Join Our Mailing List

What We Do
Preventive Program
Adult Education and Literacy
Youth Program
Legal Services Program
Health Program
Anti-Violence Program
Khalil Gibran International Academy
I Need To Be Heard!

Program Contact Information

Danny Salim
Anti-Violence Program Manager
(718) 250 - 5122


By T. Marus. Westmont College.

Adequate finger extension is defined as a good release of grasp position buy generic lasuna 60caps on line, meaning extension of the metacarpophalangeal and interphalangeal joints to −30° buy lasuna 60 caps visa. If this level of extension cannot be passively obtained with the wrist in 0° to 20° of extension discount 60 caps lasuna with visa, lengthening of the finger flexors is indicated buy 60 caps lasuna with mastercard. Lengthening of flexor digitorum superficialis is usually sufficient in a functional hand purchase lasuna 60 caps without a prescription. Simultaneous lengthening of the flexor digi- torum profundus is best avoided in a potentially functional hand because it may cause an excessively weak grasp. However, if the flexor digitorum profundus is excessively tight, it too may require lengthening. When finger flexor contractures are severe, proper hygiene and cleaning of the hand is difficult. In these severe contractures, both the flexor digitorum superficialis and flexor digitorum profundus have to be lengthened. Fractional lengthening at the musculotendinous junction of the flexor digitorum superficialis in mild to moderate deformity is preferred as it does not disrupt the continuity of the muscle and is less likely to result in over- lengthening. Care has to be taken that not too much lengthening occurs or the muscle tendon junc- tion will become completely disrupted. In more severe cases, we prefer to do Z-lengthening, usually lengthening the index and middle finger as a group and also the ring and little finger as a group. Outcome of Treatment There are very few studies that report the outcome of finger flexor length- ening. These results are more specifically a demonstration that the muscles have severe decreased excursion and unless the active range is perfectly placed, they are likely to be perceived as weak- ness. Over time, there is a tendency for the finger flexion contracture to recur, but seldom to the level it was before surgery. Other Treatment Several other methods of lengthening are possible including flexor prona- tor slide (proximal lengthening), Z-lengthening of individual flexor tendons, selective peripheral motor neurectomy,39 and sublimus to profundus trans- fer. The flexor pronator slide provides little control and excessive weakness for children with any function; for those who are severely involved, the Z- lengthening is an easier and simpler operation. Another option similar to the slide is excision of the proximal muscle fascia with detaching the muscle from the bone. With the limited con- trol present in spastic hands, individual tendon Z-lengthening is more com- plicated and provides little gain. Transfers of flexor digitorum superficialis to flexor digitorum profundus to create a single motor unit for the fingers seem to also provide little benefit over simpler lengthening procedures. Most of the function of a hemiplegic hand is for gross finger grasp and thumb key pinch, both ac- tivities requiring power more than fine control. Complications of Treatment The major complication is overlengthening, leaving the fingers with no power in the range where individuals need power for function. This loss of function usually recovers over several years, but only partially. We have not had any individuals with such severe weakness that they desired an operative attempt to correct the overlengthening. Some individuals want ad- ditional lengthening if there is still too much flexion. Those who want addi- tional lengthening are mainly individuals in whom a decision was initially made that the finger flexors need lengthening but no or very minimal length- ening was performed. The other complication is leaving an imbalance with an excessively strong flexor digitorum profundus and extensor digitorum longus causing the swan neck deformity to develop. This deformity can be extremely dis- abling because it locks the fingers so that they cannot be used. Treatment indicated is described in the next section. Finger Swan Neck Tightening of the finger flexors secondary to the wrist flexion deformity plus spasticity of the intrinsic muscles and the extensor digitorum longus results in hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint, which causes the swan neck deformity. The volar cap- sule of the proximal interphalangeal joint becomes stretched out secondarily. When the deformity is severe, the fingers may become locked into extension and cannot actively flex (Figure 8.

