Koman L A, Gelberman R H, Toby E B, Poehling G G
Department of Orthopedic Surgery, Wake Forest University Medical Center, Winston-Salem, North Carolina.
Clin Orthop Relat Res. 1990 Apr(253):62-74.
Although only a small number of children with cerebral palsy have indications for surgical treatment of dynamic or structural upper-extremity deformities, orthopedic surgery does improve function and appearance of the involved hand, particularly in spastic hemiplegia. For further assessment of the patient after careful physical examination, myoneural nerve blocks and dynamic electromyography are useful. Physical and occupational therapists have an important role as crucial links among parents, patients, and physicians. Surgeons can try to prevent deformity with splints; however, their use in prevention of deformities of the hand has not been validated by scientific studies. Shoulder deformities can be managed with myotomies, tendon transfers, and (if fixed) osteotomies; rarely is arthrodesis used. Elbow flexion and dynamic or fixed deformities greater than 60 degrees are treated by lengthening of the muscles and tendons. Pronation deformities of the forearm are managed by myotomies, lengthenings, and tendon transfers. Wrist flexion deformities can be corrected with tendon lengthenings and transfers. The best results have been obtained with transfer of the flexor carpi ulnaris to the extensor digitorum communis. Finger flexion deformities can be managed satisfactorily with Z-lengthenings of the flexor digitorum superficialis in the forearm; rarely is it necessary to lengthen the flexor digitorum profundus. For adduction deformity of the thumb, division of the proximal or distal insertions of the adductor pollicis and release of the first dorsal interosseus muscle from the first and second metacarpals are preferred.
尽管只有少数脑瘫儿童有手术治疗上肢动态或结构性畸形的指征，但矫形外科手术确实能改善受累手部的功能和外观，尤其是在痉挛性偏瘫患者中。在仔细的体格检查后，为进一步评估患者，肌神经阻滞和动态肌电图检查很有用。物理治疗师和职业治疗师作为家长、患者和医生之间的关键纽带，发挥着重要作用。外科医生可以尝试使用夹板预防畸形；然而，夹板在预防手部畸形方面的作用尚未得到科学研究的验证。肩部畸形可通过肌肉切断术、肌腱转移术以及（如为固定性畸形）截骨术来处理；很少使用关节融合术。肘部屈曲以及大于60度的动态或固定性畸形通过肌肉和肌腱延长术治疗。前臂旋前畸形通过肌肉切断术、延长术和肌腱转移术处理。腕部屈曲畸形可通过肌腱延长术和转移术矫正。将尺侧腕屈肌转移至指总伸肌已取得最佳效果。手指屈曲畸形在前臂通过指浅屈肌的Z形延长术可得到满意处理；很少需要延长指深屈肌。对于拇指内收畸形，首选切断拇收肌的近端或远端附着点，并从第一和第二掌骨松解第一背侧骨间肌。
