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Contractures in cerebral palsy (CP) are usually in flexion at the hips and knees, and in plantar flexion at the ankles. When correctly indicated, surgical release is appropriate. Occasionally, extension contractures of the hip and knee develop, and dorsiflexion contractures of the ankle may ensue. In CP, the management of each of these deformities may require different sets of operative procedures.
The present investigation presents preliminary results of the operative method, where resection of the palmaris longus tendon is combined with regional fasciectomy in the treatment of Dupuytren's contracture. This procedure was developed to prevent recurrence which has been the biggest problem in the treatment regardless the surgical methods employed. The investigation included 70 consecutive patients (80 hands) treated for Dupuytren's contracture; the mean follow-up time was 47 months (62 patients). 96% of the recurrences occurred during the first two years. 42 hands were treated with regional fasciectomy and in these 18 recurrences (43%) were observed. Recurrences were found only in 23% (6/26) of the patients in whom the palmaris longus tendon was eliminated. Following resection of the palmaris longus tendon recurrences manifested themselves mainly in the fingers in the nodular cutaneously fixed form. From the promising results and absence of side effects of resection of the palmaris longus tendon the procedure can be recommended combined with surgical treatment of Dupuytren's contracture.
The authors have previously described four types of intrinsic contracture in the first intermetacarpal web space. They now report a fifth group in which all the muscles in the space are involved. In this condition the thumb is flexed and adducted, and there is also radial deviation of the index finger with hyperextension of the proximal interphalangeal joint. These deformities are produced by contractures of the adductor pollicis, the flexor pollicis brevis and the first dorsal interosseous muscles. Three patients with this type of contracture are described. Operation produced an excellent result in each case, but it is essential to achieve complete correction. in a prospective study
A child with an abduction contracture of the left shoulder secondary to diffuse fibrosis of the deltoid muscle was successfully treated by recession of the inserting muscle fibers proximally. Previously reported cases of deltoid muscle contracture were secondary to fibrous cords or nodules within the muscle. This patient's contracture may be related to either a brachial plexus birth injury or may be similar to the idiopathic fibrosis seen in the quadriceps muscle.
Dupuytren's contracture was observed in 21,6 percent of 524 patients with epilepsy. This combination is characterised by a steadily progression by relatively benign course with a consequenly low frequency of operation and rate of recurrence. Possible genetic association has to be taken into consideration, because idiopathic epilepsy is the type most frequently found with Dupuytren's contracture. In this material no correlation has been found between Dupuytren's contracture and liver disease. Diabetes mellitus and other aetiologic factor which have been suggested. The duration of epilepsy and the medication given have not been analysed.
Another case of flexion contracture in a 60 year-old patient with hypopituitarism, chronic alcoholism and starvation is reported. The contracture, as in the other cases, involved the lower limbs, but in this particular patient it extended to the abdominal and extensor neck muscles and neurological signs were associated: cerebellar atrophy and peripheral neuropathy of the lower limbs probably due to alcoholism. As in the other reported cases, severe hyponatremia was observed (105 mmol/l) the physiopathology of which is discussed: starvation and glucocorticoid deficiency alone or associated with aldosterone deficiency. The special feature of the anterior pituitary deficiency is that it is partly functional, at least with regards to the gonadotrophic secretion, perhaps related to the denutrition. The authors emphasize the necessity of searching for adrenal insufficiency in cases of abdomino-crural contracture because of the beneficial effects that result from hydrocortisone replacement therapy.
Sixty-eight children with contracture of the deltoid muscle (82 shoulders) were treated operatively. These cases showed a minimum angle of 25 degrees of abduction in the resting position. The postoperative course with a minimum follow-up of 5 years was analyzed in 40 cases (49 shoulders). Abduction contracture of the shoulder joint completely disappeared after surgery in 23 shoulders (47%), and winging of the scapula disappeared in 39 shoulders (78%). The angle of horizontal adduction was restored in 14 shoulders (41%) postoperatively. Contracture recurred in only three shoulders (6%).
