Cerebral palsy of the upper limb

What is cerebral palsy of the upper limb?

Cerebral palsy is a lifelong condition caused by a disturbance to the brain as it develops, usually before, during or shortly after birth, which affects movement and posture. When it affects the arm and hand, known as the upper limb, it can make it harder for your child to reach, grasp and use their hand for everyday tasks.

Symptoms of upper limb cerebral palsy

Upper limb involvement is common in children with cerebral palsy, affecting around 8 in 10 overall. Around a third go on to develop a fixed tightening of the joint, called a contracture, and around 7 in 10 have some reduction in hand control.

Symptoms can include:

• stiffness or tightness in the shoulder, elbow, wrist or fingers
• reduced or awkward hand use, or difficulty grasping and manipulating objects
• weakness affecting one side of the body, or all four limbs, depending on the type of cerebral palsy
• a tendency for the arm to rest in a particular position, such as the shoulder turned inward, the forearm turned palm-down, the elbow bent, the wrist bent, or the thumb pulled into the palm.

The most common patterns seen are the thumb pulled into a clenched palm, the shoulder turned inward, and the wrist bent with the forearm turned palm-down.

Beyond function, these patterns can also affect your child's confidence and how comfortable they feel about the appearance of their hand, which matters just as much as physical function when planning care.

Causes of upper limb cerebral palsy and who's at risk

Cerebral palsy itself is caused by an injury or disturbance to the developing brain around the time of birth. In the arm, the resulting poor muscle control creates unbalanced pulling across the joints: the muscles that bend a joint (flexors) are naturally a little stronger than the muscles that straighten it (extensors), so without treatment, the arm tends to be pulled gradually into a bent position over time.

Upper limb problems are typically seen in children with hemiplegia (cerebral palsy affecting one side of the body) or quadriplegia (affecting all four limbs).

How is upper limb involvement classified?

Rather than distinct types, upper limb cerebral palsy is usually described using standardised scales that capture how a child's arm and hand actually function, since this guides treatment more usefully than a label alone.

• Manual Ability Classification System (MACS): A 5-level scale describing how well a child handles everyday objects, from level I (handles objects easily) to level V (severely limited ability to perform even simple actions)
• House functional classification: An 8-level scale describing how much a child actually uses their affected hand, from 0 (does not use it at all) up to 8 (uses it completely independently).

A child's level on one scale doesn't always match the other. For example, a child may have well-preserved use of their affected hand for fine tasks even if their overall walking ability is more limited, or vice versa.

How is upper limb cerebral palsy assessed?

Assessment usually involves a multidisciplinary team, which may include a physiotherapist, an occupational therapist, a paediatric orthopaedic or hand surgeon, and sometimes a paediatric neurologist, working together with you and your child.

This typically includes watching how your child's arm and hand move, both at rest and during a task, and measuring range of movement, both actively (movement your child makes themselves) and passively (movement made gently by someone else). This helps distinguish between muscle tightness that comes and goes (spasticity) and a fixed, established contracture.

Because movement patterns can change as children grow, especially during growth spurts, repeated assessments over time, rather than a single visit, give the clearest picture.

How is upper limb cerebral palsy treated?

Many children with upper limb cerebral palsy will not need surgery. Treatment is tailored to your child and usually starts with non-surgical approaches, with surgery reserved for a smaller number of children.

Non-surgical treatment

• Stretching: Done regularly at home and in therapy sessions, to help prevent contractures and maintain range of movement
• Splints: Which may be worn during the day to support function and hand position, or overnight for a longer, gentler stretch. These often need periodic adjustment as your child grows
• Serial casting: This is where a series of casts are changed every week or two to gradually increase movement at a joint
• Occupational therapy: This is to help your child use their hand as effectively as possible for everyday activities. This sometimes includes a period of constraint therapy, where the less-affected arm is temporarily restricted to encourage more use of the affected side
• Baclofen: A muscle-relaxing medicine taken by mouth or, for more widespread stiffness, delivered continuously via a small pump, which can help with tightness affecting more than one limb.

Surgical treatment

Surgery is generally only considered for a smaller number of children, usually once growth has slowed and movement patterns have settled.

It has two broad aims:

• Helping with positioning: For hygiene, dressing and comfort in children with more limited hand use
• Rebalancing the arm: To improve active use in children with better underlying hand control.

Depending on what's needed, this may involve lengthening a tight tendon or muscle, releasing a tight structure, moving a tendon to work more usefully (a tendon transfer), or occasionally fixing a joint in a more useful position.

Because the arm works as a connected chain, from shoulder to fingertips, several procedures are often planned together in a single operation, and the surgical team will consider how a change at one joint might affect the others.

When should I speak to my child's care team?

Speak to your child's paediatrician, therapist, or specialist team if you notice increasing stiffness, a change in your child's arm or hand position, or if everyday tasks such as dressing or washing are becoming more difficult. Assessment and treatment work best when changes are picked up and monitored early, ideally before a fixed contracture develops.