الفهرس 
anatomyOnly 14 pages are availabe for public view
 |  | from | 101 |  |  |
| | | from | 101 | | |
Abstract
Clinical decision making for the management of foot deformities in children with CP is based on the collection and integration of data from 5 sources: the clinical history, physical examination, plain radiographs, observational gait analysis, and quantitative gait analysis (which includes kinematic/ kinetic analyses, dynamic EMG, and dynamic pedobarography).
The 3 most common foot segmental malalignments in children with CP are equinus, equinoplanovalgus, and equinocavovarus. The 2 most common associated deformitiesare ankle valgus and hallux valgus. Level I foot andankle deformities (caused by dynamic overactivityand imbalance of muscles) are best treated with pharmacologic or neurosurgical interventions designed to manage muscle tone and spasticity, or muscle tendon unit transfers. Level II deformities (caused by fixed or myostatic soft tissue imbalance without fixed skeletal malalignment) are best treated with muscle tendon unit lengthening surgery. Level III deformities (consisting of structural skeletal malalignment associated with fixed or myostaticsoft tissue imbalance) are best treated with a combination of soft tissue and skeletal surgeries.15
The orthopedic surgeon is a constant participant inthe care of children with cerebral palsy. Pediatric orthopedic surgeons are uniquely qualified to plan and orchestrate a program to decrease the risk ofdeformity and improve overall function. Treatingboth spasticity and dystonia during the growth years improves the orthopedic and functional outcomes of children with cerebral palsy. Being well acquainted with the hypertonic syndromes as well as being able to discriminate between themis important for the orthopedic surgeon.
Orthopedic surgeons are in an ideal position to begin treatment of hypertonia but may depend on other members of the team to monitor or expand on the treatment methods chosen. First line medications are initiated by the orthopedic surgeon; however, children with cerebral palsy need close monitoring for dose adjustments, side effect monitoring, and evaluation of progress toward rehabilitation goals. A pediatric physiatrist, pediatric neurologist, or developmental pediatrician can typically provide expertise in tone management. The efforts of these professionals to control tone and manage the possible side effects of treatment will complement the work of the orthopedic surgeon. Pediatric orthopedic surgeons pioneered the use of botulinum toxins in children with cerebral palsy.
The neurolytics can effectively control the focal tone that is found in both spasticity and dystonia. These procedures can be performed during office visits or concurrently during surgery. Despite aggressive treatment of hypertonia, deformity can still occur. Decisions regarding the timing of treatments such as intrathecal baclofen therapy and selective posterior rhizotomy occur in the context of the overall functional and rehabilitation goals of the patient. These neurosurgical procedures are complementary and do notobviate careful orthopedic assessment.