The general method for contractures

A contracture is a deformity which prevents the movement of a joint through its normal range. Structurally, contractures are the result of shortening of the soft tissues of a limb, and/or tightening of the ligaments of a joint. This can happen as the result of: (1) Disuse (see below). (2) Soft tissue or bony injuries, especially burns (58.24 to 58.26) and fractures. (3) Muscle imbalance, due to weakness of the nerves supplying a group of muscles. This can be temporary, when you expect the nerve to recover, or permanent, when you expect it not to. (4) Poliomyelitis, and other lower motor neurone lesions, which weaken one muscle group more than another. (5) The spastic paralysis of an upper motor neurone lesion, such as that following a cerebrovascular accident, the cerebral diplegia or paraplegia of a birth injury, encephalitis, or a head injury. (6) Sepsis in bones (osteomyelitis, 7.2), joints (septic arthritis, 7.16), or lymph nodes with periadenitis (iliac abscesses, 5.12).

That ''prevention is better than cure' is never more true than with contractures. If a joint is to remain useful, it must move regularly through its full range. Anything which prevents it from doing this eventually causes a contracture. The soft tissues surrounding a disused joint become shorter, and less elastic, and its muscles waste and will not extend normally. Ultimately, its bones change their shape, and become deformed; it lacks a full range of movement, or becomes fixed near one end of its range, usually flexion.

The two important principles in prevention are: (1) Most importantly, to keep all joints moving whenever you possibly can. The need to do this is well shown by the the patient with the severe buttock injury in Figure 54-10. When she was admitted, both her elbows were normal, but as she lay on her front for several weeks, she kept them flexed, and never moved them. The result was that when she was discharged, she had severe contractures in both her elbows, which had been perfectly normal on admission. The burnt child in Fig. 58-1 developed contractures in his unburnt joints because he did not move them. Contractures like this can happen quite unnoticed, and when you do notice them, it may be too late. (2) When movements are temporarily difficult, or inadequate for any reason, prevent deformity by splinting or skin traction (70.10), as with the burnt child in Fig. 58-17.

Treatment starts with a careful assessment, so begin by deciding:

(1) Which tissues are causing the patient's contracture? If his joint is merely stiff, releasing it should not be too difficult. If only his skin, subcutaneous tissues, and muscles are involved, you should also be able to release them. But contractures of his tendons, or nerves (as in his popliteal fossa), are more difficult. Involvement of a joint can be due to: (a) Mild or dense adhesions. (b) Shortening of its capsule or ligaments. (c) Destructive changes, as the result of past infection. (d) A fibrous ankylosis. (e) A bony ankylosis. If his bones are not deformed, you should be able to release his contracted soft tissues. If they are deformed, you will have to refer him for an osteotomy.

(2) What range of movement is there in the joint? Record the movement he still has.

(3) How much power is there in his muscles? This is important if he has a lower motor neurone lesion, such as that following polio, or an upper motor neurone lesion as the result of paraplegia. Muscle power is graded from 0 to 5. The important grade is 3, because this is the grade at which a muscle is just able do its work against gravity. It varies with the muscle; the quadriceps, for example, has to lift a heavy leg against gravity, whereas the extensor of the little finger has only a finger to lift. Any muscle which can lift its part of a limb against gravity, must have a power of at least 3. Charting is difficult to do accurately, especially in young children. In an older patient trick movements can easily deceive you.

Try non-operative methods first. You have several choices: (1) You can use active and passive movements. These might seem the simplest, but they need a determined physiotherapist, or someone, such as a nurse, with some physiotherapy training. (2) You can apply skin or skeletal traction (70.10, 70.11). (3) You can manipulate a joint. (4) You can apply serial corrective casts. Manipulation and casts can often be usefully combined. For example, you can manipulate a joint, and then apply a cast almost at the limit of its range of movement. Later, you can manipulate his joint again, and replace the cast with another one, in which his joint is nearer to the limit of its normal range of movement. If manipulation is to be thorough, you will have to anaesthetize him. The danger is that, during manipulation, a joint may bleed, and the blood in it may organize and cause more adhesions. You can easily break a bone when you manipulate it, so follow the instructions we give, which are designed to prevent this happening. You can also wedge a cast, as in Figs. 70-8 and 70-9. This is economical in plaster, but it has the disadvantage that you cannot combine it with manipulation. (5) You can release soft tissues surgically. Polio contractures are easier to release than the contractures which follow burns, because there is less scar tissue, and no skin loss.