In the immediate postoperative period buy discount lasuna 60 caps, both the surgery was successful buy cheap lasuna 60 caps on-line. This ossification may occur with exu- berant callus formation and sometimes occurs as pericapsular ossification (Case 10 buy 60 caps lasuna with visa. Sleep Problems The postoperative pain sometimes causes children to develop very poor sleep patterns order 60caps lasuna fast delivery, become depressed buy lasuna 60 caps low price, and lose their appetite. This pain should be treated using a standard postoperative protocol that depends primarily on antidepressants, such as amitriptyline hydrochloride (Elavil). Prolonged Hip Pain Prolonged pain in the hip joint may occur because of degenerative arthri- tis, which can be treated using a steroid injection protocol. If the pain is per- sistent after three steroid injections, additional palliative treatment should be considered (Case 10. Avascular Necrosis Avascular necrosis following reconstruction has not been encountered at our facility in any patient; however, it has been reported. Treatment of the avascular necrosis should be with gentle range of 564 Cerebral Palsy Management Case 10. A good, stable hip was obtained; however, still uncomfortable with full hip extension and hip rota- he continued with significant pain with range of motion tion. The heterotopic ossification had matured (Figure even at the 6-month follow-up. Often, this ossification slowly resolves over time demonstrated periacetabular ossification (Figure the 6- to 18-month period following surgery, although C10. He was injected with deposteroid several times this has not happened in this boy. Intraarticular Extension of Pelvic Osteotomy Osteotomy extending into the acetabulum is sometimes done inten- tionally, especially in a child with a closed triradiate cartilage, because it is not possible otherwise to open the wedge. If this extension should occur in- advertently, it usually does not cause any long-term problems, and it is im- portant to start and continue to work on the range of motion immediately postoperatively. Other Premature closure of the triradiate cartilage has not been reported with either the peri-ilial osteotomy or the Pemberton osteotomy in children with CP. His parents a 3-week rest from therapy, another attempt at therapy did not feel that he had much pain; however, dressing and caused severe pain. At 4 months after surgery, a radiograph bathing were getting more difficult as he had severe ad- showed a well-healed osteotomy, but there was erosion duction deformities. He was orally fed and had seizures on the medial side of the joint on the right side where the that were well controlled by medication. He had severe growth plate had caused a ridge to form in the acetabu- mental retardation. On physical examination he was noted lum (Figure C10. The pain was believed to be caused to have severe upper extremity spasticity, and the hips by degenerative arthritis from the incongruent hip joint. The hip joint was then injected with deposteroid and gen- Hip flexion was to 100° and popliteal angles were 70°. After 2 weeks, he Radiographs of both hips showed completely dislocated tolerated hip motion somewhat better. A second injection hips with a more dysplastic acetabulum on the right (Fig- was given 1 month after the first and the pain continued ure C10. He underwent bilateral adductor length- to improve; finally, by 1 year after surgery, the hip plate ening, varus derotation osteotomy, and peri-ilial pelvic was also removed to make sure it was not causing pain. His recovery went well for the first month, but The erosions were still there, although the pain was greatly his parents noted that he slept and ate very poorly due to decreased (Figure C10. He was then started on amitriptyline came completely pain free, and by the 5-year follow-up, hydrochloride, 25 mg in the evening. After 4 weeks, he the hip remodeled almost completely so he had excellent slept and ate a little better so the amitriptyline was in- flexion motion, 30° of abduction, and 20° of adduction, creased to 50 mg per night. After 3 months, he ate and but he still continued to have only 20° of total rotation slept well; however, he had not tolerated therapy. The excellent remodeling is typical of hips in children with open growth plates, and the steroid injections seem to decrease the inflammation and allow this remodeling to continue.

