Treating pronator deformation of a forearm in pre-school children with cerebral palsy
Authors:   A.I. Yevdokimov Moscow State University of Medicine and Dentistry, YARYGIN N. V. , BOSYKH V. G. ,   A.I. Yevdokimov Moscow State University of Medicine and Dentistry, PARSHIKOV M. V. ,   A.I. Yevdokimov Moscow State University of Medicine and Dentistry, KHOROSHKOV S. N. ,   A.I. Yevdokimov Moscow State University of Medicine and Dentistry
Published: January 2022

Cerebral palsy (CP) remains one of the main neurological diseases leading to disability of children. One of the leading causes is pronator deformity of the forearms, in which the development of voluntary hand movements is not only slowed down, but qualitatively impaired. In 75–90% of children, the manipulative activity of the upper extremities remains defective, and in 30–45% of cases it is sharply limited throughout life, especially in hemiparetic form and spastic diplegia. With a severe form of spastic diplegia, by the age of 3, flexion contractures of the elbow joints, pronator contractures of the forearm, with elbow deviation of the hand, with violation of all types of grips, make self-service difficult. Lack of attention to these deformities of the upper limbs on the part of neurologists and orthopedists leads to an incorrect treatment plan, primarily surgical, to eliminate pronator deformities of the forearm. In the literature, there are few publications on upper limb deformities in cerebral palsy, although the positive results of surgical correction of pronator deformities are recognized in 85%. However, the indications for surgical treatment are not clearly defined, especially regarding the choice of the method of surgical correction in a particular case. The analysis of preoperative treatment of 54 children with spastic diplegia at the age of 3–4 years showed a low efficiency of conservative therapy with pronator settings of the forearms and a complete lack of effect in case of contractures. This led to the understanding that in case of pronator contractures and deformities of the forearm by 3–4 years of age, with spastic diplegia, surgical treatment is indicated, aimed either at restoring active movements or at eliminating a cosmetic defect. The main reason for the formation of pronator deformity of the forearms was the contraction of the round pronator of the forearm. The observed patients were divided into 3 groups. In children of the first group (27 patients), contracture was 30-70º, due to contraction of the m.pronator teres, while maintaining the manipulative function of the hand. In the second group (6 patients), hand function was also not impaired, but there was a decrease in the strength of the forearm instep support (up to 3 points) with pronator contracture of the forearm at 40–90º. The third group (6 children) lacked the function of the instep support while maintaining the function of m.pronator teres and a decrease in manipulative activity. The dysfunction was accompanied by the absence of one or two main grips, with manifestations of afunctionality. In this group, MRI studies revealed porencephalic and arachnoid cysts of the contralateral hemispheres. The indications for surgical treatment are cosmetic only. 39 children of 3–7 years old with cerebral palsy with pronatonator deformity of the forearm were operated. Before surgery, pronator contractures were 40–90° with no convincing age correlation. With surgical treatment at 3–4 years of age, pronator deformity of the forearm up to 50° was completely eliminated, and with initial values of 70–90° — to a residual of 15–30°, with a decrease to 10–15° after a year. With surgery at the age of 6–7 years, a residual contracture of 10–30° was observed in more than half of the patients, due to the torsion of the forearm bones and disturbed relationships in the distal and proximal radioulnar joints at this age. Complete restoration of forearm supination and elimination of deformity (good result) was achieved in 21 (53,8%) children. An increase in supination of the forearm with residual deformity and an improvement in the manipulative function of the hand, or the desired cosmetic effect (satisfactory result) was observed in 18 (46,2%) patients. In three children of the first and second groups, despite a pronounced clinical improvement, the expected effect on the complete restoration of the manipulative function of the forearm and hand was not obtained, due to gross organic changes in the 4 and 6 fields of the brain, revealed by MRI. In the postoperative period after aponeurotic lengthening of the round pronator or its myotomy, we applied a method developed by us for the functional treatment of early kinesitherapy of the operated forearm. In children of the first and second groups, an improvement in the vegetative state on the part of the forearm and hand was revealed (symptoms of «cold hands» and hyperhidrosis disappeared), associated with the elimination of the «tunnel» state of the median nerve in the zone of its passage at the circular pronator in the upper third of the forearm and improving microcirculation of the forearm and hand. Thus, a differentiated approach to surgical correction of deformities made it possible to obtain a good result in 21 (53,8%) children, and a satisfactory one in 18 (46,2%) children.