MC inherited
neurological disorder
1886 described
together
Professor Jean Martin
Charcot and his student Pierre Marie – Peroneal Muscular Atrophy
Howard Henry Tooth –
Peroneal Progressive Muscular Atrophy. Attributed it correctly to neuropathy.
1912 Hoffman
described peroneal muscular atrophy with thickened nerve; Hoffman’s disease.
Hereditary Sensory
and Motor Neuropathy type I, II and III (Dejerine-Sotta’s disease)
Classification
Type 1
Demyelinating;
further subdivided A
(MC, 70%), B & C.
Autosomal dominant
Type 2
Axonal degeneration;
Autosomal dominant or
recessive
Type C
Intermediate between
axonal degeneration and demyelinating
Autosomal dominant
Clinical Features
Incidence of all
types of CMT varies from 1 in 5000 to 1 in 2500
Presents with
Progressive weakness and atrophy of distal muscles
Depressed DTRs
Slowed nerve conduction velocities
Family h/o similar disease
Varied age of onset
Most commonly onset at the 2nd
decade of life
CMT Type 2 onset 3rd decade of life
Normal motor
milestone
Incidence equal in
both sexes, severity more in boys with CMTX
Physical signs
•Diminished to absent DTRs
Ankle jerk lost before knee jerk
Sensory loss
2/3rd
of the patients
More common in CMT 1
than CMT 2
Muscular weakness
Varied involvement of
muscle
MC muscles involved
are tibialis anterior and peroneus brevis. May involve all the muscles of the
calf
Most severe form –
generalized muscle weakness → inability to walk
Atrophy of calf
muscles → stork leg appearance
Gait changes
Early stages – slight
foot drop seen only in swing phase
Progressively develop
complete plantigrade foot with hyperflexion of knee then hip and elevation of
hemipelvis
Steppage gait
Foot deformity
Pes cavus, pes
cavovarus or claw toe
Hands show atrophy of
intrinsic muscles
Progressive scoliosis
of spine seen in adolescent and teens
Sensorineural
deafness maybe seen in CMTX.
Investigations
Blood tests – known
mutations
EMG-NCV
Demyelinating:
decrease in velocity with amplitude same as normal
Axonal degeneration:
same velocity with decrease amplitude
EMG shows
fibrillation due to denervation
Nerve Biopsy
Sural nerve is used
Demyelinating – Onion
Bulb appearance
Type 2 – Axonal
degeneration
Muscle biopsy –
atrophic muscles
MRI Spine
Diffuse enlargement
of cauda equina, nerve roots and ganglia
Sonography
Enlargement of median
nerve
Medical management
No medical treatment
to slow or stop the disease
71% of the patients
present with severe neuropathic pain requiring medications
Orthopaedic manifestations
Foot
MC manifestation is
pes cavovarus
Atrophy due to
denervation of the intrinsic muscles → contractures → elevation of the medial
longitudinal arch because of the contracture of plantar fascia
Plantar flexion of
the first ray and forefoot equinus → varus of the hind foot
Claw toes – absent
intrinsic muscles
Radiographs
Meary’s angle
Angle between the
longitudinal axis of talus and the 1st metatarsal
Normal 0-5°
Coleman’s block test
Patient made to stand
on a block of wood with the 1st metatarsal head
falling off the block
Supple hind foot
varus – corrects
Fixed varus – does
not correct
Surgical management
Olney divided
surgical management into two components
Deformity correction
Soft tissue release
Plantar fascia
release
Capsulotomies
Bony fusions or
osteotomies
1st
metatarsal osteotomy
Calcaneal osteotomy
Triple arthrodesis
Rebalancing of muscle
forces
Tendon transfers
Dorsiflexion weakness
– EDL or posterior tibial transfer
Overpowering peroneus
longus – transfer to
peroneus brevis
Hindfoot equinus – tendoachilles lengthening
Claw toes
Paralyses and
contracture of intrinsic muscles
Toe extensors
recruited to dorsiflex ankle
Jones transfer of the
long extensors to the metatarsal to help ankle dorsiflexion
Fusion of IP joint of
great toe and PIP joint of the other toes
Hip
Dysplasia of hip
Subtle weakness of
the proximal musculature → progressive dysplasia of hip
Asymptomatic till
adolescent
Treatment similar to
idiopathic adolescent dysplasia of hip
Spine
Scoliosis seen in 37%
Similar to idiopathic
scoliosis with increased kyphosis
Highest risk in girls
& CMT 1
May present with hyperkyphosis without scoliosis
Treatment
Orthosis
Posterior spinal
fusion – failure of orthotic management and with progressive curves
Hand
Onset of hand
symptoms occur in 1st to 3rd decade of life; 8
years after the appearance of lower limb symptoms
Present with
intrinsic muscle weakness with clawing of ring and small digits occur.
Involvement of ulnar
and median nerve innervated forearm and intrinsic muscles
Sparing of radial
nerve innervated muscles
Functional problems:
Loss of opposition
Loss of side to side
pinch
Clawing of fingers
Management
Electrodiagnostic studies done to
determine the best muscle for tendon transfer
Transfers without
pulley or if required with static pulley preferred to tendon or tendon loop
pulley
Opponensplasty – extensor carpi ulnaris or extensor indicisproprius
Side to side pinch –
extensor pollicis brevis, abductor pollicislongus or extensor indicis to 1st
dorsal interosseous or adductor pollicis
Muscle transfer done
in flexion of MCP joints to compensate extrinsic extensors
Delayed till age when
patient can understand the limitations and aftercare
The disease and
deformity can be progressive
Transfer requires
protection from excessive abuse
Dejerine-Sottas
Disease
(Hypertrophic Interstitial Neuritis)
(Hypertrophic Interstitial Neuritis)
Severe,
infantile-onset demyelinating polyneuropathy
Related to same gene
as CMT 1A
Enlarged peripheral
nerves – proliferation of perineural and endoneural tissues
Classical onion bulb
appearance
Presenting complaint
Disability of gait
under 3 years of age
Floppy muscles,
thickened nerves.
Severe cases present
with respiratory failure at birth.
Similar findings as
CMT with increased severity and earlier age of onset.
No treatment
Steroids can be given
in severe cases.