CONTRACTURE (contractura narrowing) — restriction of movements in a joint. The full immovability in a joint is called an anchylosis, and existence of kachatelny movements — rigidity. At To. there is bigger or smaller, but clearly a definable volume of movements.
Depending on the principle of division exists several types of classifications
of K. K. divide on inborn and acquired, active (restriction of active movements), passive (restriction of passive movements) and active and passive. Allocate primary To. — restriction of mobility in the affected joint and secondary — restriction of mobility in next with struck joints. To. divide also by the form provisions, in Krom there is an extremity, i.e. by the form the limited movement: flexion To. — restriction of bending, extensive To. — restriction of extension, bringing or taking away To. — restriction of reduction or assignment, rotational To. — restriction of rotation. The clinic meets combined To more often. — flexion and extensive, flexion bringing.
According to localization of primary changes To. divide on dermatogenny, desmogenny, tendogenny, myogenetic and artrogenny. And, at last, To. distinguish but to an etiopatogenetichesky sign: posttraumatic, postburn, neurogenic, reflex, immobilized, professional, ischemic.
Inborn To. are an obligatory component of many inborn malformations — clubfoot (see), wrynecks (see), arthrogryposis (see), inborn talipomanus (see), etc. Inborn To. quite often happen multiple and are combined with other changes of an extremity (fig. 1).
Acquired To. result local traumatic, inflammatory, reactive and dystrophic patol, from changes in this joint or in the soft tissues surrounding a joint — skin, hypodermic cellulose, fastion, ligaments, sinews, vessels and nerves, and also under the influence of the general factors causing an atrophy of muscles and loss of elastic properties of the soft tissues surrounding joints (e.g., at hysterical To., plumbism).
The etiology and a pathogeny
Dermatogennye K. arise owing to draft of the wrinkled skin hem which is formed in the field of an injury or inf. damages of skin (wounds, burns, hron, infections). Desmogennye K. develop during the wrinkling of fastion, aponeuroses and sheaves after deep damages or hron, inflammatory processes. To desmogenny To., in particular, the palmar fibromatosis belongs (see. Dyupyuitrena contracture ). Tendogenny and myogenetic To. are a consequence of development of cicatricial process around sinews and in muscular tissue after an injury and inflammatory process. Besides, also other conditions of development myogenetic are possible To. They develop as a result of disturbance of muscular balance, napr, after poliomyelitis or an injury of peripheral nerves. A part of muscles at the same time loses the function, and draft of the muscles which kept function begins to prevail. At spastic paralyzes and paresis in response to a painful irritant there is a spastic muscular contraction. Over time it becomes resistant and is clinically expressed as K. Myshechnaya K. can develop at long fixing of a joint in vicious situation; here too redistribution of draft of muscles plays a role.
The reason of development artrogenny To. changes in the joint ends or in the copular and capsular device are patol, at acute or hron, diseases of a joint, later inside - and circumarticular changes. Inflammatory or traumatic destruction leads to development of commissures in a joint and to cicatricial wrinkling of the capsule.
Dystrophic changes in joints often lead (osteoarthroses) to development artrogenny To.
Patol, process seldom strikes one any fabric within a joint. In clinic the mixed forms, napr, dermatodesmogenny are frequent To. after deep burns (fig. 2); after heavy open intra joint changes are possible To., which reason changes in all tissues of a joint are, since skin and finishing bone and cartilaginous tissue.
Differ in big variety of the reasons neurogenic To., quite often arising at diseases or damages of a nervous system. By the form it is most often myogenetic To. as a result of disturbance of normal muscular balance and education new patol, the muscular balance holding a joint in forced situation. To neurogenic To. on the etiopathogenesis are close reflex To. They arise at neuritis as result of chronic irritation of various sites of a reflex arc, at the severe pains caused by wounds, ulcers and fractures with bad fixing of fragments. An example nervnoreflektorny To. data of a brush and fingers at traumatic neuritis of a back interosseous nerve (Turner's neuritis) at a fracture of a beam bone in the typical place are. To reflex artromiogenny To. Bonnet's contracture arising at some inf belongs. damages of joints with at the same time sharply arising atrophy of muscles and bones.
