Traumatologists and orthopedists treat Dupuytren's contracture. Treatment can be either conservative or surgical. The choice of methods is made taking into account the severity of pathological changes.
Conservative therapy is used in the initial stages of Dupuytren's contracture. The patient is prescribed physiotherapy (thermal procedures) and special exercises to stretch the palmar aponeurosis. Removable splints can also be used to fix the fingers in the extension position. As a rule, they are worn at night and removed during the day.
For persistent pain syndrome, therapeutic blockades with hormonal drugs (diprospan, triamcinolone, hydrocortisone) are used. The drug solution is mixed with a local anesthetic and injected into the area of ​​the painful node. Typically, the effect of one blockade lasts for 6-8 weeks. Please note that the use of hormones is a treatment that should be used with caution. Conservative remedies cannot eliminate all manifestations of the disease. They only slow down the rate of contracture development. The only radical treatment option is surgery.
There are currently no clear recommendations regarding the severity of symptoms that require surgical treatment. The decision to undergo surgery is based on the rate of progression of the disease and the patient's complaints of pain, limitation of movement and associated difficulties in self-care or performing professional duties.
Doctors usually recommend surgery if there is a flexion contracture of 30 degrees or more. The purpose of the operation, as a rule, is to excise scar tissue and restore full range of motion in the joints. However, in severe cases, especially with chronic contractures, the patient may be offered arthrodesis (creation of a fixed joint with fixation of the finger in a functionally advantageous position) or even amputation of the finger.
Reconstructive surgery for Dupuytren's contracture can be performed under general anesthesia or local anesthesia. With pronounced changes in the skin and palmar aponeurosis, surgical intervention can be quite lengthy, so in such cases general anesthesia is recommended.
There are many incision options for Dupuytren's contractures. The most common is a transverse incision in the area of ​​the palmar fold in combination with L- or S-shaped incisions along the palmar surface of the main phalanges of the fingers. The choice of a specific method is made taking into account the location of the scar tissue. During the operation, the palmar aponeurosis is completely or partially excised. In the presence of extensive adhesions, which are usually accompanied by thinning of the skin, free skin flap dermoplasty may be required.
The wound is then sutured and drained with a rubber graduate. A tight pressure bandage is applied to the palm, which prevents the accumulation of blood and the development of new scar changes. The hand is fixed with a plaster splint so that the fingers are in a functionally advantageous position. Stitches are usually removed on the tenth day. Subsequently, the patient is prescribed therapeutic exercises to restore range of motion in the fingers. Sometimes (especially with early onset and rapid progression), recurrence of contracture may occur over several years or decades. In this case, repeated surgery is required.

Many joint diseases are accompanied by limited mobility of the limb and the inability to perform the simplest movements. Contracture of the elbow joint occurs for various reasons, and with the combined form, movement in any direction is limited.

What's happened?

The elbow joint is a complex joint and is therefore often subject to various injuries.

In a healthy person, the arm at the elbow bends and extends without problems. If a person bends his arm, then the elbow is at an angle of 40 degrees, and when extended, it is at 180. You can turn the arm back, rotate and unfold the forearm.

Contracture of the elbow joint is a partial or complete limitation of the range of motion. Difficulties may occur with a certain type of movement, for example, with flexion or extension. With the combined form of the pathology, the hand becomes almost lifeless.

Causes

Factors provoking contracture:

• congenital pathologies in the form of underdevelopment of bone tissue, shortened muscle fibers, altered structure of muscle tissue;
• the presence of scars in the articular cavity formed after an inflammatory process, or in the post-traumatic period;
• violation of the integrity of articular tissues;
• the growth of connective tissue, which begins to replace the muscle tissue of the joint, and it becomes impossible to bend the arm;
• joint injuries, which include fractures and dislocations. Any traumatic injury. Elbow contracture after fracture is common;
• gunshot wound;
• blood flow problems;
• severe burns;
• abscess;
• diseases of the nervous system;
• arthritis that occurs in a purulent form;
• hysterical psychosis.

In elderly patients, a post-traumatic type of contracture is diagnosed.

The post-traumatic type of pathology is most often caused by unsuccessful falls on the elbow, bruises, problems with blood circulation, and pathological loss of elasticity of soft tissues.

Classification of contractures

Post-traumatic contracture is classified as follows:

• Stage 1 occurs a month after the injury. Limited movement occurs after motor fixation and pain. The psychological factor also influences the development of the phenomenon. If you seek medical help at the initial stage, the problem can be easily eliminated;
• Grade 2 contracture can develop when more than a month has passed since the joint injury. It is difficult to make basic movements due to the formation of adhesions and scars;
• Grade 3 contracture appears several months after the joint is injured. During this time, scars on the flexor muscle degenerate into fibrous tissue and shrink, which leads to limited mobility.