order lasuna 60 caps fast delivery

Indications for surgical resection of the heterotopic ossification should include decreased range of motion or lesions that cause persistent pain after maturation purchase lasuna 60 caps mastercard. Surgical excision can be planned after maturity of the heterotopic ossification lesion is demonstrated by having a bone scan purchase lasuna 60 caps on-line, usually approximately 1 year after onset order 60 caps lasuna, with activity 650 Cerebral Palsy Management Figure 10 60caps lasuna overnight delivery. A small order lasuna 60caps, thin amount of het- erotopic ossification may develop in the iliop- soas tendon after myofascial recession. This seldom causes any pain; however, occasion- ally in a very active child this small wisp of bone can fracture and cause hip pain for 4 to 6 weeks until it heals. For large lesions, especially those that involve a hip fusion, there is a remarkable tendency for the heterotopic ossification to slowly return in spite of this radiation treat- ment. Based on the adult data, the most effective preventative method for avoiding recurrent heterotopic ossification is the use of radiation, and we be- lieve this must apply to children as well. Radiation does have long-term risks, such as the development of malignancy, which need to be considered in the balance of the risk–benefit ratio. Postoperative Hip Pain Hip pain is present in all children after hip surgery, and control of this pain is a mandatory part of the orthopaedic management of these children. The standard pain treatment program should anticipate that it will take 6 to 8 weeks after surgery until most of the pain is resolved. If there continues to be a significant amount of pain present by 8 to 12 weeks after hip recon- struction or muscle lengthening, the cause of this pain needs to be specifically diagnosed and treatment designed based on the diagnosis. Many potential causes of this pain can be identified. The development of heterotopic ossification should be suspected, espe- cially if children are continuing to have severe pain after only having muscle surgery. If radiographs are normal and heterotopic ossification is suspected, a bone scan, which will identify the early stages of heterotopic ossification, should be obtained (Case 10. Hip 651 Plate Bursitis Bursitis over the lateral trochanter and the lateral aspect of the blade plate can be identified by the presence of point tenderness in this region, especially when the hip is internally and externally rotated. If there is inflammation with erythema, a deep wound infection needs to be ruled out. If the presence of a deep wound infection is in question, the wound should be aspirated down to the plate. Chronic bursitis over the plate that develops because chil- dren have been either sitting or lying on the plate is more common. This deep wound infection or chronic bursitis tends to occur late, usually 6 to 12 months following surgery. In the acute phase, it is often just wound erythema and inflammation from high weight bearing over the prominent plate. Most typ- ically this bursitis occurs while children are side lying, although it may also occur when they are sitting. In this instance, careful physical examination of children lying supine and side lying, and then sitting in the typical wheelchair posture, is very important to determine where the problem is occurring. The posture then needs to be addressed with appropriate relief. If difficulty with posture results from seating, seating adaptations such as seating wedges are necessary. If problems with posture are coming from the side lying position, caretakers should be given instructions on using a blanket roll under the il- ium as the children side lie to help lift some of the weight off the lateral aspect of the hip (Figure 10. If this is a chronic bursitis over the plate and the osteotomy has healed, the plate should be removed. If the plate cannot be removed immediately, the bursa can be injected with a deposteroid such as triamcinolone acetate, 40 to 80 mg. Medial Plate Protrusion Medial protrusion through the calcar or the femoral neck by the blade plate may cause pain by producing an iliopsoas bursitis. This bursitis is most typ- ically a problem in children who have had derotation to improve their walk- ing ability but continue to have increased pain 3 to 9 months after surgery and are not quite making the rehabilitation progress expected. These children typically refuse to stand with the hip fully extended. Often, the primary com- plaint is not pain but rather the inability to make progress in rehabilitation, especially in the ability to gain straight upright standing. On physical exam- ination, it is often very difficult to localize the problem because when these children are relaxed they have full hip range of motion with no pain.