Flexion neurogenic To. develops at the diffusion defeats of all diameter of a spinal cord taking both pyramidal, and extra pyramidal ways (myelites, a prelum of a spinal cord a tumor, etc.) - At preferential defeat of pyramidal ways (a spastic paraplegia of Shtryumpell, a side amyotrophic sclerosis, etc.) arises more often To. extensive type.
Neurogenic To., arising owing to patol, processes in hemicerebrums, divide on To. at paralyzes owing to defeat of corticospinal ways and at defeat of subcrustal nuclear educations.
Neurogenic To. at defeats of corticospinal ways mostly complicate hemiplegia (see) because of hemorrhage or thrombosis of brain vessels. They are divided on early also by late hemiplegic K. Rannyaya hemiplegic To. develops quickly after a stroke and at especially massive central centers of defeat (hemorrhage in ventricles, etc.). Late hemiplegic To. it is shown in terms from 3 weeks up to several months later stroke (see).
From hemiplegic To., developed at the central paralyzes, essentially differ To. at defeats of subcrustal educations, hl. obr. pale sphere and black substance. This Extrapyramidal pallidarny or pallidonigralny To., or Extrapyramidal rigidity, differs in so-called plastic character of hypertensive muscles (the tone of muscles is raised in antagonistic groups evenly). This look To. it is characteristic of trembling paralysis, postencephalitic parkinsonism, and also of some vascular (arteriosclerosis) and toxic (poisoning with manganese) diseases of a brain. To extrapyramidal To. also some other types of hypertensions at diseases belong basal gangliyev: at a hepatolenticular degeneration, the torsion dystonia and a wryneck. The syndrome of a so-called apoplectic gemitoniya described by V. M. Bekhterev in 1899 and which is found at cerebrospinal paralysis at children (absence of paralysis, the hyper tone of muscles amplifying at autokinesias) also shall be carried to them, apparently.
On the nature of a syndrome reflex To. there were various points of view. Assumed ischemia of nervous trunks, direct irritation of motive fibers of a peripheral nerve, opinions on a role of a psychogenia were expressed. Most likely, education is the cornerstone of a syndrome (as a result of a long irritation of the affected nerve) it is permanent the recorded reflex which is becoming isolated through a sympathetic trunk and through cells of side horns of a spinal cord (A. M. Grinstein). Disappearance reflex To. as a result of a preganglionic sympathectomy validates such explanation.
There are bases to consider that neurogenic To. can develop also as a result of direct irritation of peripheral motive neurone. It can be so explained resistant To. facial muscles at paralyzes of a facial nerve.
Neurogenic To. also manifestation of toxi-infectious irritation of an arch of a corresponding reflex, napr, convulsive data of muscles at tetanus which can not only be expressed in separate paroxysms can be, but also have character resistant To. face muscles, trunk and extremities. Tonic spasms at poisoning with strychnine have a similar origin. Long tonic spasms can take place and at a tetany, occupying preferential distal departments of top and bottom extremities, leading to development of characteristic poses and being followed by a number of changes of exchange. Resistant To. can be observed also at hysteria. At the same time distribution of the cramped muscles always reproduces any autokinesia or expressive action, and all syndrome clearly is connected with any mental experiences; single-step removal To. as a result of psychotherapy confirms its hysterical origin.
To. one of joints of an extremity can cause development in adjacent joints of the vicious installation which is functionally compensating primary deformation. Such installation is functional and adaptive (compensatory) K. Vnachale these To. have reflex myogenetic character; over time all fabrics within a joint are exposed to change. An example functional and adaptive To. is To. a knee joint, arising often under influence To. a hip joint at polyarthritis, a tubercular coxitis, and also permanent ekvinusny installation of foot (see. Horse foot ) during the shortening of the lower extremity.
