Orthopedics - Oleksa A.P. 2006

Metabolic bone diseases
Contractures (contracturae)

A contracture refers to the restriction of joint mobility, measured in degrees using a goniometer. Rocking movements in a joint, the range of which is difficult to measure with a goniometer, are referred to as joint rigidity. Ankylosis is the complete absence of joint movement caused by fibrous or bony fusion of the articular surfaces (fibrous ankylosis, bony ankylosis). The term contracture originates from the Latin word contraho, meaning to draw together.

There are several classifications of contractures, dividing them into congenital and acquired, active (restriction of active movements), passive (restriction of passive movements), and active-passive. Depending on THE POSITION OF the limb or its segment and the direction of movement restriction, contractures are categorized into: flexion (limited extension), extension (limited flexion), abduction (limited adduction of a limb segment), adduction (limited abduction), rotational (restriction of rotational movements), and combined.

In clinical practice, flexion-adduction and flexion contractures are the most common.

Depending on the localization of primary tissue alterations, contractures are subdivided into dermatogenic, myogenic, arthrogenic, neurogenic, etc.

Furthermore, based on etiopathogenetic features, they are classified as post-traumatic, post-burn, post-immobilization, ischemic, antalgic (reflex), neurogenic, occupational, etc.

During patient examination, the physician determines the cause, nature, and severity of the contracture based on the Anamnesis, clinical findings, and radiological data.

Congenital contractures are an essential component of many congenital musculoskeletal malformations (Clubfoot, Torticollis, hip dislocation, Clubhand, etc.). Congenital contractures can be multiple and associated with other pathological tissue changes (Arthrogryposis).

Acquired contractures result from trauma (intra-articular fractures, hemorrhages into the joint and periarticular Tissues, ligamentous and capsular injuries), inflammatory, reactive, and dystrophic processes in the joint, prolonged immobilization, and post-operative interventions on joints, among others.

In other words, passive or local contractures are caused by mechanical barriers to the range of motion originating within the joint or by periarticular pathological tissue changes (Skin, fascia, ligaments, tendons, etc.).

Neurogenic contractures arise from pathological changes in The Nervous system. The impairment of joint range of motion is secondary in long-standing conditions, and its nature depends on the localization, cause, and severity of the nervous system lesion. Initially, neurogenic contractures are unstable and amenable to correction; following successful Treatment of the nervous system disorder, they typically disappear, although in cerebral palsy, they may persist for life.

Undoubtedly, in all passive contractures, the Central Nervous System also plays a certain role as the regulator of reflex mechanisms.

Dermatogenic contractures result from skin shrinkage and tightening in periarticular areas following infectious, parasitic processes, or trauma. They can also be congenital, presenting as a "web" in the axillary region in arthrogryposis, in the neck region, or in membranous Syndactyly, etc.

Desmogenic contractures develop due to the tightening of periarticular scars in tissues following deep Burns, trauma, or purulent-inflammatory processes, particularly in the hand and fingers.

Tendogenic contractures are observed in inflammatory and occupational tenosynovitis, initially manifesting as a protective (reflex) reaction, followed by a tendodesmogenic reaction due to immobilization and adhesion of the tendon to its sheath.

Myogenic contractures can be congenital (torticollis, myogenic factor in arthrogryposis, etc.) or acquired following traumatic injuries, inflammatory, or degenerative Muscle processes, such as those occurring in edema and Blood supply disorders (Volkmann's contracture, etc.).

In clinical practice, antalgic contractures—pain-relieving, protective contractures—are quite common. They result from a reflex protective reaction to pain, manifested by the equilibration of antagonistic muscle tension. In the course of Human Evolution, flexor and adductor Muscles have become stronger than extensor and abductor muscles. Consequently, when their tension forces are balanced, the limb assumes a specific posture corresponding to the mid-physiological position.

Myogenic or even myoarthrogenic contractures also occur after prolonged limb immobilization using a plaster cast or skeletal traction, thus classified as post-immobilization contractures.

Contractures can arise from an imbalance of antagonistic muscles following poliomyelitis, infantile cerebral palsy, central and Peripheral Nervous System injuries, although these are categorized under the primary causes of neurogenic contractures.

Arthrogenic contractures develop due to pathological Changes in the joints or the ligamentous-capsular apparatus during acute inflammatory or chronic diseases, following intra-articular fractures, etc. Intra- or periarticular adhesions, scars, articular Cartilage destruction, or marginal bone outgrowths lead to restricted joint mobility.

Contractures frequently accompany osteoarthrosis, particularly coxarthrosis (flexion-adduction contractures) and gonarthrosis (flexion-extension contractures).