discount lasuna 60 caps visa

Typically buy generic lasuna 60 caps on line, these contractures start to become noticeable in 8 generic lasuna 60 caps with amex. Upper Extremity 395 middle childhood and become more noticeable in adolescence discount 60 caps lasuna with visa. The most common deformity is protraction and elevation of the shoulder through the scapulothoracic joint purchase 60caps lasuna amex, with the clavicle becoming more vertical and anteri- orly directed order lasuna 60 caps overnight delivery. As severely involved patients become adults, this shoulder po- sition becomes fixed but seldom causes any pain or discomfort. In spastic patients, internal rotation contracture of the shoulder develops as a result of spasticity of the pectoralis major and subscapularis muscle. On rare occa- sions, extension and external rotation abduction contractures develop, often caused predominantly by the long head of the triceps and teres muscles. Natural History The natural history of shoulder contractures is for increasing severity during late childhood and adolescence with minimal change after hormonal and skeletal maturity. Also in middle childhood, primarily in children with quad- riplegia, shoulder adduction, internal rotation, and flexion contractures develop. As these contractures become more severe, especially at puberty with the hormonal changes and the growth of axillary hair, the contractures become so severe that proper cleaning and drying of the axilla becomes very difficult. Also, dressing these children, especially placing arms in sleeves, becomes very difficult. For other functional positions, such as seating and different reclining positions, this upper extremity position is good. During adolescence, there are a small group of children who develop an external rotational abduction contracture of the shoulder. This becomes a functional problem, especially when seated in a wheelchair, as the arms tend to strike walls as these children are being transported. Shoulder and elbow extension For ambulatory children, the most common hemiplegic posturing is with can be disabling because it causes the arm to shoulder elevation and protraction combined with adduction, flexion, and be behind and lateral to the individual. This becomes severe enough to cause functional problems may lead to the arm getting bumped or strik- only in rare ambulatory children with hemiplegia. There are also a few chil- ing furniture, and it is a significant cosmetic dren who develop shoulder extension and external rotation combined with problem (A). In ambulatory children this is usually a sign of dystonia, lateral and long head of the triceps, the although this may be encountered in individuals with spasticity and con- elbow and shoulder flexion are greatly im- tracture (Figure 8. This also allows the arm to hang at the side during ambulation (B). Splinting is of no use, especially the attempt to use figure-of-eight straps on the shoulders to counteract the shoulder pro- traction and elevation. These straps have too little mechanical advantage to make an impact without causing children discomfort. As children with quadriplegia enter puberty and approach maturity, problems related to dressing and hygiene develop. When the parents or care- takers report problems, treatment is indicated. By this time the contractures are fixed and only surgical lengthening will make a difference. The goal of surgery is to lengthen the shoulder internal rotator and adductors enough so children’s arms can easily be placed in sleeves and the axilla can be cleaned. Obtaining 90° of shoulder abduction in the operating room is very adequate to accomplish these goals. Usually, this abduction is accomplished with com- plete release of the pectoral muscles (Case 8. Her mother cared for her at home one weekend a month and was also pres- ent. They agreed that the major problem was difficulty in dressing her left upper extremity because her arms were very stiff. The caregivers also complained that it was very difficult to clean her axilla and they could not control her strong body odor because of difficulty with bathing, especially in her axilla and wrist flexion crease. She had had multiple previous surgeries including spinal fusion for scoliosis and hip osteotomies for spastic hip disease.

10 of 10 - Review by T. Marus
Votes: 308 votes
Total customer reviews: 308


The Arab-American Family Support Center is a 501(c)3 non-profit, non-sectarian organization that provides culturally and linguistically sensitive services to immigrant communities throughout New York City.  © 2017 All Rights Reserved.

AAFSC Brooklyn
150 Court Street, 3rd Flr
Brooklyn, NY 11201
T: 718 - 643 - 8000
F: 718 - 797 - 0410
E: info@aafscny.org
AAFSC Queens
37-10 30th Street, 2nd Fl.

Queens, NY 11101
T: 718 - 937 - 8000
F: 347 - 808 - 8778
AAFSC @ the Family Justice Centers
FJC Bronx (718) 508-1220
FJC Brooklyn (718) 250 - 5035
FJC Manhattan (212) 602-2800
FJC Queens (718) 575 - 4500
FJC Staten Island (718) 697 - 4300