The most difficult To. result from severe mechanical injuries, gunshot wounds or inflammatory (infectious) processes at the same time in skin, fastion, nerves and joints. V. O. Marx (1944) on big a wedge, material showed that at gunshot wounds To. can result from combined action of several etiopatogenetichesky factors: rough scarring of extensive and deep wounds of various localization, as a result of wrinkling of fastion and emergence of commissures between sinews and their vaginas; disturbances of a muscular synergism; wounds of the central and peripheral nervous system and vessels of extremities; long pains and reflex muscular tension; long fixing of an extremity in functionally disadvantage.
Immobilized To. can be a component of posttraumatic, postburn and other types To. They develop at a long immobilization, most often in the affected joint, but are possible also in the absence of damage of formations of a joint. At an immobilization of the affected joint in vicious situation K. develops much more often and quicker. In this case in a pathogeny To. plays a role and myogenetic! component.
In development professional To. constant or long overfatigue and tension of certain groups of muscles (at cutters, shoemakers, stomatologists, etc.) and hron, microtraumas with injury of muscles, sheaves, sinews play a role (at athletes, ballet dancers, loaders). Most often it is neuromyogenetic (reflex) K.
Ishemicheskiye K. develop as a result of disturbance of blood circulation in muscles, nerves and other fabrics with the subsequent their cicatricial change. These To. develop after injuries of large arterial trunks, at their prelum a plaster bandage, in connection with hypostasis of fabrics and from many other reasons. The most typical ischemic To. Folkmann's contracture is (a synonym: ischemic contracture of muscles of a forearm, Folkmann's syndrome, ischemic paralysis of Folkmann). It develops as a result of acute arterial insufficiency — ischemia of nerves and muscles of a forearm, at a long prelum of a neurovascular bunch of an extremity hardly imposed plait, at the big hemorrhages in the field of an elbow bend squeezing vessels, nerves and muscles at big hypostasis of soft tissues after severe injuries or operations; at hypostasis under circular plaster bandages (especially at children); after stretching, a prelum, an excess of blood vessels at their wound. This To. quite often arises after epicondylic fractures of a humeral bone and fractures of bones of a forearm.
A clinical picture
In most cases To. is one of many symptoms of a disease or patol, conditions of a joint or all organism.
One instruction by sight To. (e.g., flexion, bringing etc.) does not give an idea about a wedge, value for the sick available restriction of movements yet. Important, in what range there was this restriction: in functionally favorable or in functionally unprofitable. So, e.g., flexion and extensive To. in an elbow joint in limits extension 175 °, bending 120 ° (the volume of the movements 55 °) is unprofitable from the point of view of function of an upper extremity; bigger restriction of movements on volume, but in other range (extension 120 °, bending 80 °, the volume of the movements 40 °) for the patient functionally more favourably.
Features of clinic To. a wedge, pictures of a basic disease are connected with specifics. Time of emergence To. fluctuates over a wide range and depends on an etiology. So, after an injury or inflammatory process deformation as a result of slowly developing cicatricial process can progress within several months; the ischemic contracture of Folkmann develops quickly — within several hours.
Are richest a wedge, manifestations neurogenic To., and in particular To. at various diseases of a spinal cord — in the form of extensive installation of legs (tonic extension of hips and shins and bending of feet — so-called ex-tensor To.) or in the form of flexion installation of legs (tonic bending of hips and shins and extension of feet — so-called fleksorny To.). Extensive To. matches usually strengthening tendon jerks (see) and emergence of a clonus of a patella and feet, flexion — with strong development protective reflexes (see).
Early hemiplegic To. it is quite often characterized by attacks of especially strong tonic spasm. These attacks can develop under the influence of various irritations and be followed by changes of pulse, breath and size of pupils. In favorably proceeding cases protective reflexes begin to regress further what disappearance of symptoms early is connected with To. Manifestations late hemiplegic To. come down usually to bending of a forearm, to pronation and bending of a brush, bending of fingers and to extension of a hip and shin (a so-called pose of Vernike — Mann). In addition to the most frequent pose, in a cut extremities stiffen at late hemiplegic To., there is a number of its separate options. Are that To. with dominance of excessive convulsive pronation or supination of a brush or with rotation of foot inside or outside, and also with flexion installation on the party of paralysis not only a hand, but also leg. These flexion poses at late hemiplegic To. are connected with the pain which is available at the same time.