Fig. 27-1 MUSCLE CHARTING. Grade three is the critical one, because this is the grade which allows a patient to lift his limb against gravity. You can test all other muscle groups in the same way. Kindly contributed by Ronald Huckstep PREVENTING CONTRACTURES IS EASIER THAN TREATING THEM

GENERAL METHOD FOR CONTRACTURES PREVENTION. Most contractures can be prevented by: (1) Putting a patient's joints through their full range of active and passive movement, several times a day, as with paraplegia (64.13). This is such a simple measure, yet it is so often forgotten. You probably won't have physiotherapists, but this is something that all nurses can do[md]so show them how. (2) Appropriate splinting, as for burns (58.24), tuberculosis of the knee (29.3), or a radial nerve palsy, as in Fig. 69-2. (3) Skin traction for burns, as in Fig. 58-17. (4) Early movements in bone and joint injuries, as with Perkins traction for a fractured femur (78.4), or fractures of the femoral condyles (79.15). (5) The early drainage of pus, as with septic arthritis of the hip, which readily causes a flexion contracture (7.18). (6) The early grafting of wounds and burns over joints (58.32). (7) Early manipulation and immobilization, as for neonatal talipes equinovarus (27.15).

Often, you will need to do several of these preventive measures at the same time. For example, you may need to combine splinting and active and passive movements.

ASSESSING A PATIENT [s7]WITH A CONTRACTURE Where relevant, assess him lying, sitting, standing, and walking. Remember that abduction is movement away from the midline, and adduction is movement towards it. ''Varus' is a deformity towards the midline from the line of a long bone, and ''valgus' is a deformity away from it. In an equinus deformity of the ankle the foot points downwards, like that of a horse (equus, a horse), in a calcaneus deformity his foot points upwards so that his calcaneus is downwards.

RANGE OF MOVEMENT. In the anatomical position all joints are at 0[de], so record the movement he has from this position (69-1), and state whether they are active or passive.

For example, the range of movement for a normal hip could be: flexion 0[de]/120[de], that is from 0[de] to 120[de]. Its other movements might be extension 0[de]/10[de], abduction 0[de]/40[de], adduction 0[de]/30[de], external rotation 0[de]/60[de], internal rotation 0[de]/30[de]. ''Normal' people vary somewhat.

A patient with a flexion contracture might have: flexion 30[de]/110[de], extension [mi]30[de]/[mi]30[de] (this means that there is no extension in his hip, movement starts at [mi]30[de] of extension and ]]ends there), abduction 0[de]/20[de], adduction 0[de]/20[de], internal rotation 0[de]/10[de], external rotation 0[de]/40[de]. This means that his hip is flexed, but will not extend at all; it will flex a bit more, but not as much as normal. In other directions its movements are slightly limited.

MUSCLE POWER and movements are usually assessed by a physiotherapist, but if you don't have one, you will have to assess them yourself.

Grade 0[md]no power, not even a flicker.

Grade 1[md]a flicker of movement, but no more.

Grade 2[md]movement with gravity eliminated.

Grade 3[md]movement is just possible against gravity.

Grade 4[md]movement is possible against gravity and some resistance.

Grade 5[md]full normal power.

PARTICULAR JOINTS. A contracture of one joint can affect movement in another, so assess him like this.

Hip. If you are assessing a flexion contracture of his hip, flex his other hip as far as it will go. This will correct any lumbar lordosis, which may disguise as much as 60[de] of fixed hip flexion. Extend and adduct his hip, because a tight abduction contracture may be responsible for most of his deformity.

Knee. If you are assessing a flexion deformity of his knee, do so with his hip in both the neutral and the flexed positions. Assess a varus or valgus deformity from the line of the shaft of his femur. Assess backward, or lateral subluxation of his tibia on his femur as mild, moderate, or severe. Assess external rotation of his tibia on his femur with his knee extended as much as possible.

Ankle. If you are assessing an equinus deformity of his ankle, do so with his knee flexed and extended, because this will help in deciding management. If the deformity is in his ankle joint, it will be the same whether his knee is flexed or extended. But if the deformity is in his gastrocnemius muscle, the range of movement in his ankle will vary with the position of his knee. This is because the gastrocnemius muscle spans both the knee and the ankle. So, if this is short an equinus deformity of his ankle will be less if his knee is flexed, than if it is extended, because his gastrocnemius is not being stretched by an extended knee.

X-RAYS. If necessary, X-ray the bones and joints involved in his contracture. Look for: deformity of the joint surfaces, evidence of active disease, and the degree of osteoporosis.

