Cambria
In a few individuals with hemiplegia, there is a very mild dynamic wrist flexion and forearm pronation present with no fixed contractures. When the child is not aware of the extremity position the wrist tends to be in flexion, and when the child uses the hand it tends to be predominantly in flexion and pronation. The child has full independent active control of the hand and wrist function. This extremity is classified as Type 5 extremity. The next level of involvement includes those individuals with some fixed flexion contracture of the wrist but good active finger extension with wrist held passively extended. These fall into Type 4 on the classification scale. Cambria, a 9-year-old girl with right hemiplegia, presented in orthopedic clinic with a concern about the appearance of her arm. She felt other children noticed the arm and some children had called her crippled. Her mother was concerned because Cambria used the arm infrequently and only for activities where she definitely had to use two hands. Cambria was in a regular fourth grade and was completely age appropriate and independent in all activities except she could not tie her own shoes. On physical examination, her elbow flexion lacked 10 degrees to full extension, supination lacked 20 degrees to full supination, wrist flexion and extension was full and thumb abduction was full. On attempted active finger extension her wrist flexed to 30 degrees. With the wrist held passively at 30 degrees of dorsiflexion she could extend her fingers fully at the PIP and DIP joints, but lacked 40 degrees of extension at the MCP joints. When she was observed standing, her elbow was flexed 60 degrees, forearm was pronated, wrist flexed, thumb was adducted, and the fingers were mid-point between flexion and extension. She had a myofascial lengthening of the biceps at the elbow, distal release of the pronator teres and a transfer around the ulnar border of the FCU to the ECRB. A midsubstance myotomy of the adductor pollicis was performed in the palm. She was placed in a long arm cast in 80 degrees of elbow flexion, full supination, 30 degrees of wrist dorsiflexion, thumb in full abduction at the metacarpal carpal joint and mild flexion at the MCP and IP joints. The fingers were in 30 degrees of flexion at the MCP and IP joints. After fours weeks, the cast was removed, and therapy began three times a week focusing on joint range of motion, with the only limitation being that there was no passive wrist flexion stretching. She was to wear a wrist extension splint that held her wrist in 20 to 30 degrees of extension fulltime, except during bathing, for six more weeks to protect the transferred tendon. After six weeks the splint was removed except for nighttime wear, which was to be used for six months. Functional activities in therapy focused on activities of daily living, and teaching her how to tie her shoes using a one handed technique. After one year, Cambria returned for follow-up with her mother and she was very happy with the surgical outcome because she felt her arm now looked nearly normal. Her mother, however, was unhappy because she said Cambria, in spite of the surgery and extensive therapy, still did not use her hand more frequently. She noted that although her daughter had learned to tie her shoes, she only used one hand.
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