2. Muscle contractures can occur for many
reasons, such as paralysis, muscular atrophy ,
and forms of muscular dystrophy.
Fundamentally, the muscle and its tendons
shorten, resulting in reduced flexibility.
the loss of strength
Loss of muscle control
leading to an imbalance between the various
muscle groups around specific joints.
3. Various interventions can slow, stop, or even
reverse muscle contractures
physical therapy
surgery.
4. Contractures occur when the soft tissues
cannot accommodate changes in bone length.
To treat contractures effectively, one needs to
identify the potential problem muscles.
In tibial lengthening, for example, the
problem muscles are the gastrocnemius and
toe flexors. As a result, patients can develop
knee flexion, ankle plantar flexion, and toe
flexion contractures.
In the femur, both rectus femoris and
hamstring muscles resist lengthening..
5. This can result in a fixed flexion deformity of
the knee and a flexion range of motion
deficit. Lengthening of the humerus involves
the fewest problems. If problems do arise,
they are the result of biceps and
brachioradialis tightness.
In the forearm, finger flexors tighten more
quickly, causing proximal and distal
interphalangeal flexion and hyperextension of
the metacarpophalangeal joints.
6. Positioning: Optimal maximal positions vary
based on the body parts that are affected. For
example, patients who are undergoing tibial
lengthening should be positioned with the knee
extended straight and the ankle flexed up. Knee
extension along with hip abduction is a desirable
position for patients who are undergoing femoral
lengthening. Patients undergoing humeral
lengthening need elbow extension. Patients
undergoing forearm lengthening require elbow
extension (elbow straight), wrist in slight
dorsiflexion (bent upward and backward), and
finger extension (straight).
7. Splints: Custom designed splints help to keep
the soft tissues (muscles and tendons)
stretched properly. Using a splint to place a
muscle under tension for as many hours as
possible helps prevent contractures by
obtaining plastic response in the connective
tissue
8. Dynamic splinting: In certain situations, we use
special dynamic splints. These are different from
static splints because they include a spring-like
or elastic mechanism to produce elongation of
the tissues through a low load prolonged
duration stretch. Dynamic splints work most
effectively in treating knee and elbow flexion
contractures. Note that splints work only in
optimal positions and that their tension should
always be increased gradually. These types of
splints are also often used for the fingers and
toes.
9. Electrical stimulation: Electrical stimulation
can be used as an adjunct to a strengthening
program and to augment voluntary muscle
contraction. To accomplish this, a muscle
stimulator machine is applied to the surface
of the limb (thigh, for example) and a low
level electrical signal stimulates the
underlying muscle to contract. Some children
do not tolerate this well.
10. Hydrotherapy (water therapy): Hydrotherapy
helps patients avoid significant muscle
weakness, especially when both legs are
being lengthened. It promotes active range of
motion. The natural buoyancy allows
simulated weight bearing. The higher the
level of the water (chest deep versus waist
deep, for example), the more "weightless"
one feels. Hydrotherapy also helps in keeping
pin sites clean.
11. Progressive weight bearing: Programs of progressive
weight bearing are important during all phases of limb
lengthening rehabilitation. During the lengthening phase,
patients should be encouraged to perform weight bearing
as prescribed. Some patients may experience pain from
increased weight bearing, and the increased weight
bearing can cause undue stress on the pins or wires.
Weight bearing is even more critical during the
consolidation phase. The patient should progress from two
crutches to one and then to none. He or she should also
perform closed chain exercises. (Closed chain exercises
are defined as resistive exercises with which the load is
applied through the feet; some examples of closed chain
exercises are leg press, stair climber, and bicycle). Many
patients can walk without assistive devices and have no
limp during the latter part of the consolidation phase
12. Nerve injury occurs primarily in patients who are undergoing tibial lengthening. It
happens when certain nerves do not stretch enough to accommodate the bone
lengthening. Peroneal nerve symptoms during tibial lengthening are caused by
referred pain in the dorsum of the foot. This pain may present initially as
hyperesthesia (increased sensitivity) and then as hypoesthesia (reduced
sensitivity). Weakness in the muscles that control toe and foot action are
sometimes observed. Pain medications usually do not help. Referred pain in the
top of the foot is increased with knee extension and is relieved by flexing the
knee. When signs of peroneal nerve irritation occur, the use of a dynamic knee
extension splint should be discontinued and knee extension exercises should be
reduced. A patient who may be developing this condition should notify us as soon
as possible. We monitor nerve function using a quantitative sensory testing device
called a pressure specified sensory device (PSSD). This device measures tactile
sensitivity (feeling ability) for one- and two-point touch. This device often allows
us to identify nerve stretch problems even before they cause symptoms. This
device does not work reliably in children younger than 6 years. In most cases,
reducing the rate of lengthening reduces the symptoms of nerve irritation and the
PSSD results return to normal. In cases in which patients do not respond to rate
reduction, peroneal nerve decompression surgery is required. This is a small
procedure that involves a small incision and, at most, an overnight hospital stay.
When indicated, nerve decompression prevents permanent nerve injury and allows
the nerve to recover. This, in turn, allows the lengthening to continue.
13. Joint Contracture
Contracture around a joint can occur as a result of tissue trauma
and subsequent scar formation, or joint immobilisation and
resultant tissue adaptation, or as a combination of both.
Connective and periarticular tissues which surround a joint heal
in a clearly defined and predictable manner. Healing by mitosis
(cell division) is not always possible due to either the
nature/capacity of the specific tissue or size of insult. Most
frequently lost cells and structure are replaced by with scar
tissue, often complicating complete recovery of
function. Timeframes and success of healing may vary with size,
location and nature of wound (accidental or surgical), and initial
management.
14. Surgical wounds heal by first intention, healing
rapidly with small degree of scarring and low risk of
infection or complication (Knottenbelt, 2003). Degree
of scarring is related to size and degree of the
incision, and keyhole surgery is often preferred over
open surgery as it limits tissue trauma, scarring and
recovery time (apposition of edges). Open surgery to
a joint is likely to result in some scarring as several
structures are involved, and also contracture
formation as postoperative ROM is likely to be
restricted due to pain, functionally splinting the
affected joint.
15. As scar tissue cannot fully replicate the
strength of the tissue it has replaced. Surgical
incisions therefore tend to be performed
longitudinally to tissues tension lines rather
than transecting them, as the tissue can then
has potential to regain more dynamic and
tensile strength. Adhesions formed can be
broken, but this induces further inflammation
and can thus further scar tissue formation
and this occurrence is therefore best
prevented (Johnston, 1985).
16. Joint contracture is mostly caused by
immobilisation, either physical or physiological.
Joint immobilisation is often used as a prescribed
treatment following surgery or trauma, but can
also occur as a result from any disease or
situation which leads to limb disuse or
recumbency. Contracture formation is therefore
an adaptive reaction of affected tissues to
diminished mechanical loading and altered joint
position.
