Children and Adolescent Hand and Arm (CHArm) Center

Caroline Knadler, PA-C, CHArm Director of Research

Caroline Knadler oversees the research division of the CHArm Center. She manages all CHArm research projects which includes completing IRB submissions, conducting literature reviews, collecting and analyzing data, and submitting articles for publication.

The CHArm Center specializes in the surgical and non-surgical treatment of hand and upper extremity conditions including, but not limited to:

• Cerebral Palsy and Neurological Upper Extremity issues
• Sports Injuries
• Congenital Disorders
• Tumors
• Brachial Plexus
• Juvenile Rheumatoid Arthritis
• Shoulder Injuries
• Elbow Injuries
• Hand Injuries
• Arm Injuries
• Hand and Arm Fractures

The CHArm staff also serves in a liaison capacity between patients, doctors, therapists, and others involved in the treatment of a patient's hand or other upper extremity issue. For those patients who do not seek follow up care locally, our rehabilitation staff will connect them with a local therapist to ensure that they receive the best possible rehabilitative care.

The Cerebral Palsy and Neurological Upper Extremity (CPNUE) Program addresses the orthopedic needs in the upper extremity for patients with cerebral palsy and other neurological disorders. Problems related to extremity posturing, hygiene, and functional limitations are addressed in the shoulder, elbow, hand, digits, and thumb. This is accomplished through in-depth assessments and surgical reconstruction, when indicated. While the Program is offered by the CHArm Center — which caters to the needs of children and adolescents — all ages of patients may attend the service, and patients with all types of involvement are appropriate for referral.

The complete process of our Cerebral Palsy and Neurological Upper Extremity Service includes an in-depth traditional evaluation, often an electromyographic (EMG) evaluation, surgery, and post-surgical care.

Evaluation

The upper extremity evaluation for people with cerebral palsy is critical. A thorough evaluation process includes several components. It is often recommended to come in on more than one occasion to allow our professionals to have the opportunity to see your child under different conditions, as we know spasticity can have subtle and not-so-subtle changes from day to day. Your child's nervousness may also be a factor and must be considered.

Since everyone moves their hands and arms differently and has different strategies to get things done, our team also wants the opportunity to fully appreciate the individual characteristics of each patient. It is always helpful for our orthopedic team to see evaluations and progress reports from the therapists and doctors that are working with your child to further their understanding of his or her strengths and needs.

The pre-surgical evaluation for patients with cerebral palsy (CP) includes typical rehabilitation assessments such as range of motion (ROM), sensory testing, timed movement tests, and an activities of daily living (ADL) assessment. A videotape (in order to prevent your child from having to do tasks repeatedly) is often useful. A test called dynamic electromyography (EMG) may also be recommended.

The evaluation process may include giving your child time to develop goals and skills through pre-operative exercises and splinting. Since surgery is most often elective and able to be planned at the family's convenience, these factors dictate that from the first visit to surgery can be anywhere from 2 months to over a year.

Electromyography (EMG)

Electromyography (EMG) is a test that shows how much activity is being produced in each muscle. It is a very technical subject, but the basics of EMG are quite simple to understand. When your body moves a muscle, electricity is produced. Special electrodes are placed on the skin to listen to the electrical signal of muscles. The signal is converted to a line tracing very similar to one that you would see on a heart exam or EKG. Your therapist and doctor then read the pattern to determine which muscles may be showing more or less of a problem.

This type of exam works best on elbow muscles, where it is sometimes difficult to tell in a regular office visit which muscle is pulling too strongly. The EMG can help to show this. Below are EMG line tracings of muscles near the elbow. The top three muscles - the biceps, brachialis and brachioradialis — are muscles that bend the elbow. In the bottom row is the triceps, which straightens the elbow. The high and low part of each line drawing shows you that the muscle is "on" or "off". When the benders (flexors) have a high signal, the straighteners (extensors) should have a low signal, and vice versa.

Surgery

Common upper extremity orthopedic surgical techniques for cerebral palsy include muscle releases, lengthenings, and muscle transfers. These procedures address the soft tissues only, which include the muscles, tendons, and tissues around the joint capsules.

In lengthenings and releases, a portion of the muscle close to where it attaches to the bone is surgically cut to loosen it. In a muscle transfer, one end of a muscle is surgically cut and moved to an area nearby in order to change the direction of its pull. Neither of these procedures prevent future medical advances from being implemented, and both are relatively reversible.

If an area around a joint capsule is addressed (often in the fingers and thumb), a small wire may be placed in the joint space to help secure the joint while your child is healing. It comes out when the dressing is removed. In very extreme cases, where the hand position is very compromised, work on the bone may be done. This is not very common and is only done on adults with severe involvement, as it is not reversible.

The anesthesia plan differs with each patient and can vary from general anesthesia to local anesthesia with sedation. The type of surgery planned, the age of your child, his or her general medical status, and the family preferences all play a role in deciding the anesthesia plan. Patients and family members should have an opportunity to speak with the attending anesthesiologist to learn the pros and cons of each situation.

Most patients stay over in the hospital one night and some even go home the same day. After surgery, the arm and hand is placed in a half cast with a bulky dressing. Most patients are discharged with a simple pain reliever prescription. Ice and elevation help to keep the arm comfortable.

Within a few days, your child is ready to return to school. The dressing needs to stay dry for the next four weeks. The hard work begins four weeks after surgery when the bulky dressing comes off. This is usually an exciting but overwhelming day. The dressing is taken off, pins are removed, a plastic splint needs to be made, and exercises are performed. Many of the children, as well as their parents, are nervous. It is a big day, and anxiety is normal. The good news is that the real gains now start to take place during the post-operative period!