TREATMENT [s7]FOR CONTRACTURES The need for treatment usually means that prevention has failed. See elsewhere for burns (58.25, 58.26), for polio contractures (27.3 to 27.7), and for paraplegia (64.13). Here are some general methods which you can apply to most contractures. The first two are the safest.

ACTIVE AND PASSIVE MOVEMENTS [s7]FOR CONTRACTURES These may gradually stretch a patient's shortened soft tissues and correct his deformity. If possible, encourage him to do them himself (active movements). Or, they can be done by a physiotherapist, or nurse (passive movements). Most useful are ''assisted active movements': (1) Support his limb while he gently moves it himself. This eliminates gravity and gives him a greater feeling of security. (2) At the extremes of movement use a little passive movement, as he moves his limb himself assisted by you. Chart the range of its movement at least every week.

TRACTION [s7]FOR CONTRACTURES If satisfactory correction is not possible by exercises alone, consider skin traction (70.10), or skeletal traction (70.11).

MANIPULATION [s7]FOR CONTRACTURES This is often combined with casting.

INDICATIONS. (1) Joints in which active and passive movements or traction have failed, or are not possible because the deformity is too great. (2) Hip contractures of less than 45[de]. (3) Knee contractures of less than 30[de]. (4) Ankle contractures of less than 20[de].

ANAESTHESIA. If you decide to anaesthetize him, ketamine will be adequate.

METHOD. Press firmly for at least five minutes in a direction opposite to that of the contracture. If necessary, repeat the manipulations fortnightly.

CAUTION ! Before you begin, remember that a bone which has not been moving is soft and breaks easily. To prevent this, reduce the leverage that you can exert, by holding a patient's bones close to his contracted joint, as in Fig. 27-2.

HIP. Flex his opposite hip to eliminate a lumbar lordosis. Press the upper third of his thigh backwards, to bring his leg down on the table in slight abduction. This will also stretch his adductors, which will probably be tight.

''Laying the patient prone' is a very useful nursing procedure for preventing and treating flexion contractures of the hip. If he will tolerate it, lay him face down with a pillow under his lower thigh. He is more likely to accept this uncomfortable position if his head faces towards the middle of the ward, rather than the wall.

KNEE. Hold his knee close to the joint. If you don't, you may break his tibia or his femur, displace his epiphyses, or sublux his tibia on his femur.

CAUTION ! Don't try to release contractures of his knee too forcibly, or you may injure his popliteal nerve, or damage the joint.

ANKLE. If he has an equinus deformity, support his ankle, and firmly dorsiflex his foot. If he has a varus deformity, or an adduction deformity of his forefoot, be especially firm and gentle. Don't push up his forefoot only; this may merely extend his mid tarsal and tarsometatarsal joints, without extending his ankle.

CASTING [s7]FOR CONTRACTURES Apply a well-padded plaster cast, close to but not at the extreme range of movement of the joint. If you do, pressure on its cartilage may cause necrosis and osteoarthritis later. So let it relax a little, before you apply the cast. A few weeks later, if necessary, manipulate his joint again, and replace the cast with another one, in which his joint is nearer to the limit of its normal range of movement.

CAUTION ! (1) Never put a joint, especially a knee, into a cast under tension. (2) Don't wedge a cast to correct a knee contracture. Both these mistakes may cause an early painful osteoarthritis, in what was previously a painless mobile joint. These are both very important rules. Fortunately, osteoarthritis and painful joints are rare in polio; it is tragic to create them unnecessarily.

OPERATIVE METHODS [s7]FOR CONTRACTURES You can release his soft tissues if he has a burns contracture (58.25 and 26). If he has polio, you can release the tendons of his ankle (27.7), his knee, or his hip (27.6). If his contracture is severe and long-standing, you may be able to refer him for a release combined with a myocutaneous flap, or by an osteotomy.

Fig. 27-2 MANIPULATING POLIO CONTRACTURES. When you manipulate a patient's joint under anaesthesia, always exert pressure close to a joint, or you may break a bone or displace his epiphyses. A, when you manipulate his hip, flex his opposite hip, and grasp his thigh. Push it down in extension and slight abduction. B, don't push down on his knee! C, exert pressure near his knee, and not as in D! For an equinus deformity of his ankle (E), grasp him near his ankle, and dorsiflex it (F, and G), not as in H! For a varus deformity of his foot (I), evert it and dorsiflex it for at least five minutes (J). Manipulate an adduction deformity of his forefoot firmly and gently over a wedge (K and L). Kindly contributed by Ronald Huckstep.