Restriction of movements in a joint — rather demonstrative symptom. At diagnosis To. it is important to study its quantitative parameters. For this purpose by means of a goniometer (goniometer) measure as the active movements in joints which are carried out by the patient, and passive, made by the investigating doctor. Clinical (in particular, orthopedic) the diagnosis at To. includes the instruction by sight (or types) To. and its etiology, napr, flexion and extensive artrogenny To. a knee joint in connection with incorrectly accrete change of condyles of a femur.
Rentgenol, studying of a joint at To. has crucial importance in the presence of artrogenny changes. At other types To. this research helps with differential diagnosis. At the same time it is necessary to remember that long existence of dermatodesmogenny or myogenetic contractures leads to secondary changes in a joint like an osteoarthrosis which are also visible in a picture.
Differential diagnosis To. it is considerably facilitated after establishment of a type of a basic disease (an injury in the anamnesis, a disease of a head or spinal cord etc.). The differential diagnosis is difficult at neurogenic To. They should be distinguished from restriction of the volume of passive mobility which is caused retractions i.e. shortening of the corresponding muscles, without simultaneous development in them a persistent hypertension. Such retractions easily come in muscles which points of an attachment were pulled together for a long time, napr, at long fixing of an extremity in any pose. Muscular and tendinous and copular retractions can easily develop at long paralysis of antagonists (a so-called contracture of antagonists), and also at various patol, the processes breaking a trophicity of the most muscular tissue (ischemic To., retractions of muscles at miozita and a dermatomyositis, myoscleroses of various etiology, etc.). All this so-called mechanical irritativnye To. They should be distinguished from inborn retractions of the muscles leading to permanent restriction of volume of possible passive mobility in various segments.
Treatment To. carry out depending on a basic disease, localization and a type of the fabrics struck at deformation.
Treatment of the majority of types To. begin with conservative actions: carry out active and passive to lay down. gymnastics, work therapy, massage, parafino-and an ozoceritotherapy, electrostimulation of muscles, fonoforez with ronidazy and lidazy, a pirogenaloterapiya and hydrotherapeutic procedures (heat baths, active movements in water, to lay down. swimming). Single-step or stage redressment with the subsequent imposing of plaster bandages is less often shown.
Basis of complex conservative treatment To. is to lay down. physical culture: it is directed to recovery of function against the background of treatment by situation (use of the orthopedic means promoting stretching of kontragirovanny muscles and rapprochement of points of an attachment of the stretched muscles); use of the means promoting relaxation of muscles (physical. exercises in warm water, a right choice of the initial position during the performance physical. exercises, use of the special receptions directed to relaxation of muscles); use passive physical. the exercises leading to stretching of the reduced muscles and periartikulyarny fabrics and active physical. the exercises increasing force of the stretched muscles; use of exercises on devices of mechanotherapy — preferential pendular character (fig. 3 and 4); carrying out funkts, treatments in a close combination to the means exerting direct impact on changes in the muscular and joint device and process of scarring of fabrics (a thermotherapy, resorptional medicinal therapy, etc.).
At neurogenic To. a basis to lay down. physical cultures are giving of the correct position of an extremity of the patient and the organization full funkts, treatments. Stretchings of kontragirovanny muscles and for the second time reach the changed periartikulyarny fabrics by use of passive movements in joints. The passive movements repeat repeatedly (4 — 5 times) for day, it is desirable after preliminary thermal influence (hot wrapping, a paraffinotherapy, mud cure). In parallel with it for recovery of muscular balance active physical are used. the exercises promoting strengthening of the weakened muscles in the optimal conditions for their function (reached by massage, easy thermal influences, performance physical. exercises in warm water). After physical. exercises enshrine a joint in the provision of the reached correction — by means of tires, plaster bandages, bags with sand, etc.