The most complex, combined contractures occur following severe trauma complicated by purulent-inflammatory processes that involve muscles, tendons, periarticular tissues, and the joint itself. Occasionally, in the absence of proper treatment, one type of contracture transitions into another. For example, a prolonged antalgic contracture in tuberculous coxitis evolves into an arthrogenic one.

We do not focus on contractures caused by tetanus, stroke, intoxications, or hysterical seizures, as these fall within the competence of other specialists.

Clinical manifestations of contractures. As follows from the above, contractures are the consequence of multiple pathogenic factors and clinically manifest as a symptom of various pathological states of the joint, adjacent tissues, or The Human Body as a whole. In some cases, a contracture may develop rapidly (ischemic Volkmann's contracture), while in others, it develops gradually (Dupuytren's Contracture, in osteoarthrosis, following purulent-inflammatory processes, etc.).

From a clinical perspective, it is practical to distinguish between functionally advantageous and functionally disadvantageous contractures, which depend on the direction of joint motion restriction, its range, and Etiology. For instance, a flexion-adduction contracture of the hip or a flexion contracture of the lower leg is functionally disadvantageous because it leads to functional shortening of the limb. A FOOT flexion contracture (pes equinus) is also functionally disadvantageous as it causes relative limb lengthening. It should be noted that this contracture may be functionally advantageous if the length of the affected limb equals that of the healthy one, and the foot is positioned at an angle of 90-100°.

Regarding contractures of upper limb segments, they can also be functionally advantageous or disadvantageous, depending on their causes, the angles at which the limb segment is positioned, and the range and direction of the segment's movements. For example, in a flexion-extension contracture of the forearm, if flexion in the elbow joint is possible up to an angle of 110° and extension up to 50°, this represents a relatively favorable position for upper limb function. At the same time, with the same range of motion in the elbow (60°), but with forearm flexion to 60° and extension to 0°, the contracture becomes functionally disadvantageous. That is, given an equivalent range of motion (60°)

Depending on the position of the limb segment within the joint, a contracture can be either functionally advantageous or disadvantageous.

In all cases of arthrogenic and arthrodesmogenic contractures, a radiographic examination is performed, supplemented when necessary by computed tomography or even Magnetic Resonance imaging to clarify pathological changes. X-ray findings enable Cytology/practical/136.html">Differential Diagnosis OF the pathology, which is further supported by a carefully compiled medical history. Furthermore, joint radiography is essential for Congenital Malformations and long-standing desmo- or desmomyogenic contractures, as secondary arthrogenic changes develop within a non-functioning joint.

For neurogenic contractures, the cause and nature of movement disorders are identified, and the strength of all limb muscle groups is assessed using a 5-point scale (see "Orthopedic deformities following Poliomyelitis"). The range of motion is measured with a goniometer to determine the degree of restriction and the functional capabilities of the limb. When necessary, a neurological consultation is obtained.

Treatment of contractures. Taking into account the various etiological factors contributing to the onset of contractures, as well as The Nature and severity of their clinical manifestations, treatment is tailored individually for each patient.

As a rule, treatment begins with Conservative Methods, which yield excellent results in the majority of cases. For contractures that can only be resolved surgically, conservative treatment serves as preparation for the operation.

Patients are prescribed active and passive Therapeutic Exercises, performed initially under the supervision and with the assistance of a physical therapy instructor. It should be kept in mind that joint mobilization exercises must be performed frequently throughout the day and within a pain-free range. Pain triggers a protective reaction and hinders therapeutic exercises. Therefore, we advise instructors to teach the patient—especially a child—how to correctly perform therapeutic physical exercises and to explain The Essence and purpose of the treatment. When using pendulum apparatuses for joint mobilization, the load and range of motion angles should be increased gradually. Simultaneously, patients are prescribed muscle massage, thermal Procedures, and, if necessary, electrical stimulation.

Ozokerite-paraffin Applications, warm baths (hydrogen sulfide), and active movements in Water (swimming) are highly beneficial. These procedures improve local Blood Circulation and promote the relaxation of contracted muscles, while performing therapeutic exercises facilitates their stretching and strengthening.

In cases of desmogenic contractures, local Electrophoresis with rhonidase or lidase is applied in combination with the aforementioned measures.