Elbow flexion contracture is classified into 4 stages:

• 1st degree. You can straighten your arm at the elbow no less than 170 degrees;
• Stage 2. The extension angle decreases from 170 to 130 degrees;
• Stage 3 is characterized by an extension angle from 90 to 130 degrees;
• Grade 4 is the most severe. It is possible to perform extension less than 90 degrees.

With a flexion contracture, extension of the limb is limited, with an extension contracture, flexion is limited. Flexion contracture is the most common phenomenon.

You can see what a joint looks like during contracture in the photo.

Diagnosis of contractures

To confirm the diagnosis and prescribe the correct treatment for contracture of the elbow joint, a comprehensive diagnosis is prescribed, consisting of the following measures:

1. X-ray examination to study the condition of cartilage and bone tissue;
2. Computed tomography or MRI to examine internal joint tissues and detect articular changes in them;
3. Laboratory blood tests.

After the above procedures, additional diagnostics may be required if the contracture is caused by neurogenic factors.

When making a diagnosis, ICD10 - International Classification of Diseases is used. Code M24.52 indicates contracture in the shoulder area. These are the humerus and elbow joint.

The post-traumatic type of elbow contracture according to ICD10 is coded M24.5 and refers to acquired deformities designated by code M20-M21.

Treatment

For contracture of the elbow joint, traditional treatment methods are usually used. Conservative treatment is effective if you consult a doctor in a timely manner and consists of the following procedures:

• applying plaster casts to correct the position of the joint;
• physiotherapy;
• thermal physiotherapeutic procedures;
• massage;
• traction technique.

During active medical procedures, pain may occur during treatment. Therefore, in order to avoid additional inflammation of the joint tissues, they begin to treat with medications from the group of non-steroids. These are drugs with analgesic and anti-inflammatory effects. For severe pain, an elbow joint block is indicated.

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If massive scar tissue is detected in the connective apparatus of the elbow joint, the problem is treated with surgery in the form of arthroscopy. Surgical intervention is also prescribed in cases where traditional methods have not been able to eliminate the limitation of movements.

An effective surgical method for contracture is arthrolysis of the elbow. During arthrolysis, the joint cavity is opened, then a part of the connective tissue that interferes with the normal motor activity of the limb is excised.

After excision of scars during arthrolysis, the affected tissue is replaced with implants.

If all the connective tissue is affected by scars, then joint replacement is indicated.

If the contracture begins to develop against the background of a fracture and subsequent malunion of the bones, then surgical intervention cannot be avoided. A number of activities are carried out before the operation. These are physiotherapy sessions, special exercises for exercise therapy, intra-articular injections that help eliminate signs of contracture. This comprehensive approach to surgery allows you to reduce the recovery period and also prevents the development of negative consequences after surgery.

If the elbow contracture is advanced and lasts for a long time, if surgical intervention is not performed, the patient may remain disabled.

In case of timely treatment, both conservative and surgical techniques give a favorable outcome. Therefore, when signs of pathology appear, it is important to seek medical help in time.

Physiotherapy

Physiotherapeutic procedures are part of complex conservative treatment for limited joint mobility. Physiotherapy gives the following results:

1. Improves blood supply to the joint. The tissues receive the necessary amount of oxygen and nutrition.
2. Scars dissolve faster.
3. The swelling goes away.
4. The inflammatory process stops.

The following types of physiotherapeutic procedures are prescribed:

• electrophoresis with non-steroidal drugs to relieve pain and relieve the inflammatory process. Electrophoresis can also deliver drugs from the group of corticosteroids and analgesics to the joint;
• magnetic therapy;
• laser treatment;
• shock wave procedures;
• applications with paraffin and ozokerite;
• balneotherapy.

Physiotherapy is effective at the initial stage of elbow contracture. During this period, galvanization procedures are indicated, when the affected area is exposed to low-frequency current. If you consult a doctor in a timely manner, several galvanization sessions are enough to eliminate the problem.

Massage

For the treatment and subsequent development of the elbow joint, massage sessions are included in the complex treatment.

Benefits of massage for contractures:

• blood flow stabilizes. Tissues receive the right amount of nutrition and oxygen;
• swelling in the elbow area is eliminated;
• pain goes away;
• general well-being and mood improves.

After each massage session, the injured arm should be at rest. Any overexertion of the affected limb is prohibited.

Massage sessions are performed with the patient in a lying or sitting position. Stroking and squeezing movements are used.

The massage begins from the area above the shoulder. First comes stroking, squeezing and kneading, then shaking manipulations. The movements are directed from the elbow joint to the shoulder joint, affecting all the muscles of the shoulder girdle.