In experiments on 34 dogs, the authors studied myocardial rigidity, ATP levels and Ca2+-accumulating function of the membranes of the sarcoplasmic reticulum (SR) in the external (subepicardial) and internal (subendocardial) layers of the myocardium at 1 and 2 h of total ischemia at 37 degrees C and also 30 min after cardiac reperfusion by heterotopic transplantation. It was revealed that contracture changes in ischemia first affect the internal and then the external layer of the myocardium which corresponds to the initial and completed phases of ischemic contracture (IC) of the heart, correspondingly. IC of the heart is irreversible and in cases of total contracture of all layers of the myocardium (the completed phase) the heart loses contractile function. Changes in the contractility in the external and internal layers of the myocardium show a stronger inverse correlation with the capacity of SR membranes to absorb Ca2+ rather than with ATP levels in the tissues which indicates an essential role of the Ca2+ accumulating function of SR in the pathogenesis of IC.
We studied 34 unselected insulin-dependent juvenile diabetics by seeking contractures at the proximal interphalangeal (PIP) joints and scleroderma-like changes of the hands or elsewhere. We found 14 contractures of only the 5th PIP in 7 and of the PIP of other fingers as well in the others. Nine of these patients also had scleroderma-like skin changes. Only one of 34 age and sex matched healthy controls had a minimal contracture of the 5th PIP joint but had no skin changes. All patients found to have these abnormalities had had diabetes for 6 or more years and the difference in the disease duration between those with hand changes and those without was significant (p less than 0.01). There was no correlation of these changes with renal or ocular vascular changes in this small group of patients.
Hypothermia during calcium-free perfusion of hearts protects them from injury caused by subsequent calcium repletion at 37 C (calcium paradox). Injury to calcium-free hearts is also associated with contracture caused by anoxia, 2,4-dinitrophenol (DNP), or caffeine. This study was done for the purpose of determining whether hypothermia during calcium-free perfusions protects hearts from contracture-associated injury. Langendorff-perfused rat hearts were studied in four experimental groups: I) Anoxia: Thirty minutes of anoxic perfusion at 37 C was followed by thirty minutes of anoxic calcium-free perfusion at 37-18 C. II) Calcium paradox: Five minutes of calcium-free perfusion at 37-18 C was followed by calcium repletion at 37 C. III, IVa) Caffeine or DNP: Five minutes of calcium-free perfusion at 37-18 C was followed by addition of 10 mM caffeine or 1 mM DNP in calcium-free medium at 37 C or, IVb) 1 mM DNP in calcium-free medium at 22 C. Injury was assessed by measurement of serial releases of creatine kinase (CK) in effluents and by cellular morphology. The results show that progressive hypothermia to 22 C during calcium-free perfusion periods produced a progressive reduction of CK release and morphologic evidence of injury due to anoxia, caffeine, or DNP, which closely paralleled protection of hearts from the calcium paradox. Protection from injury in all experimental groups was associated with preservation of sarcolemmal membrane integrity and prevention of cell separations at intercalated disk junctions. It is proposed that weakening of intercalated disks occurs during calcium-free perfusions and may be a cause of mechanical fragility of the sarcolemma. Hypothermia may protect hearts from contracture-associated injury by preserving the integrity of intercalated disk junctions during periods of extracellular calcium depletion.
Abduction contracture of the hip (frog-leg deformity) is caused by contracture of the gluteus maximus muscle. A simple operation consisting of complete detachment of involved fibrous portions of the gluteus maximus from the greater trochanter to the ischial tuberosity is sufficient to release the contracture and enable the patient to squat without abducting the hips. Possible sciatic nerve injury is avoided by a periosteal elevator inserted between the muscle and the greater trochanter before division of the muscle. All patients showed marked improvement, and complications were virtually nonexistent. The etiology is probably associated with injections, but keloidal collagen disease may be important. A small incision is desirable because skin keloid formation invariably occurred in 200 cases followed for one to eight years.
