22

CONTRACTURES — CONSERVATIVE MANAGEMENT

INTRODUCTION

Contractures will usually occur if there is imbalance of single groups of muscles which are not held in check. Although this is the most important cause, there are other primary causes as well. These include the effects of gravity, the effects of flexed joints in bed, and the results of bearing weight on a leg.

Crawling boy on elbow and knees Secondary to the primary causes are the effects on joint, bone connective tissue of the initial contracture. The joint capsules become contracted on the flexed side, the epiphysis may become flattened or deformed, and intermuscular septa, nerves and vessels become shortened in time. The skin over the flexed face may also become tight.

Long-standing contractures, especially of a major joint such as or knee, may cause multiple problems in their correction. Standard open operations are often successful in correcting the contracture. These often entail a major operation requiring blood transfusion, plus the need for a qualified surgeon. Complications which may follow these operations include skin loss, infection, and damage to important structures.

Subcutaneous methods of dividing tight structures and straightening contracted hips, knees and ankles are not new. They were in fact used in the 19th century, but have been superseded by open methods. These simple methods, however, have their advantages in developing countries. They can be performed by doctors in country hospitals, they require no blood transfusion, and complications seldom occur.

In less severe contractures these procedures have many advantages over major open operations. Modifications to the more conventional methods of subcutaneous tenotomies will therefore be described in detail. Fig. 22(a) shows the commoner deformities and contractures of hip, knee and ankle in poliomyelitis. Knee and ankle contractures may prevent the fitting of calipers, severe. Operative correction is required, with certain options which will be discussed.

PREVENTION OF CONTRACTURES

The prevention of contractures in the acute and subacute stages is very important. In many cases the patients are children who will be treated at home. The parents must be shown how to stretch the paralysed limbs daily to prevent contractures. In children, the muscles in acute polio are tender for a much shorter duration than in adults, and stretching of muscles can be commenced almost immediately with very little pain. This is essential, as contractures can occur in a matter of days.

Splints

Splints, except for back slabs for a drop foot, are now seldom used. Reliance is placed much more on daily stretching plus correct support of paralysed limbs in bed, as already illustrated.

Stretching of muscles and joints (Fig. 22(b))

Joints must be stretched in the direction opposite to that of the contracture, i.e. an equinus ankle dorsally. This must be carried out at least once a day by the physiotherapist or nurse, and at least three times a day by relatives. The important contractures are those of hip, knee and ankle, but other contractures such as a varus contracture of the foot, or an adduction contracture of the shoulder may occur.

The illustrations show the correct method of stretching contracted joints. The same method of manipulation is used by the surgeon. In this case, a general anaesthetic is used, and this allows a greater degree of correction to be obtained.

Flexion contracture of the hip Fig. 22(b)

In manipulation of the hip, the pressure backwards should be in the upper third of the thigh, lest excessive leverage should cause a fracture. The opposite hip must be fully flexed to eliminate lumbar lordosis, and the leg should be brought down in slight adduction to stretch the abductors which are usually also tight.

Lying the patient on his face in bed, as shown, with a pillow under the lower thigh is useful, provided the patient will tolerate the position. The hips can also be extended while the patient is in this position.

Flexion contracture of knee Fig. 22(b)

It is essential that the knee is manipulated as shown in the illustration, and that pressure is exerted near the joint. If this is not done, fractures of the tibia or femur plus slipping of the epiphyses and backward subluxation of the tibia on the femur are liable to occur.

Preventing a recurrence of contracture

Apart from stretching imbalanced muscles, the only way of preventing a recurrence of a contracture is to hold a joint in an overcorrected position. This is so the deforming muscles are acting at a mechanical disadvantage.

This is most easily achieved by fitting calipers as soon as the tender muscles will allow, (in small children within a few days or even immediately), and leaving the calipers on for most of the day and night in the acute and subacute stages.

Calipers for deformed knees

The special supports for deformed knees are illustrated in Fig. 23(c). This caliper for a slight flexion deformity of the knee is merely an ordinary caliper with a loose posterior strap plus a tight knee piece which may need to be padded. This type of support, which helps correct the knee as a patient walks, can only be used to correct a deformity of 30° or less due to the difficulty of fitting. A caliper for genu recurvatum has the opposite effect with a tight broad posterior strap, and the knee piece needs to be fairly loose anteriorly. In this type of support, only slight tension on the posterior strap is required as the deformity is easily correctable when the patient ceases to stand. The caliper in genu valgum requires to be bent to compensate for this, and in addition a second knee-piece will need to be fitted so that it presses on the medial side of the knee-joint and correct the valgus as the patient walks. This knee-piece is in addition to the ordinary anterior knee-piece.

Manipulation of ankle and foot deformities Fig. 22(d)

This is shown, and the most important deformity to correct is equinus. The correct method is demonstrated with the ankle firmly supported as the foot is dorsi-flexed. In the case of varus of the foot, or adduction of the forefoot, it is important to be firm yet gentle, and to avoid too rapid or forceful a manipulation. Much more is achieved by firm pressure for at least five minutes in the opposite direction to the deformity. This will usually need to be repeated, and followed by surgical correction to prevent recurrence.