Massage sessions are carried out in a gentle manner. Painful and other uncomfortable movements are excluded. The areas where the tendons attach are thoroughly massaged.

The duration of the session depends on the stage of contracture and the size of the elbow joint. Massage goes well with thermal procedures and therapeutic exercises.

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Contracture—limitation of passive movements in a joint—is one of the most common complications in hand surgery. A particularly acute problem is the treatment of patients with post-traumatic contractures of the metacarpophalangeal joints (MCP). Being spherical in shape, the MCP joints provide movement of the fingers in the most important sector. According to R. Kosh, the loss of this ability leads to a decrease in the functionality of the hand by 40-66.5%.

Etiology and pathogenesis

Primary PFJ contractures occur due to direct (primary) damage to the tissues that form the joint. By their origin, they can be arthrogenic (after intra-articular fractures) and desmogenic (after damage to the ligaments and joint capsule) (Diagram 27.10.1).

Scheme 27.10.1. Pathogenesis of primary post-traumatic contractures of the PFJ.

Primary contractures are distinguished by the fact that, firstly, they form quickly (during the first 4-6 weeks after injury). Secondly, primary contractures are difficult to treat. The more pronounced the damage to the elements of the PFJ, the worse the prognosis for the function.

Secondary contractures develop after trauma to tissues located outside the MCP joint, when tendons, muscles, nerves or skin are damaged, but the joint itself remains intact (Diagram 27.10.2).

Scheme 27.10.2. Pathogenesis of secondary post-traumatic contractures of the metacarpophalangeal joints (explanation in the text).

It is important to note that at this stage the contracture is false, since all elements of the PFJ remain normal, and after eliminating the extra-articular causes, movement in the joint is immediately restored in full.

However, with the long-term existence of false contracture in the PFJ capsule, secondary degenerative-dystrophic changes gradually develop, as a result of which its relaxed parts contract, limiting the range of passive movements in the joint. A relatively persistent restriction of movements in the PFJ occurs, which is no longer completely eliminated after the elimination of the extra-articular causes that caused it. This contracture can be called true and requires special treatment, involving a direct effect on the articular structures.

It is important to note that, unlike primary contractures, secondary contractures develop more slowly, sometimes over many months or even years.

From a practical point of view, the process of development of true contracture can be divided into two periods: unstable and persistent contractures. Unstable contractures are distinguished by the fact that with appropriate efforts (for example, after a session of mechanotherapy combined with thermal exposure), the range of motion in the joint is restored, but then limited again. In these cases, conservative treatment quickly gives a good and stable result.

For persistent contractures, conservative treatment can also increase range of motion to some extent, but not always. In most cases, only surgical treatment provides a chance for a significant improvement in function.

The rate of development of secondary contractures increases significantly when neurodystrophic syndrome develops in the post-traumatic period with trophoneurotic tissue changes in the form of edema, cyanosis, sensory disturbances and pain.

Depending on the sector of movement restriction, contractures can be flexion (when the proximal phalanx is fixed in a flexion position and therefore the extension sector is limited), extension (when the main phalanx is in an extension position and the flexion sector is limited) and combined. The greatest loss of finger function occurs with extension contractures, since in this case the most important (flexion) sector of movement suffers (Fig. 27.10.1).

Rice. 27.10.1. The location of the sector of lost finger movements (shaded) with flexion (a) and extension (b) contractures of the PFJ (explanation in the text).

It is important to note that with long-term extensor contracture, shortening occurs not only in the relaxed dorsal parts of the capsule and collateral ligaments, but also in the skin covering the dorsal surface of the joint. Its elasticity decreases sharply, therefore, when the main phalanges are bent, the skin stretches, its area above the head loses blood supply and can become dead if this position is maintained for a long time. All this is taken into account when choosing a treatment method.

Choosing a contracture treatment method

Scheme 27.10.3. The choice of treatment method for various types and degrees of development of contractures of the metacarpophalangeal joints (explanation in the text).

Joint endoprosthesis replacement has also not become widespread due to the lack of sufficiently reliable prostheses in design, as well as the presence in the vast majority of cases of concomitant damage to the periarticular tissues and capsular apparatus.

Transplantation of blood-supplied small joints from the foot is possible, including the inclusion of tendon tissue in the complex. However, the need to revascularize the graft by performing microvascular anastomoses makes this operation complex and expensive. In addition, practice has shown that these interventions allow only a very limited amount of active movements in the transplanted joint. This makes the indications for this treatment method very relative.

In general, in clinical practice, surgeons are often forced to stabilize fingers by arthrodesing the joints.

Primary desmogenic contractures.

