Lower limbs

Children who are unable to walk or who are partially ambulant (Gross Motor Function Classification System [GMFCS] levels III to V) are at risk of hip subluxation and dislocation. Subluxed or dislocated hips may be present in people with cerebral palsy who:

• complain of hip or knee pain
• are in pain when hoisted or moved in ways requiring hip flexion
• have severe motor dysfunction, particularly those who do not walk or have a reduced range of hip movement.

Hip surveillance in children with cerebral palsy must begin at birth. Hip X-rays should be performed at regular intervals—see Australian standards of care. Refer children with evidence of hip subluxation or dislocation to an orthopaedic surgeon. Gait analysis is helpful in planning and evaluating orthopaedic surgical procedures.

Equinus deformity is the most common orthopaedic problem in children with cerebral palsy. In young children, toe walking is treated conservatively with orthoses and botulinum toxin type A therapy. Older children may benefit from surgery.

Flexion contractures at the knee may require hamstring surgery. Some children require surgery at several levels (eg hip, knee and ankle) to correct deformities and improve the efficiency of walking (eg single event multilevel surgery [SEMLS]).

Refer children and adults with significant lower limb musculoskeletal problems (eg GMFCS level II and higher) to a rehabilitation paediatrician or rehabilitation physician.