Contractures occur most frequently in the elbow and knee joints. For instance, nearly all cases of reduced supra- and transcondylar fractures result in desmoarthrogenic contractures of the elbow joint after bone union, requiring prolonged rehabilitation treatment. Our experience demonstrates that active joint mobilization by the patients themselves within a pain-free range, combined with physical balneotherapy, yields the best results, although it demands patience and perseverance from both the patient and the physician. Persistent passive mobilization causes pain and a negative reaction, particularly in children, which prolongs the treatment duration.

Similar contractures following reduced intra-articular fractures of other locations respond more readily to conservative treatment in both children and adults. During physical exercises for post-traumatic contractures (following prolonged plaster immobilization, skeletal traction, or peri- or intra-articular fractures), the following stages are distinguished:

1) for myogenic unstable contractures, light active joint mobilization is used in combination with physiotherapeutic procedures;

2) for desmogenic contractures resulting from the scarring of hematomas and periarticular tissues, a more intensive conservative combination treatment is applied;

3) for long-standing desmomyogenic contractures complicated by arthrogenic changes, complex treatment is performed using mechanotherapy on pendulum apparatuses, sometimes supplemented by serial manual derotation under anesthesia and fixation of the limb segment in the corrected position with a plaster cast.

During manual derotation under anesthesia, excessive force should be avoided to prevent potential complications, especially in patients with chronic joint pathology and Osteoporosis, as well as in cases of incompletely united bone fractures.

We are aware of two cases of complications resulting from forceful manual derotation of flexion-extension desmogenic contractures of the knee joints in patients with Rheumatoid Polyarthritis on the 21st day after synovectomy. In one female patient (aged 42), the posterior part of the medial femoral condyle fractured, while In the second patient (aged 62), the lower pole of the Patella was torn off. Both patients underwent repeat surgery. The first woman had an unsatisfactory final outcome due to The Development of ankylosis, albeit in a functionally favorable position of the limb; in the second patient, joint movement ranging from 15 to 75° was restored following comprehensive therapy.

Contractures of the knee joint very frequently occur following femoral fractures with muscle damage and multiple fractures treated conservatively, or after unstable intramedullary osteosynthesis that requires additional limb immobilization with a plaster cast.

If the bone fragments have united and a persistent contracture remains despite treatment, the Ilizarov or Volkov-Oganesyan apparatus is employed. Two pairs of intersecting wires inserted through the Femur and Tibia are fixed in the semi-arcs of the Ilizarov apparatus, which are connected by threaded distraction rods; in the Volkov-Oganesyan apparatus, they are connected by rods with a "hinge" block at the level of the knee joint to regulate the range of motion. When necessary, distraction is performed using the apparatus to widen the joint space. Flexion-extension contractures can be gradually eliminated without surgery, painlessly for the patient, through serial derotation within the Ilizarov apparatus. Contractures are eliminated in a similar manner using the more advanced Volkov-Oganesyan apparatus.

V.I. Karptsov (1984) passed a Kirschner wire through the upper pole of the patella and applied traction to pull it down by 1–2 cm, thereby stretching and lengthening the quadriceps muscle and achieving an increase in knee flexion by 10–20°.

All of these treatment methods are suitable and effective only when the joint surfaces are congruent. If conservative methods fail to eliminate the contracture, Surgical treatment is applied.

Depending on the identified clinical and radiographic changes in the tissues and the joint, plastic surgeries are performed on the soft tissues, joint, or bones.

In cases of dermatogenic contractures, skin lesions that restrict movement are excised, and tissue flap transplantation is occasionally utilized. For desmogenic contractures resulting from deep burns, purulent-inflammatory processes, and wounds, all tethering scars are excised along with skin flap transplantation; for defects, free skin grafting, pedicle flaps, or previously formed tubed pedicle flaps (Filatov flaps) are used. It is particularly important to use a high-quality skin-subcutaneous pedicle graft to cover defects in functionally critical joint areas and weight-bearing surfaces.

Flexion-extension contractures resulting from purulent-inflammatory processes in muscles and tendons (particularly felon), which are invariably complicated by scarring, generally do not respond to conservative treatment. In such cases, myotenolysis is performed—releasing muscles and tendons from scars—along with tenoplasty when possible. Tendon transplantation is performed for the sequelae of poliomyelitis, while tenotomy is most frequently used for spastic contractures of the thigh and persistent contractures resulting from coxarthrosis or coxitis, which typically present as flexion-adduction contractures.

For contractures resulting from peripheral nerve trunk injuries, neurolysis and the restoration of nerve integrity are most commonly performed, and very rarely, Erlacher neurotization—excising a pedicled flap from an adjacent healthy, normally innervated muscle and suturing it to the paralyzed muscle. Nerve fibers then grow into the paralyzed muscle, which is verified by assessing its electrical excitability.