Vascular spiders, palmar erythema and Dupuytren's contracture had been studied in four groups of patients with alcoholic cirrhosis, hepatic alcoholic involvement without cirrhosis, alcoholism without hepatic involvement, extrahepatic diseases without alcoholism. these cutaneous lesions had been observed more frequently in alcoholic cirrhosis, with an incidence of 72%, 38%, 24% respectively. Vascular spiders, palmar erythema and Dupuytren's contracture appeared related to the hepatic involvement from alcoholism rather than to the alcoholism by oneself. In the alcoholic cirrhosis the Dupuytren's contracture affected patients younger than those of the others groups and had been influenced from the association of diabetes mellitus, but not from the occupational activity.
Clinical and electromyographic examinations of the mimic muscles were carried out in 24 patients with facial neuritis. A method of kinesthetic palpation of the mimic muscles has been developed, which has enabled one to reveal pathological infiltrations (myogeloses) in 13 patients with secondary contractures. In 6 patients the emergence and development of the myogeloses before the appearance of distinct symptoms of the facial muscle contractures were followed. In the course of these examinations clinico-electromyographic comparisons were made that gave the authors an opportunity to specify the role of the myogeloses in the formation of principal symptoms of initial manifestations of the post-neuritic contractures.
Hard and soft tissue injury to the elbow may be complicated by progressive secondary joint contracture. Motion-directed therapy often improves or eliminates elbow contracture if it is recognized early in treatment. Progressive soft tissue contracture, with or without the concomitant development of heterotopic ossification, is best treated by surgical release. This article discusses the operative technique and the results of treatment.
Four cases of Dupuytren's contracture treated at Mpilo Central Hospital over the last 13 years are presented. Three of these patients were men aged 45, 59 and 74 years. Only one woman aged 55 years was treated during this period. All the four patients were indigenous Black Zimbabweans. There was some history of trauma to the affected upper limb in all three of the male patients and all of them agreed to being moderate smokers but only two gave a history of drinking alcohol. One of the men had been treated for pulmonary tuberculosis. The female patient has been on treatment for epilepsy for more than 10 years. There was no family history of Dupuytren's contracture in any of these patients. Although Dupuytren's contracture is generally considered to be a European disease this report and a few isolated case reports confirm that this condition occurs in indigenous Black Africans.
We report on three cases of a nonpainful flexion contracture of the proximal interphalangeal joint of the little finger. The word camptodactyly means bent finger, and the condition can occur either as an inherited or as a sporadic disorder. Simple camptodactyly should be borne in mind in the differential diagnosis of Dupuytren's contractures, other nontraumatic contractures of the fingers, and sclerodermia.
The successful use of electroconvulsive therapy (ECT) for a patient in catatonic stupor with joint contracture is reported. A 53-year-old woman, who had been diagnosed with schizophrenia, developed a catatonic stupor unresponsive to neuroleptics. Physical emaciation gradually developed under food refusal and poor nutrition. Joint contracture of her extremities resulted from the long period of being bedridden in the same posture. In this case, modified ECT was dramatically effective for catatonic stupor without any complication despite the joint contracture.
For the first time the model of secondary contractures of facial nerves was used to study by long-term sterotaxic implanted electrodes the state of the cortex, amygdal complex, reticular formation of the middle brain, reticular nuclei of the pons and nuclei of the facial nerves. The experiments were accomplished on 31 rabbits. The experiments confirmed a close functional connnection of the VII pair of cranial nerves with the limbico-reticular complex. In secondary contracture there were factors facilitating the influence of pons reticular structures on the deficient system the facial nerve--facial muscles. The achieved data are used to explain the origination of the main symptom of secondary contractures--a stable increase of the muscular tone.