A fundamentally different situation arises in cases where the articular surfaces are preserved, and the limitation of mobility is associated with damage and cicatricial changes in the capsule and collateral ligaments of the MCP.

Depending on the severity of the contracture, the surgeon makes a choice between a conservative program and complex surgical treatment.

Secondary contractures. The special pathogenesis of secondary contractures also determines a differentiated approach to choosing the optimal treatment method for each patient.

In case of false secondary contractures, when movements in the PFJ are limited due to extra-articular causes, elimination of the latter makes it possible to restore movements in full.

In case of true unstable contractures, when there are already unexpressed secondary changes in the joint capsule, in addition to eliminating extra-articular causes of movement limitation, a fairly long course of conservative treatment is necessary. It usually includes the development of active and passive finger movements, heat and other physiotherapeutic procedures.

However, with persistent true contractures this is not enough. In most cases, the desired effect can only be achieved using complex surgical treatment.

Basic principles and treatment regimens for primary desmogenic and secondary contractures of metacarpophalangeal joints

Principle 2. Elimination of extra-articular (initial) causes of secondary contractures. Extra-articular causes of the development of PFJ contractures most often have a tenogenic, dermatogenic or myogenic nature. Often all three reasons are combined, and in general, eliminating extra-articular causes of limited finger movement may require the surgeon to perform a wide variety of operations.

In tenogenic extensor contractures of the PFJ, the extensor tendon is fixed to the surrounding tissues at a more proximal level. As a result, the amount of finger flexion decreases sharply (Fig. 27.10.2).

Rice. 27.10.2. Range of finger movements (a, b) when blocking the extensor tendon at the level of the metacarpus.
F - precise blocking of the extensor tendon; F - possible displacement of point F when pulling on the flexor tendon (CO (explanation in the text).

In a more complex situation, tendolysis can be supplemented by isolating the tendon surface with a polymer film. With the consequences of severe hand injuries with widespread fibrosis of the soft tissues, as well as with damage to the extensor tendons within the synovial canals, a satisfactory surgical result can often be achieved only if the scar-free tendon (or tendon graft) is surrounded by well-supplied tissues. Their grafting (fixed or free) can be the most difficult element of a patient's surgical treatment.

The cause of tenogenic flexion contractures in the PFJ is the fixation of the flexor tendons (or their damaged ends) to the walls of the osteofibrous canals. In this case, the traction of the extensor tendons allows the proximal phalanx to straighten only within certain limits (Fig. 27.10.3).

Rice. 27.10.3. Range of finger movements (a, b) when blocking the flexor tendons at the level of the wrist.
F - point of blocking of the flexor tendons; P - possible movement of the F point when pulling on the extensor tendon (CP) (explanation in the text).

Otherwise, the need for relative rest of the injured hand precludes full rehabilitation and inevitably leads to loss of active function. That is why, in many cases, with a more extensive injury to the flexor tendon apparatus, the most correct option is excision of the flexor tendons and implantation of polymer rods into the osteofibrous canals of the fingers (the first stage of two-stage tendoplasty). In this situation, the choice of postoperative movement development mode is significantly expanded, and the achievement of the desired result becomes more guaranteed.

This approach often becomes the only alternative in case of combined injury of the flexor and extensor tendons.

The presence of extensive skin scars and tissue defects with pronounced fibrosis of the sliding structures involved in the affected area may require the surgeon to perform a wide variety of plastic surgeries: from Z-plasty that limits the function of scars to free transplantation of blood-supplied tissue complexes.

In some cases, limited movement of the fingers is associated with the loss of the ability of the forearm muscles to fully stretch due to a long stay in a non-functioning state. This problem may require both mobilization of the muscle areas involved and lengthening of the tendons.

Principle 3. Impact on the metacarpophalangeal joints to restore passive movements. After the extra-articular causes of limited mobility in the joint have been eliminated, the surgeon is faced with the task of restoring passive movements in the joint by stretching (tearing, cutting) the contracted sections of the joint capsule.

There are three main schemes for solving this problem:
1) redressing + immobilization with plaster splints;
2) capsulotomy + redressing + immobilization with plaster splints;
3) (capsulotomy +) redressing + use of an external fixation device (AVF).

Redress + immobilization with plaster splints can be used in the simplest cases, when the main phalanges are relatively easily brought to extreme positions and can be held in them without significant pressure on the surface of the finger.

The advantages of this approach include its simplicity and non-invasiveness, although significant disadvantages of this treatment regimen limit its use. Thus, a plaster splint provides only limited possibilities for influencing the main phalanx of the finger due to the fact that the pressure of the plaster can cause local circulatory disorders in the tissues and severe pain. Monitoring the condition of the skin under the bandage is impossible, which does not allow timely diagnosis of circulatory disorders in it. It is practically impossible to do gradual gradual bending of the main phalanges of the finger, and the plaster splint itself requires frequent replacement.

