Difficult conditions of the spastic upper limb

In mild cases of spasticity, it requires detailed, repeated assessment of the patient
to understand the problem with the hand and the need for intervention. Dynamic flexion
deformity of the wrist is a common but relatively neglected category. The patient
on examination would be having good flexion and extension of the wrist and fingers
but they would complain of inability to use the hand for day to day activities. While
assessing them at work one would note that their wrist flexes excessively when they
try to open up the fingers and also flexes when they try to hold objects tightly and
hence their grasp on things is weaker. On clinical examination one can note hyperactivity
of FCU when the patient is asked to extend the fingers and also out of phase activity
of FCU when power grasp is made. Such patients do well with FCU tenotomy or FCU to
ECRB tendon transfer in less tension depending on the power of the wrist extensors.

Swan neck deformity of the fingers in cerebral palsy can result from two reasons and
it is a must to differentiate them in order to treat it appropriately. A swan neck
deformity of the fingers with MCP flexion posture is because of intrinsic spasticity
and the one with MCP extension posture is because of over activity of the long extensors.
The former needs release of the spastic intrinsic muscle and the latter can get better
with correction of the wrist flexion posture itself. Arthrodesis of the PIP joints
in functional position in selected patients can give good results.

While doing correction of the spastic thumb we need to address four issues- release
of the spastic adductor and flexor muscles; augmentation of the weak extensors and
abductors; addressing the first web contracture and stabilization of the joints. A
detailed assessment is needed to find out the contribution of each component and all
need to be addressed at same time or else the result would be poor.