Surgery for the Pronated Forearm and Flexed Wrist in Children with Cerebral Palsy

  • Maximillian MifsudEmail author
  • Jules Letherland
  • Rachel Buckingham
Original Article



There is no consensus in the literature on how best to manage wrist flexion and forearm pronation deformities in children with cerebral palsy (CP). The aim of this research was to come up with a treatment algorithm for the surgical management of such cases.


Children with CP who underwent upper limb surgery between 2009 and 2016 at a single centre and by a single lead surgeon were reviewed retrospectively. Movement analysis and Shriners Hospital Upper Extremity Evaluation (SHUEE) data collected pre- and post-operatively.


Thirteen patients were recruited. Most patients underwent a flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB) transfer, with or without pronator teres (PT) re-routing, and finger flexor or elbow flexor releases. Mean increase in active range of supination was 40.8° (p = 0.002) and wrist extension 28.9° (p = 0.004). The mean increase in dynamic positional analysis (part of the SHUEE) was 25.4% (of which 40.3% was due the increases in wrist function and 16.8% due to forearm function). The loss of wrist flexion was not significant (p = 0.125). The mean follow-up was 14 months (range 9–21).


To tackle both a pronation and flexion deformity, the authors favour performing a FCU to ECRB transfer in isolation if there is active supination to neutral; if active supination is short of neutral, then a FCU to ECRB with a PT release and possible re-routing performed. A treatment algorithm is proposed.

Level of evidence



Cerebral palsy Flexion Pronation FCU ECRB Paediatrics Movement analysis Surgery 


Author Contributions

MM: study design, data collection, statistical analysis and writing of paper. JL: data collection and writing of paper. RB: study design, statistical analysis and writing of paper.



Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

This manuscript represents honest and original work. The manuscript has been read and approved by all the authors.