In this regard, the use of this scheme of influence on the PFS is indicated in the following cases:
- with relatively easily removable (“soft”) contractures, when the skin over the joint turns white only when the joint is fully flexed;
- with a relatively short period of time after the injury (2-3 months);
- in the absence of other significant damage to the hand.

Capsulotomy + redressing + immobilization with plaster splints. The advisability of including capsulotomy in the treatment regimen is most often determined on the operating table, if redressation does not allow the proximal phalanx of the finger to be moved to a position of full flexion due to tissue resistance. This procedure is advisable only for less “hard” PFJ contractures, when there is no pronounced traction after capsulotomy and redressation the main phalanx to its previous position, provided that the skin over the joint turns white only in the last 30-degree sector of flexion of the main phalanx.

The last requirement is very important, as it determines the 4th principle of contracture treatment: prevention of acute circulatory disorders in the skin and para-articular tissues above the heads of the metacarpal bones that occur during forced flexion of the main phalanges of the finger. As mentioned above, when the main phalanges remain in extension for a long time, not only the PFJ capsule, but also the skin covering it loses its elasticity.

With forced flexion of the main phalanges, the skin over the heads of the metacarpal bones becomes tense and a white spot appears on it. Within this spot, a mechanical blockade of the microvasculature develops, blood from which is squeezed out into the surrounding tissues. The boundaries of this zone are directly proportional to the degree of flexion in the MCP joint
(Fig. 27.10.4).

Rice. 27.10.4. The boundaries of the zone of blockade of the microvasculature of the tissues covering the head of the metacarpal bone (A, A"), which occurs during forced flexion of the main phalanx (b, c) with an extension contracture of the MCP joint (explanation in the text).

The latter requirements can only be met when using the third scheme for influencing the PPS, which involves the use of AVF.

Capsulotomy + redressing + use of AVF. Indications for the use of this treatment regimen are long-term “hard” contractures, when the skin over the PFJ turns white already in the second (first) 30-degree sector of flexion.

Operation technique. After eliminating the extra-articular causes of contracture, the surgeon performs a dorsal-external capsulotomy and redressing the PFJ with the proximal phalanges moving to a position of full flexion. Then an external fixation device (EFD) is applied to the limb: two rings on the forearm and a half-ring at the level of the metacarpus. In this case, the needles are carried out so that the sliding structures of the forearm remain intact.

After fixing the hand in the average physiological position, a special attachment is fixed to the distal ring, which allows for dosed flexion of the main phalanges of the fingers by moving the spokes.

The latter are carried out at the level of the neck of the main phalanges closer to the dorsal cortical layer, bent accordingly and fixed in a special device (Fig. 27.10.5).

Rice. 27.10.5. Appearance of the hand fixed in the AVF for gradual flexion of the main phalanges.

Rice. 27.10.6. Stages (a, b) of flexion of the fingers in the metacarpophalangeal joints using an external fixation device (explanation in the text).

The use of AVF in the treatment of persistent extension contractures of the PFJ provides the surgeon with unique advantages. First of all, when flexing the main phalanges, there is no pressure on the skin from the outside. Secondly, it becomes possible to gradually move the main phalanges into the flexion position, as well as implement a differentiated flexion program for each finger Thirdly, constant monitoring of the condition of the skin over the joint is ensured.Finally, the intensity of the pain syndrome is reduced due to the gradual movement of the fingers and the effect of bending force not on the soft tissue, but on the bone.

These advantages make it possible to obtain good treatment results even with the most severe hand lesions.

Principle 5. Effective treatment of pain. The main cause of pain in the treatment of extension contractures of the PFJ is stretching of the tissues of the joint capsule during flexion of the main phalanx. When an ischemic area of ​​tissue appears above the heads of the metacarpal bones, the pain increases sharply and can become unbearable. Finally, another component of the formation of pain syndrome is the development of postoperative inflammation caused by surgical trauma.

In the treatment of pain, it is important to highlight two main directions. The first is the maximum reduction of sources of pain impulses, which is achieved by preventing the formation of ischemic foci of soft tissue with the help of anti-inflammatory therapy, as well as through a strictly dosed rate of flexion of the main phalanges, adequate to the specific situation.

The second direction of treatment involves the use of analgesic drugs. For large scale operations, a good analgesic effect can be obtained using stellate ganglion blockades.
Principle 6. Restoring the function of the main kinematic chains of the finger. Restoring passive movements in the PFJ, as a rule, is only a fragment of treatment that involves restoring tendon function.