In a technique to lay down. the physical culture directed to elimination posttraumatic To., distinguish three stages: 1) at the least resistant (myogenetic) To. at an early stage after an injury apply active physical. exercises of the facilitated character against the background of relaxation of painfully tight muscles; 2) at the desmogenny changes which arose in connection with cicatricial and commissural process use more intensive active physical. exercises for stretching of periartikulyarny fabrics and the shortened muscles; 3) at a late stage of development To. with dominance of joint changes use along with active exercises passive exercises on special devices mechanotherapies (see). Therapeutic effect, the reached physical. exercises, fixes the provision of correction given to the affected joint.
Folkmann's contracture demands especially early treatment. During the first hours after its emergence it is necessary to create the conditions improving blood circulation of the struck department of an extremity: to immediately remove a plaster bandage, to give extremities sublime situation, to carry out a constant hypothermia, to use vasodilating, spasmolytic and anticoagulating drugs. Also periarterial novocainic blockade or blockade of a cervical sympathetic node are shown.
Boundary between conservative and operational ways of treatment To. use pivotally-distraktsionnykh of devices is (see. Distraktsionno-kompressionnye devices ). They give the chance gradually and is dosed to eliminate To. (fig. 5).
Operational treatment consists in various plastic surgeries on soft tissues and bones.
At dermatogenny To. with formation of a hem in the form of a sail make its excision and skin plastics local fabrics (skin plastics on Morestena, to Limberg and other ways). At dermatodesmogenny To. with rough, the subject fabrics soldered with and a bone hems as a result of their keloid regeneration or primary defect of skin which cause permanent restriction of movements in joints apply full excision of hems with the subsequent free skin plastics the full-layer or split skin rags, is more rare rags on a leg, including also a pedicellate Filatov's graft (see. Skin plastics ).
At ischemic To., especially on an upper extremity, sinew and muscles operations are shown. Make a myotenolysis — release of a muscle and sinew from hems; allocate muscles and sinews on all their extent; according to indications make tenotomy (see) and myotomy, and also lengthening and change of sinews of muscles. The tenotomy is often made at bringing To. in a hip joint. This operation has wide indications also at patients with spastic To. Changes of sinews of muscles most often make at paralytic To. after the postponed poliomyelitis or after injuries of peripheral nervous trunks (especially beam nerve). Lengthenings of sinews at their shortening on a forearm are shown for elimination To. fingers of a brush after severe injuries and burns. At heavy tendogenny To. make excision rubtsovo the regenerated sinews or an exposure of the ends of defect with the subsequent change free tendinous auto-and allotransplants or transplants from synthetics (lavsan, etc.).
At To., the nervous trunks connected with damage, make neurolysis (see) — allocation of a nerve from cicatricial commissures with sinews, muscles and a bone; at a break of a nerve put an epinevralny stitch. Positive takes are yielded by a method of muscular neurotization on Erlakhera — excision from the next healthy muscle of a rag on a leg and its vshivaniye in a crevice of the paralyzed muscle. Electroexcitability of the last is recovered in a month due to germination in it nervous elements of the replaced rag.
At artrogenny To., caused by changes of the capsule of a joint, apply a section of the capsule (capsulotomia) or removal patholologically of the changed synovial membrane of a joint (synovectomy). Synovectomy (see) yields good results at rhematoid and tubercular arthritises with existence resistant artrogenny To. joints of a top and bottom extremity. According to indications make an arthrolysis (a section of fibrous commissures with mobilization of a joint). The arthrectomy and its artificial ankylosis are applied at resistant painful To. and a sharp atrophy of muscles (e.g., at effects of tubercular or heavy purulent arthritis). However in some cases even at resistant artrogenny To. mobilization of a joint by means of pivotally-distraktsionnykh devices is possible. According to indications make an arthrectomy in combination with internal prosthetics by a metal joint or a joint from polymeric materials. Except joint operations, at the same time carry out extraarticular operations, napr, an epicondylic osteotomy of a femur at flexion To. knee joint.
