasticity, contractures, joint dislocations, and deformity — progress as the child grows. Orthopaedic management is therefore an ongoing, lifelong process focused on maximising function, preventing deformity, and maintaining independence.

CP results from brain injury occurring before, during, or shortly after birth:

• Periventricular leukomalacia: White matter injury in premature infants — the most common cause in developed countries
• Hypoxic-ischaemic encephalopathy (HIE): Brain damage from oxygen deprivation during or around the time of birth
• Cerebral haemorrhage: Intraventricular haemorrhage in premature newborns
• Prenatal infections: Cytomegalovirus, toxoplasmosis, rubella affecting brain development
• Stroke: Focal arterial infarction in utero or in the neonatal period
• Risk factors: Prematurity (major risk), multiple births, birth asphyxia, maternal infections, placental problems

Presentation varies widely depending on the type and severity. The main types are:

• Spastic CP (most common ~80%): Increased muscle tone (stiffness), brisk reflexes, scissor gait, toe walking, hip dislocation risk. Can be hemiplegia (one side), diplegia (both legs), or quadriplegia (all four limbs)
• Dyskinetic CP: Uncontrolled, involuntary movements — writhing (athetosis) or twisting (dystonia). Often affects the whole body
• Ataxic CP: Poor coordination and balance, wide-based gait, intention tremor
• Delayed motor milestones (not sitting, not walking by expected ages)
• Associated features: intellectual disability, epilepsy, visual/hearing problems, speech difficulties, feeding problems
• GMFCS (Gross Motor Function Classification System) levels I–V describe walking ability from independent walking to wheelchair use

• Clinical neurological and developmental assessment — GMFCS and MACS (Manual Ability) classification
• MRI brain — to identify the type, timing, and extent of brain injury
• Hip surveillance X-rays — standardised programme from age 12 months onwards as hip dislocation is a major risk. Migration percentage measured
• 3D gait analysis (computerised) — objectively quantifies walking pattern, joint angles, and muscle activity to guide surgical decision-making
• Hamstring, hip flexor, and calf flexibility assessment
• EEG if epilepsy is present
• Vision and hearing assessment

Management of CP is multidisciplinary — paediatric neurologist, orthopaedic surgeon, physiotherapist, occupational therapist, orthotist, and speech therapist all play key roles:

• Physiotherapy: Core of management — stretching, strengthening, balance, gait training. Started early and continued throughout childhood
• Orthotics (splints/AFOs): Ankle-foot orthoses support the foot, improve gait pattern, and prevent contractures
• Botulinum toxin (Botox) injections: Injected into spastic muscles (calf, hamstrings, hip adductors) to reduce tone and improve gait. Effect lasts 3–6 months; combined with physiotherapy and casting for maximum benefit
• Oral medications: Baclofen, diazepam — for generalised spasticity or dystonia
• Intrathecal baclofen (ITB) pump: For severe spasticity or dystonia not controlled by oral drugs — a pump delivers baclofen directly to the spinal fluid
• Selective dorsal rhizotomy (SDR): Neurosurgical procedure cutting selected sensory nerve roots to permanently reduce spasticity in the lower limbs — suitable for diplegic children
• Orthopaedic surgery (Single Event Multilevel Surgery — SEMLS): Once gait analysis identifies multiple deformities, a single operation corrects all simultaneously — tendon lengthenings, tendon transfers, bone corrections (osteotomies), and hip procedures. This avoids multiple separate admissions
• Hip surveillance and surgery: Preventive adductor releases and hip osteotomies to prevent or treat hip dislocation — the most important long-term orthopaedic goal in non-ambulant children