Only restoration of the function of all the most important kinematic chains of the fingers allows the patient to gain full function.

IN AND. Arkhangelsky, V.F. Kirillov

A persistent restriction in joint mobility is called contracture. Physiology is based on the occurrence of inflammatory and pathological changes in soft tissues, tendons, facial and other muscles. The classification is associated with the causes and nature of impaired mobility of the joints of the legs, arms and face.

According to the International Classification of Diseases, 10th revision (ICD-10), the ICD 10 code is assigned to M24.5. There are contractures with other highlighted ICD-10 codes. Most often it affects the most active joints - the knee, elbow, temporomandibular joint (TMJ).

The physiology, occurrence and types of contractures are still being studied. The classification divides them into congenital and acquired joint pathologies. Congenital ones appear due to malformations of muscles and joints (congenital clubfoot, torticollis).

Acquired pathologies, in turn, are divided into several types:

1. Neurogenic – occurs when there are disorders in the central or peripheral nervous system. There is a violation of facial facial functions (TMJ), innervation of other organs.
2. Myogenic is characterized by pathological changes in muscles, leading to atrophic processes. Extensor function is often impaired.
3. Desmogenic contracture is associated with shrinkage of the fascia and ligaments.
4. Tendogenic appears when there is damage and inflammation in the tendons.
5. Arthrogenic – consequences of pathological processes of the joint.
6. Immobilization contracture appears after long-term immobilization of the injured limb after injury or surgery or anesthesia.

Mixed types are often encountered in practice. This is due to the fact that the resulting contracture of a certain type leads to disruption of normal nutrition and blood supply to the affected joint, and over time other pathological processes are added.

The physiology of the process of joint damage differs into primary and secondary. The primary process is limited to the affected joint. Secondary contracture involves a healthy adjacent joint.

The general classification is divided into flexion, extension, adduction and abduction. There is also rotational pathology of the joint, which disrupts rotational movements.

Etiology of the disease

Based on the above types and types, it can be determined that there are many reasons that can cause joint contracture. The term itself is essentially a symptom meaning a restriction in the movement of a joint. Despite this, it is assigned a separate ICD-10 code. Consequently, a pathological process can occur after illness, injury, anesthesia or a congenital anomaly.

The resulting mechanical damage causes post-traumatic contracture. This could be a dislocation, bruise, fracture or even a burn. The formation of a scar reduces the elasticity around the joint tissue and makes it difficult for the joint to move.

Degenerative-inflammatory processes of bones and joints have a similar effect. Damaged nerve fibers and muscle tissue also have a negative impact on the normal functioning of the joint.

A period of prolonged restriction of the functions of certain parts of the body due to the application of a cast, splint or anesthesia causes immobilization contracture. Depending on the recovery period for post-traumatic immobilization, the severity of the process is revealed.

A fairly common disease is contracture of the lower jaw of the face (TMJ) due to the fact that the muscles and joints of the face are constantly in motion. The function of the facial muscles is almost constant.

Contracture of the lower jaw is a consequence of pathological changes in the properties of soft tissues (decreased elasticity). The natural functions of the facial and chewing muscles of the TMJ are disrupted. Unstable contracture occurs with inflammatory diseases of the lower jaw of the face, facial muscles, and after prolonged use of a splint. Persistent contracture occurs after facial trauma, anesthesia during dental procedures, or injury to facial muscles. The period of immobilization affects the development of the disease and the condition of the facial muscles. According to ICD-10, it refers to other diseases of the jaws.

Symptoms of contracture of the lower jaw are based on difficulty eating, dysfunction of facial muscles, and speech. A person feels a feeling like after anesthesia at the dentist.

Treatment of contracture of the lower jaw of the face (TMJ) is performed using surgical methods. The resulting scars are dissected, which leads to the return of normal function of the facial muscles and chewing activity. Of particular importance is the recovery period after surgery, which includes therapeutic exercises and physiotherapy.

Hand lesion

Volkmann's contracture manifests itself as a persistent limitation of hand mobility. The hand begins to resemble the clawed paw of an animal. The left hand is less affected than the right.

Volkmann's ischemic contracture is characterized by rapid development and affects the joints of the shoulder and forearm. According to ICD-10, it has the number M62-23; M62-24. The condition can provoke pain associated with injury to the joints of the hand. There is a disturbance of innervation and motor activity, a feeling like after anesthesia.

The physiology is based on a violation of both extensor and flexion functions. The position of the hand is constantly bent and motionless. The consequence of the pathological process is a disruption of the blood supply due to a fracture or dislocation in the elbow or shoulder joint. Prolonged compression of the bandage can also lead to contracture.

