9.1. Contractures and ankylosis
Contractures
Contracture - limitation of mobility in the joint during passive movements. Depending on the direction in which movement in the joint is limited, flexion (limited extension in the joint), extensor (limited flexion), adduction, abduction and rotation contractures are distinguished. Contractures develop due to pathological changes in both the joint itself and soft tissues functionally associated with this joint (muscles, aponeurotic sprains, tendons, skin, nerves). Long-term dysfunctions with joint contractures lead to fibrous degeneration of soft tissues, the development of osteoporosis and sclerosis of bone tissue in places of increased stress.
Classification
Contractures are congenital and acquired. The basis of congenital contractures is underdevelopment of bones, muscles, hypoplasia of the skin, etc. Acquired contractures can be of traumatic, inflammatory, paralytic, dystrophic and fixation (prolonged forced immobility, including as a result of medical immobilization in case of a fracture) origin. Initially, usually one of the tissues is affected: skin, subcutaneous tissue, aponeurosis, fascia, tendons, muscles, nerves or articular ligaments with an articular capsule. Accordingly, dermato-, desmo-, aponeuro-, fascio-, tendon-, myo-, neuro- and arthrogenic contractures are distinguished.
Dermato-desmogenic сontractures occur after burns or extensive traumatic skin injuries if secondary wound healing leads to the formation of a rough, rigid scar. Scars tighten the limb and place the joints in a certain position, limiting movement. Then, secondary changes usually occur in the joint, and even after removal of the scar, the function of the joint may not fully recover.
Tendongenic contractures occur after damage or inflammation of the tendons as a result of their adhesions to the surrounding tissues (including bone), as well as after a complete rupture of the tendon, when the antagonist muscles, meeting no resistance, deviate the joint from the average physiological position.
Myogenic contractures occur after ischemic or mechanical trauma, as well as inflammatory muscle disease. The resulting cicatricial changes in the muscle lead to its persistent shortening and a change in the position of the joint. Myogenic contracture can be an early symptom of a pathological process, for example, in the hip or knee joints.
Arthrogenic contractures are formed when the tissues that directly form the joint are damaged (bones, joint capsule, articular ligaments, menisci, cartilaginous surface), as a result of mechanical injury or disease (tuberculosis, tumor, etc.).
Pathological changes that occur primarily in the bones or joint capsule cause secondary changes in the surrounding soft tissues. In turn, the limitation of joint mobility due to the pathology of the surrounding tissues causes intra-articular disorders. Therefore, arthromyogenic or arthrotendomyogenic contractures occur more often.
Neurogenic contractures occur, as a rule, after damage, compression, or injury to the nerves. Sometimes, even a minor injury to the nerve without violating its anatomical integrity causes severe reflex contractures (for example, in the joints of the hand). Such contracture can become persistent if no preventive and therapeutic measures are taken in a timely manner. A peculiar form of reflex contracture is the contraction of the hand and fingers due to traumatic neuritis of the dorsal interosseous nerve (Turner's disease).
Ischemic (Volkmann) contracture represents a special kind. It develops as a result of acute ischemia not only of muscles, as Volkmann believed, but also of nerves. The reason for such a contracture may be prolonged presence of the tourniquet on the limbs, compression with a plaster cast, hyperextension of blood vessels and nerves during distraction by the apparatus, etc.
Oftentimes, contractures are complex, arise as a result of the simultaneous involvement of a number of tissues (muscles, nerves, joints, vessels) in the process. Most often, such contractures develop after gunshot wounds.
Diagnosis and prognosis
The presence of contracture is quite simple to establish on the basis of an assessment of the results of measurements of the volume of movements in the joint in comparison with the opposite limb and the average anthropometric data. Difficulties, especially in chronic cases, may arise in relation to establishing the cause of the contracture and the tissue that was affected primarily.
The prognosis is the better, the earlier treatment of contracture is started, the younger the patient is, the more plastic are tissues on the side of contracture (stretchability), as well as the less they are overstretched, and the better active contractions of the antagonist muscles are preserved.
Treatment
Conservative treatment
The basis for conservative treatment of contractures is combined use of heat, careful massage, active gymnastics, passive movements, mechanotherapy. In many cases, when independent active movements are still absent, or they are insignificant, it is important to combine active and passive movements. With passive movements, violent change of wound dressing should be resolutely avoided, as this can lead to additional trauma to the joint and periarticular tissues, with aggravation of contracture.
Surgical treatment
Indications for surgery are, as a rule, persistent contractures, when attempts at conservative treatment do not lead to a positive result. The following surgical options are applied:
- excision of the scar and skin grafting - with cicatricial (dermatodesmogenic) contractures are the basis for subsequent successful restoration of movements;
- excision of cicatricial degenerated tissue and palmar aponeurosis is a typical opera-tion for Dupuytren's contracture;
- fasciotomy - more often, in case of flexion contracture of the hip joint, the fascia lata of the thigh is dissected;
- muscular-plastic surgery includes a widely used group of interventions in the form of teno- and myotomies, lengthening or shortening of tendons, myotenolysis (release of muscles and tendons from the scars that restrict them with their excision), as well as muscle movements and transplants;
- neurolysis - the release of the nerve from the tissues compressing it;
- neurotomy and neurectomy are used in the treatment of spastic contractures in the form of partial excision of motor branches or resection of nerve branches immediately before their entry into the spastic contracted muscle (Stoffel's operation). With spastic reduction of the adductor muscles of the thigh, a method of dissection of the obturator nerve is used;
- corrective operations on bones are carried out with persistent contractures in the absence of effect from conservative treatment and operations on soft tissues. Osteotomies of various types are performed - transverse, oblique, arcual;
- endoprosthetics of the affected joint is indicated in cases of severe arthrogenic contractures;
- in cases of impossibility to install an endoprosthesis, arthrodesis allows relieving the patient from pain but at the same time eliminates the function of the joint.