At resistant extensive To. a knee joint after a fracture of a femur make an ulotomy and mobilization by the four-head of a muscle of a hip, partial excision rubtsovo the intermediate wide muscle of a hip regenerated and soldered to a bone callosity, mobilization of a patella, a section of the capsule of a joint at its wrinkling and if necessary — lengthening of a sinew of a direct muscle of a hip.
To. demands prolonged and persistent conservative and operational treatment. At spastic paralyzes operational treatment is begun with three-year age at To. the lower extremities and from eight-year age at To. upper extremities. Extend spastic rigid muscles and their sinews, use denervation of the muscles which are in a condition of a spasm less often. According to indications make myotomies, tenotomies, tenotomies with the subsequent lengthening of sinews and operations of movement of points of an attachment of muscles. Examples of such operations are Sauter's method — Putti — subperiostal separation of muscles from a front upper awn and change is 4 cm lower than them (at flexion To. hips) and Campbell's method — cutting off of all crest of an ileal bone and change together with the attached muscles are lower than it — on the surface of a wing of an ileal bone (also at flexion To. hip).
At an ischemic contracture of Folkmann make a longitudinal section of a superficial and deep fascia of a forearm or shin, including fibrous stretching at damages to area of an elbow bend, and delete a hematoma. Stitches on a fascia are not put. At an artherothrombosis it is necessary to remove blood clot and to put stitches on an artery.
In terms up to 2 — 3 months after an injury operative measures consist hems, allocation and mobilization of muscles and sinews, their sewing together at gaps, lengthening and plastics at defects at a distance. Especially carefully and carefully delete hems and commissures around vessels and nerves. During later period in the presence of the residual phenomena along with a tenolysis, lengthening and change of muscles according to indications make a resection of sites of bones of a forearm or an artificial ankylosis of a radiocarpal joint in functionally advantageous position, removal of the same kind of bones of a wrist across Klapp, cutting off of muscles from the place of their attachment.
the Forecast in treatment To. depends on its character and a look, time which passed from the moment of its emergence, age and a condition of patients, starting date of treatment and its look from complications. Usually the earlier treatment using sovr is begun, conservative and operational methods, the result is better.
Prevention consists in the correct carrying out sovr, methods of treatment of intra joint and circumarticular changes, burns, extensive wounds of soft tissues and inf. processes in a head and spinal cord, in soft tissues, joints and bones of extremities. Imposing of plaster bandages in the correct situation (the sufficient angle of bending in a knee joint belongs to preventive actions at a fracture of a femur and extension in a radiocarpal joint at an injury of a forearm, sufficient assignment and bending of a shoulder at injuries of a shoulder joint etc.), i.e. giving to joints most fiziol. provisions, at Krom do not stretch ligaments of a joint and the capsule and as much as possible muscles relax. The timely longitudinal section of circular plaster bandages at severe injuries at adults allows to avoid ischemia of fabrics owing to hypostasis them and a prelum in a plaster bandage. The same aim is pursued by imposing at children of splints, but not circular bandages, giving to the injured extremity of sublime situation, use according to indications of a local hypothermia and oxybarotherapy. At severe open injuries early surgical treatment, according to indications a section of a fascia without the subsequent imposing on it of seams, primary skin plastics is of great importance at defects of skin, imposing in early terms after an injury of distraktsionno-compression devices instead of plaster bandages. During the development To. after intra joint changes it is necessary to avoid rough violent passive movements in the joints causing pain and a reflex muscular spasm. It is especially urgent for an elbow joint. At damage of peripheral nervous trunks, an injury and diseases of a spinal cord for prevention To. apply a long immobilization of an extremity plaster splints in functionally advantageous position in combination with early to lay down. gymnastics and physical. by methods of treatment.
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O. H. Markova; C.H. Davidenkov (not BP.), A. F. Kaptelin (to lay down. physical.).