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Cerebral palsy (CP) of the spastic type is a neurological disorder characterized by a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks. Secondary to the spasticity, muscle adaptation is presumed to contribute to limitations in the passive range of joint motion. However, the mechanisms underlying these limitations are unknown. Using biopsies, we compared mechanical as well as histological properties of flexor carpi ulnaris muscle (FCU) from CP patients (n = 29) and healthy controls (n = 10). The sarcomere slack length (mean 2.5 µm, SEM 0.05) and slope of the normalized sarcomere length-tension characteristics of spastic fascicle segments and single myofibre segments were not different from those of control muscle. Fibre type distribution also showed no significant differences. Fibre size was significantly smaller (1933 µm2, SEM 190) in spastic muscle than in controls (2572 µm2, SEM 322). However, our statistical analyses indicate that the latter difference is likely to be explained by age, rather than by the affliction. Quantities of endomysial and perimysial networks within biopsies of control and spastic muscle were unchanged with one exception: a significant thickening of the tertiary perimysium (3-fold), i.e. the connective tissue reinforcement of neurovascular tissues penetrating the muscle. Note that this thickening in tertiary perimysium was shown in the majority of CP patients, however a small number of patients (n = 4 out of 23) did not have this feature. These results are taken as indications that enhanced myofascial loads on FCU is one among several factors contributing in a major way to the aetiology of limitation of movement at the wrist in CP and the characteristic wrist position of such patients.

Patients with spastic cerebral palsy of the upper limb typically present with various problems including an impaired range of motion that affects the positioning of the upper extremity. This impaired range of motion often develops into contractures that further limit functioning of the spastic hand and arm. Understanding why these contractures develop in cerebral palsy will affect the selection of patients suitable for surgical treatment as well as the choice for specific surgical procedures. The generally accepted hypothesis in patients with spastic cerebral palsy is that the hyper-excitability of the stretch reflex combined with increased muscle tone result in extreme angles of the involved joints at rest. Ultimately, these extreme joint angles are thought to result in fixed joint postures. There is no consensus in the literature concerning the pathophysiology of this process. Several hypotheses associated with inactivity and overactivity have been tested by examining the secondary changes in spastic muscle and its surrounding tissue. All hypotheses implicate different secondary changes that consequently require different clinical approaches. In this review, the different hypotheses concerning the development of limited joint range of motion in cerebral palsy are discussed in relation to their secondary changes on the musculoskeletal system.

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The long-term result of lateral band translocation is disappointing in our series, and it should not be advocated as a procedure with long-lasting success in patients with cerebral palsy.