  1. 1.
    Odding, E., Roebroeck, M. E., & Stam, H. J. (2006). The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disability and Rehabilitation,28, 183–191.CrossRefGoogle Scholar
  2. 2.
    Lomita, C., Ezaki, M., & Oishi, S. (2010). Upper extremity surgery in children with cerebral palsy. Journal of American Academy of Orthopaedic Surgeons,18, 160–168.CrossRefGoogle Scholar
  3. 3.
    Čobeljić, G., Rajković, S., Bajin, Z., et al. (2015). The results of surgical treatment for pronation deformities of the forearm in cerebral palsy after a mean follow-up of 17.5 years. Journal of Orthopaedic Surgery and Research,10, 106.CrossRefGoogle Scholar
  4. 4.
    El-Said, N. (2001). Selective release of the flexor origin with transfer of flexor carpi ulnaris in cerebral palsy. The Journal of Bone and Joint Surgery. British,83(2), 259–262.CrossRefGoogle Scholar
  5. 5.
    Kreulen, M., Smeulders, M., Veeger, H., & Hage, J. (2006). Movement patterns of the upper extremity and trunk before and after corrective surgery of impaired forearm rotation in patients with cerebral palsy. Developmental Medicine and Child Neurology,48(6), 436–441.CrossRefGoogle Scholar
  6. 6.
    Pletcher, D., Hoffer, M., & Koffman, D. (1976). Non-traumatic dislocation of the radial head in cerebral palsy. Journal of Bone and Joint Surgery. American Volume,58(1), 104–105.CrossRefGoogle Scholar
  7. 7.
    Patella, V., & Martucci, G. (1980). Transposition of pronator radial teres muscle to the radial extensors of the wrist, in infantile cerebral paralysis An improved operative technique. Italian Journal of Orthopaedics and Traumatology,6(1), 61–66.PubMedGoogle Scholar
  8. 8.
    Sakellarides, H., Mital, M., & Lenzi, W. (1981). Treatment of pronation contractures of the forearm in cerebral palsy by changing the insertion of the pronator radii teres. Journal of Bone and Joint Surgery. American Volume,63(4), 645–652.CrossRefGoogle Scholar
  9. 9.
    Gschwind, C., & Tonkin, M. (1992). Surgery for cerebral palsy: part 1. Classification and operative procedures for pronation deformity. The Journal of Hand Surgery: British,17(4), 391–395.CrossRefGoogle Scholar
  10. 10.
    Cheema, T., Firoozbakhsh, K., De Carvalho, A., & Mercer, D. (2006). Biomechanic comparison of 3 tendon transfers for supination of the forearm. Journal of Hand Surgery. American Volume,31(10), 1640–1644.CrossRefGoogle Scholar
  11. 11.
    Ozkan, T., Tuncer, S., Aydin, A., Hosbay, Z., & Gulgonen, A. (2004). Brachioradialis re-routing for the restoration of active supination and correction of forearm pronation deformity in cerebral palsy. The Journal of Hand Surgery: British,29(3), 265–270.Google Scholar
  12. 12.
    Moon, E., Howlett, J., Wiater, B., & Trumble, T. (2011). Treatment of plastic deformation of the forearm in young adults with double-level osteotomies: case reports. Journal of Hand Surgery. American Volume,36(4), 639–646. Scholar
  13. 13.
    Yasukawa, A. (1990). Upper extremity casting: adjunct treatment for a child with cerebral palsy hemiplegia. Case report. American Journal of Occupational Therapy,44(9), 840–846.CrossRefGoogle Scholar
  14. 14.
    Bunata, R. (2006). Pronator teres rerouting in children with cerebral palsy. Journal of Hand Surgery. American Volume,31(3), 474–482.CrossRefGoogle Scholar
  15. 15.
    Veeger, H., Kreulen, M., & Smeulders, M. (2004). Mechanical evaluation of the pronator teres rerouting tendon transfer. The Journal of Hand Surgery: British,29(3), 259–264.Google Scholar
  16. 16.
    Strecker, W., Emanuel, J., Dailey, L., & Manske, P. (1988). Comparison of pronator tenotomy and pronator rerouting in children with spastic cerebral palsy. Journal of Hand Surgery. American Volume,13(4), 540–543.CrossRefGoogle Scholar
  17. 17.
    Thuilleux, B., & Tachdjian, M. (1976). Treatment of flexon-pronation contracture of the wrist in hemiplegic children. Revue de Chirurgie Orthopedique et Reparatrice de l’Appareil Moteur,62(4), 419–431.PubMedGoogle Scholar
  18. 18.
    Gugger, Y., Kalb, K., Prommersberger, K., & van Schoonhoven, J. (2013). Brachioradialis rerouting for restoration of forearm supination or pronation. Operative Orthopadie und Traumatologie,25(4), 350–359.CrossRefGoogle Scholar
  19. 19.
    Koman, L. A., Sarlikiotis, T., & Smith, B. P. (2010). Surgery of the upper extremity in cerebral palsy. Orthopedic Clinics of North America,41(4), 519–529.CrossRefGoogle Scholar
  20. 20.
    Pollock, G. A. (1962). Surgical treatment of cerebral palsy. Journal of Bone and Joint Surgery. British Volume,44, 68–81.CrossRefGoogle Scholar
  21. 21.
    Salazard, B., & Medina, J. (2008). The upper limb of children with cerebral palsy: surgical aspects. Chirurgie de la Main,27(Suppl 1), S215–S221.CrossRefGoogle Scholar
  22. 22.
    Van Heest, A. E., Bagley, A., Molitor, F., & James, M. A. (2015). Tendon transfer surgery in upper-extremity cerebral palsy is more effective than botulinum toxin injections or regular, ongoing therapy. Journal of Bone and Joint Surgery. American Volume,97(7), 529–536.CrossRefGoogle Scholar
  23. 23.
    O’Driscoll, S. W., Horii, E., Ness, R., et al. (1992). The relationship between wrist position, grasp size, and grip strength. Journal of Hand Surgery,17, 169–177.CrossRefGoogle Scholar

Copyright information

© Indian Orthopaedics Association 2020

Authors and Affiliations

  • Maximillian Mifsud
    • 1
    Email author
  • Jules Letherland
    • 1
  • Rachel Buckingham
    • 1
  1. 1.Department of Paediatric OrthopaedicsNuffield Orthopaedic CentreOxfordUK

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