Main symptoms:

• type of clawed paw;
• difficulty in normal hand movement;
• disturbance of innervation (condition as after anesthesia);
• hand deformation.

The period of blood supply disturbance affects the course and consequences of the disease. If this is due to objects or bandages pinching the surface, then freeing the hand as soon as possible is necessary. In post-traumatic conditions, treatment is aimed at stopping further pathological processes and partially preserving normal muscle function. Surgical treatment methods using anesthesia are also allowed.

Volkmann's ischemic contracture requires an individual approach to treatment. Conservative methods such as physical therapy, physiotherapy, and gentle massage are quite effective. The recovery period, which includes sanatorium-resort treatment with the use of compresses, hydrogen sulfide baths, and mud treatments, has a positive effect.

Palmar fibromatosis

In practice, Dupuytren's contracture is quite common - a disease that leads to deformation and disruption of the normal function of hand movement. It has a separate ICD-10 code M72.0. The ring and little fingers are often affected. Dupuytren's disease is not fully understood and is a chronic disease.

Due to degenerative-inflammatory processes, the tendons of the palm become wrinkly and the extensor ability of the fingers is impaired.

Dupuytren's contracture is characterized by three degrees of severity, characterized by impaired sensitivity and severity of motor function of the joints. As the process progresses, there is an increase in pain and stiffness of the joints and muscles.

Due to the fact that predisposing factors are not precisely established, Dupuytren's contracture often occurs with concomitant diseases. One example is scleroderma (spotted idiopathic atrophoderma).

Idiopathic atrophoderma tends to affect young girls under 20 years of age and children. One of the stages of the disease is damage to the small joints of the legs and arms. It is characterized by a symptom such as Dupuytren's contracture. In children, there is a combination of diseases such as Raynaud's syndrome, idiopathic atrophoderma and Dupuytren's contracture.

The treatment algorithm for Dupuytren's disease is determined by an orthopedist. In mild stages, conservative therapy is prescribed. To restore normal joint function, surgical treatment using anesthesia is used.

Contracture of fingers

Weinstein's contracture according to ICD-10 is included in group M24. Associated with injury to the top of the finger. The cause is a post-traumatic condition, after a direct blow to the finger.

With timely treatment it does not pose a threat. But if you delay going to a medical facility, it threatens the process of deformation and disruption of motor activity of the injured finger and its muscles.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2015

Joint contracture (M24.5)

Traumatology and orthopedics

general information

Short description

Recommended
Expert advice
RSE at the RVC "Republican Center"
healthcare development"
Ministry of Health
and social development
Republic of Kazakhstan
dated November 20, 2015
Protocol No. 17

Classification

Clinical classification:
Contractures are divided into three main groups:
· passive (structural);
· active (neurogenic);
· congenital.

Classification of passive contractures is usually made taking into account the tissue that plays a predominant role in their origin. According to this principle, passive contractures are divided into:
· arthrogenic;
· myogenic;
· dermatogenic;
· desmogenic;
· combined.

How individual forms of contractures are distinguished:
· ischemic;
· immobilization.

Depending on the limitation of one or another type of movement in the joint, we can distinguish:
· flexion;
· extensor;
· adductors;
· diverting;
Rotational (supination, pronation).

According to function, contractures are distinguished in a functionally advantageous and functionally disadvantageous position of the limb.

Diagnostics

List of basic and additional diagnostic measures:
Basic diagnostic examinations performed on an outpatient basis:
· X-ray examination of the joint in 2 projections;
· UAC;
· OAM;
· Fluorography.

Additional diagnostic examinations performed on an outpatient basis: not carried out

The minimum list of examinations that must be carried out when referred for planned hospitalization: in accordance with the internal regulations of the hospital, taking into account the current order of the authorized body in the field of healthcare.

Basic (mandatory) diagnostic examinations carried out at the hospital level:
· UAC;
· OAM.

Additional diagnostic examinations carried out at the hospital level:
· computed tomography of the joint, only in cases of multiplanar, complex post-traumatic deformities of the joint.

Diagnostic measures carried out at the stage of emergency care: is not carried out.

Diagnostic criteria:
Complaints:
The leading clinical sign of joint contracture:
· restriction of movement in the joint, ultimately leading to lameness.
· pain is expressed to varying degrees, mainly during exercise.
Anamnesis: there must be an indication of the fact of forced restriction of movements in the joint as a result of injury, surgery and

Physical examination:
With joint contracture, the position of the joint depends on the type of contracture: with extension contracture, the joint is in a position of full extension, while flexion of the joint is limited; with flexion contracture, incomplete extension of the joint is observed, and extension of the joint is limited.
Upon examination, muscle wasting is often observed, developing as a result of immobilization of the joint.
On palpation, pain is observed in the projection of the joint space, pain in the projection of the entheses of muscles and tendons.

