Hand surgery is rarely indicated in children with arthritis, but presents specific problems. The initial diagnosis can be difficult due to discrete clinical symptoms and limited radiological signs. A decreased wrist extension or finger joint stiffness can be early signs of arthritis in a child. Destruction of joint surfaces are difficult to evaluate since many skeletal parts in the hand, e.g. the carpal bones, are still not ossified in young children. Accelerated skeletal maturation can often be the only radiological sign of an active synovitis in the joint. The hands and wrists are often involved at an early stage of juvenile arthritis and different growth disturbances may occur, the most commonly seen is a shortening of the distal ulna. Surgery itself may also affect growth. When performing soft tissue surgery, like synovectomies or arthrolyses on the juvenile arthritic hand, a significant risk of postoperative joint stiffness has to be considered. Surgical treatment of arthritic hands in children are often delayed until adolescence, and doing any kind of surgery in a teenager is a difficult task which requires special attention and finesse. Personal experience from the Children’s Hospital in Lund, Sweden will be presented.

Pediatric hand surgery in general requires special considerations and this is even more true when planning surgery in children with CP. It is important for the surgeon to realize that the functional problems these children exhibit have their cause in a brain damage which is not amenable to hand surgical treatment. Therefore it is crucial to carefully analyze each child’s impairment including the voluntary motor control and the child’s specific needs before endeavoring into surgery. Associated impairments, such as mental retardation, nutritional problems, epilepsy, dystonia or severe sensory deficits may influence decision-making, but the crucial factor is often the child’s own wish for an improved function. A child that completely neglects his or her extremity is usually not helped by surgery, at least not in an attempt to get a better hand function.

Hand surgery in CP mainly comes down to three techniques: 1. Reducing strength in spastic muscles by release operation, either at the origin of the muscle, at the insertion or as a fractional lengthening at the musculo-tendinous junction, 2. Increasing strength in weak antagonists by tendon transfer or 3. Stabilizing joints through an arthrodesis or a tenodesis. Most often a combination of these techniques is used. Almost all hand surgeons in this field have acquired their personal choice of procedures and scientific support for the benefits of the different techniques is scarce. My personal arsenal will be described in the panel but includes biceps-brachialis muscle release at the elbow, pronator teres rerouting, flexor carpi ulnaris to extensor carpi radialis brevis (Green’s) transfer and adductor pollicis muscle release in the palm combined with extensor pollicis longus rerouting for the thumb-in-palm deformity. In my mind, it is not most important which tendon transfer that is selected, but the choice of which child to operate and at what age. It is also important to tension the tendon transfers exactly right and to plan the postoperative treatment properly. The surgeon should, of course, also make sure that the child’s and the parent’s expectations on the results are realistic.

Botulinum toxin A has now been used for several years in the treatment of children with cerebral palsy and the drug has been shown to be safe and effective in reducing muscle tone both in the lower and the upper extremities. It has been more difficult to show effects on hand function especially in the long-term perspective. I will present our treatment protocol for botulinum toxin injections.

In 1994, a population-based health care program for children with CP was started in Lund in southern Sweden. All children in our region with a diagnosis of CP, born after Jan 1st 1990 are invited to follow the program which includes regular measurements of range of motion in extremity joints, standardized radiographic examinations of the hip joints and registration of surgery and spasticity treatments. The program, called CPUP has been very successful in the prevention of spastic hip dislocation, wind swept position and contractures. Some early results from the upper extremity part of CPUP will be presented. We believe that the program in time will give us valuable information on the natural course of joint motion and impairment of hand function in children with CP.