Management

Sensory loss

If the sensory loss is likely to he temporary (such as caused by transected sensory nerve) then the limb should be carefully protected to avoid injuries such as burns. Splints and plaster should also be applied with great caution as the patient will be unaware when they are developing sores at pressure points.

Temporary flaccid paralysis

This can be managed with splints to prevent overloading of ligaments and to maintain function of joints. Physiotherapy will be needed to maintain joint mobility, and to build up muscle power as the nerve supply returns. Lively splints are fitted with springs so that the weak muscle does not have to function but nevertheless the limb can be kept moving by the opposing muscle whose function remains normal.

Spastic paralysis

This is much more difficult to manage and requires regular gentle physiotherapy to try and put joints through a full range of movement without creating spasm. Regular physiotherapy should prevent the development of contractures which may make the deformity very difficult to manage. As a general rule, splints do not work well in spastic paralysis as they can stimulate spasm. The result is then either stress or a broken splint. Deformity as a result of spasticity can only really be treated by weakening the spastic muscle. There are various ways in which this can be done:

 (a)  the muscle can be divided;

(b) the tendinous insertion of the muscle can be lengthened;

(c) the insertion of the muscle into bone can be released and allowed to slide along the bone reducing the mechanical lever arm;

(d) the muscle can be injected with either a temporary or permanent paralytic agent such as botulin toxin;

(e) the nerve supply to the muscle can be divided.

In children many of these actions causing defunction of the muscle are reversed by the natural healing powers of a child. Transected muscles heal. Divided nerves regenerate. The procedures may therefore need repeating.

In athetosis, paralysis of the muscle with botulin or by transection of the nerve is a possibility but there is usually considerable function available despite the irregular move­ments of the limb and this loss of function must be balanced against the improvement in abnormal movements.

Trick manoeuvres

Patients with paralysed muscles develop a set of trick manoeuvres aimed to overcome their disability. For example, paralysis of the quadriceps muscle makes it difficult to lock the knee when walking. Patients with this problem frequently walk with their hand in the trouser pocket pressing firmly on the front of the knee and heel strike. This serves to lock the knee for normal locomotion. Patients with paralysis of the shoulder girdle may develop trick manoeuvres with their trunk which enable them to throw their arm high above their head.