As previously mentioned, arthrogenic contractures develop As a result of trauma and inflammatory or degenerative processes in the joints. With proper treatment of periarticular hematomas and hemarthrosis, synovitis, or damaged menisci, contractures typically do not occur. In chronic and recurrent synovitis, fibrin settles on the synovial membrane and forms a scar, leading to capsule thickening and intra-articular adhesions (shwarts) that cause desmoarthrogenic contractures. In such cases, arthrolysis and synovectomy are frequently required, followed by comprehensive restorative conservative treatment.

Contractures frequently occur following fractures of the femoral shaft and distal metaphysis, when the quadriceps muscle adheres to the callus, severely restricting knee movement. In persistent extension contractures, surgical mobilization of the quadriceps muscle of the thigh and scar excision must be performed. During this Procedure, the belly of the rectus femoris muscle with its distal tendon is separated from the vastus Muscles of the thigh, lengthened by a Z-plasty incision in the frontal plane, the patella is mobilized, and a capsulotomy is performed if necessary. The limb is immobilized in a plaster cast with the knee flexed at 80–90°.

Starting on the fourth day after pain subsides under METABOLISM/18.html">The Influence of analgesics, passive movements in the knee are initiated without removing the plaster cast, which is instead converted into a trough-like splint. From the tenth day, the patient performs active extension movements in the knee under the supervision of a physical therapist, who supplements them with passive maneuvers. Afterwards, the lower leg is lowered back into the flexed splint. If the patient is able to actively straighten the lower leg even slightly, the plaster cast is removed, and progressive flexion of the leg is introduced. The effectiveness of such treatment largely depends on the patient's persistence.

Occasionally, the tendon of the rectus femoris is lengthened not via a Z-shaped frontal incision, but through partial "chevron-style" cuts; however, the Z-shaped incision is more reliable, as the tendon is sutured after the knee is flexed, thereby enabling early active extension exercises.

In cases of contractures caused by articular surface incongruity following fractures, the choice of surgery depends on The Nature of fragment displacement, the patient's age, occupation, and personal preference. In some instances, the contracture can be eliminated or significantly reduced through open re-fracture using an osteotome, achieving anatomical reduction and stable fragment fixation, followed by early mobilization of the joint.

For manual laborers presenting with contractures and pain due to post-traumatic osteoarthritis—particularly in lower limb joints—arthrodesis in a functionally advantageous position of the segment is considered the optimal surgical approach.

Joint replacement (arthroplasty) in such cases should be recommended to patients who will not be subjected to heavy physical loads (sedentary workers, elderly individuals, etc.).

A similar surgical strategy should be applied to contractures resulting from coxarthrosis and gonarthrosis that originate as antalgic and myogenic contractures and ultimately progress to arthrogenic contractures.

Regarding surgeries for upper limb contractures, they are performed primarily on the elbow and wrist joints. Depending on the identified pathological process, procedures such as arthrolysis, arthroplasty, or, when necessary, arthrodesis in a functionally favorable position are performed.

The clinical management of Volkmann's contracture is detailed in the monograph "Traumatology" (by A.P. Oleksa) on pages 154–156.

As noted previously, the treatment of contractures is a complex and often prolonged process; therefore, preventing their development during the management of the primary acquired pathology is of paramount importance.

Because post-fracture contractures are the most common, the physician's primary objective must be their proper management and early rehabilitation. To achieve ideal fragment reduction and joint surface congruence, open reduction and stable internal fixation are frequently required, eliminating The Need for supplementary plaster immobilization and allowing for early joint mobilization. Today, clinicians are well-equipped with sufficient hardware and instrumentation to perform stable bone fixation using the AO system for fractures of various localizations, including intra-articular ones. Our observations confirm the advantages of this method in promoting bone healing and reducing the incidence of contractures through early rehabilitation.

The widespread clinical adoption of Ilizarov fixators and external fixation systems (such as AFO) not only for open fractures but also for closed fractures has likewise contributed positively to the Prevention of contractures.

In acute inflammatory processes involving the joints and periarticular tissues, a physician can never accurately predict the required duration of treatment or its outcome. Therefore, in all such cases, limb segments must be immobilized in a functionally favorable position from the very onset of the disease. Nevertheless, it should be noted that synovitis and Arthritis of various etiologies require intensive treatment to prevent contractures, even in a functionally advantageous position.

Ischemic contractures are now rarely encountered thanks to the improved qualifications and vigilance of physicians, timely diagnosis of circulatory impairment, and the prompt provision of emergency care to restore blood flow.