Surgical Treatment of Pediatric Upper Limb Spasticity: The Wrist and Hand

Abstract

The wrist and hand are essential in the placement of the upper extremity in a functional position for grasp, pinch, and release activities. This depends on the delicate balance between the extrinsic and intrinsic muscles of the wrist and hand. Spasticity alters this equilibrium, limiting the interaction of the upper limb with the environment. Classically, pediatric patients with upper limb spasticity present with a flexed wrist, thumb-in-palm, and flexed finger posture. These contractures are typically secondary to spasticity of the extrinsic flexor muscles of the wrist and hand and intrinsic muscles of the thumb and digits. Tendon release, lengthening, or transfer procedures may help correct the resultant abnormal postures. A total wrist arthrodesis with or without proximal row carpectomy may help address the severely flexed wrist deformity. With proper diagnosis, a well-executed surgical plan, and a consistent hand rehabilitation regimen, successful surgical outcomes can be achieved.

Pediatric Spastic Wrist Contractures Can Be Well Managed With Wrist Arthrodesis

“…For the patient to be included in the prospective arm, they also needed to be contactable (often a family member) to complete a telephone survey of subjective outcomes. While the exclusion criteria included (1) no postoperative imaging to assess for union and (2) wrist fusion for reasons other than a severe spastic contracture (ie, trauma).…”

“…This refers to internal rotation of the shoulder, elbow flexion, forearm pronation, wrist, and finger flexion. 1,2 As the child grows, this posturing can become rigid and fixed. 3 When looking specifically at wrist flexion contractures, severe contractures can result in difficulty with skin hygiene and breakdown, infection, and pain.…”

“…This can be achieved with wrist arthrodesis. 1,[10][11][12][13] A few small studies [10][11][12][13] have looked at the use of wrist arthrodesis in spastic contractures previously, mostly focusing on functional outcomes according to the House score and fusion rates. The largest series to date conducted by Van Heest and Strothman 12 reported on the outcomes of 34 patients (41 wrists) who were managed with a dorsal arthrodesis plate.…”

“…Children with cerebral palsy (CP) or severe spasticity secondary to traumatic brain injuries and alike who exhibit upper extremity involvement often present with “typical” upper extremity posturing. This refers to internal rotation of the shoulder, elbow flexion, forearm pronation, wrist, and finger flexion 1,2 . As the child grows, this posturing can become rigid and fixed 3 .…”

Canadian Physicians' Use of Perioperative Botulinum Toxin Injections to Spastic Limbs: A Cross-sectional National Survey

“…They may also undergo surgical procedures unrelated to their spasticity (eg, joint replacement, cervical fusion). 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 …”