Laboratory research: as a rule, are within normal limits.

Instrumental studies:
X-ray of the joint: X-ray examination of joints - mainly to exclude anatomical obstacles in the joint (chondromic bodies, consequences of intra-articular fractures) as reasons for limiting movements, and to confirm the preservation of joint congruence. As a rule, bone pathology is not detected on radiographs of the knee joint. With a long history, attention is drawn to the phenomenon of osteoporosis (due to a long absence of load on the bones).
CT joint: in case of post-traumatic multiplanar deformity in order to determine the state of congruence of the articular surfaces and the sequence of elimination of multiplanar deformity.

Indications for consultation with specialists:
· consultation with a neurologist: if the contracture is suspected to be neurogenic;
· consultation with a neurosurgeon: if the contracture is suspected to be neurogenic;
· consultation with a rheumatologist: if the disease is systemic

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment goals:
· increase/restoration of range of motion in the joint;
Increased strength of the periarticular muscles of the limb.

Treatment tactics.
Treatment of joint contracture is conservative using means intended for rehabilitation (simulators, arthromot for developing joints, hinged braces, etc.). The treatment complex includes physiotherapeutic procedures, massage of the muscles of the limbs, exercise therapy (physical therapy). If rehabilitation therapy is ineffective, surgical treatment in a hospital setting is indicated.

Non-drug treatment: no

Drug treatment:

Table 1. Medicines used forjoint contracture

Drugs (active ingredients) used in treatment

Hospitalization

Indications for hospitalization:
Indications for emergency hospitalization: No.

Indications for planned hospitalization:
· restriction of movements in the joint;
· ineffectiveness of therapy at the prehospital level.

Prevention

Preventive actions:
· early start of rehabilitation measures after injury;
· implementation of stable and functional systems of internal and external fixation, which makes it possible to refuse immobilization in the postoperative period.

Information

Sources and literature

1. Minutes of meetings of the Expert Council of the RCHR of the Ministry of Health of the Republic of Kazakhstan, 2015
   1. List of used literature: 1) “Traumatology and Orthopedics”, ed. N.V. Kornilova, G.E. Gryaznukhina, S-P. - “Hippocrates”, 2006. – T.3. – pp. 351-356. 2) Zubarev A.R., Nemenova N.A. Ultrasound diagnostics of the musculoskeletal system in adults and children. – M., 2006. 3) Friemert B., Oberländer Y., Schwarz W. Diagnosis of chondral lesions of the knee joint can MRI replace arthroscopy? // Knee Surg. Sports traumatol. Arthrosc. – 2003. - No. 8. - R. 56-75. 4) Kim Y., Ihn J., Park S. An arthroscopic analysis of lateral meniscal variants and a comparison with MRI findings // Knee Surg. Sports traumatol. Arthrosc. – 2006. - No. 14. - R. 20-26. 5) Ververidis A., Verettas D., Kazakos K. Meniscal bucket handle tears: a retrospective study of arthroscopy and the relation to MRI // Knee Surg. Sports traumatol. Arthrosc. – 2006. - No. 14. - R. 343-349.

Information

List of protocol developers with qualification information:

1) Baimagambetov Shalginbay Abyzhanovich - Doctor of Medical Sciences, RSE at the Scientific Research Institute of Traumatology and Orthopedics, Deputy Director for Clinical Work.
2) Raimagambetov Erik Kanatovich - Candidate of Medical Sciences, RSE at the Scientific Research Institute of Traumatology and Orthopedics, head of the department of orthopedics.
3) Korganbekova Gulzhanat Sansyzbaevna - Candidate of Medical Sciences, RSE at the Scientific Research Institute of Traumatology and Orthopedics, senior researcher.
4) Nabiev Ergali Nugumanovich - Candidate of Medical Sciences, Astana Medical University JSC, Associate Professor of the Department of Traumatology and Orthopedics.
5) Abisheva Saule Tleubaevna - Doctor of Medical Sciences, JSC “Astana Medical University”, head of the department of general medical practice in internship, rheumatologist.
6) Ikhambaeva Ainur Nygymanovna - JSC National Center for Neurosurgery, clinical pharmacologist.

TOconflict of interest: absent .

Reviewers: Tuleubaev Berik Erkebulanovich - Doctor of Medical Sciences, RSE at Karaganda State Medical University, Professor of the Department of General Surgery, Traumatology and Orthopedics.

Conditions for reviewing the protocol: review of the protocol 3 years after its publication and from the date of its entry into force or if new methods with a level of evidence are available.

Attached files

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