View source for Disabled Village Children:Chapter 8: Contractures: Limbs That No Longer Straighten

{{bctrail|segments=2|chaptitle=Chapter 8: Contractures: Limbs That No Longer Straighten}}
{{DISPLAYTITLE:Chapter 8: Contractures: Limbs That No Longer Straighten}}
{{SideSupplement|bookabbreviation=dvc|pagealt=is from pages 77 to 78 of|chapterpdf=http://hesperian.org/wp-content/uploads/pdf/en_dvc_2023/en_dvc_2023_08.pdf|bookurl=Disabled Village Children|booktitle=Disabled Village Children}}
{{chaptertoc|In this chapter:|
 <ul class{{=}}"noprint">
<li>[[Disabled Village Children:Chapter 8: Contractures: Limbs That No Longer Straighten|Chapter 8: Contractures: Limbs That No Longer Straighten]]</li>
    <li>[[Disabled Village Children:Chapter 8: Contractures: Limbs That No Longer Straighten#What are Contractures%3F|What are Contractures?]]</li>
    <li>[[Disabled Village Children:Examining the Child for Contractures|Examining the Child for Contractures]]</li>
    <li>[[Disabled Village Children:Prevention and Early Management of Contractures|Prevention and Early Management of Contractures]]</li>
    <li>[[Disabled Village Children:Different Methods to Correct Contractures|Different Methods to Correct Contractures]]</li>
    <li>[[Disabled Village Children:Hip Contractures|Hip Contractures]]</li>
 </ul>
}}
<div  id="What are Contractures?"></div>
=What are Contractures?=

When an arm or leg is in a bent position for a long time, some of the muscles become shorter, so that the limb cannot fully straighten. Or shortened muscles may hold a joint straight, so it cannot bend. We say the joint has a ‘contracture’. Contractures can develop in any joint of the body. For example:
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<table width=100%>
<tr valign=top>
<td style{{=}}"text-indent: -15px; padding-left: 25px;width:20%;">'''1.''' Miguel spent the first years of his life crawling because one leg was paralyzed.</td>
<td style{{=}}"text-indent: -15px; padding-left: 25px;width:33%;">'''2.''' In time, he could not straighten his hip or knee, or bend his foot up. He had developed a:</td>
<td></td></tr>

<tr>

<td style="line-height:110%;padding-left:25px;">''Because he could not stand, he kept his hip and knee bent and his foot in a tiptoe position, like this.''</td>
<td rowspan=2 >
<div class{{=}}speechbub style="position:relative;padding-bottom:25px;">[[Image:DVC_Ch8_Page_77-2.png|140px|left|alt=arrows point at Miguel's contractures]]
<div style="position:absolute; left:150px; top:50px;width:55px;text-align:left;font-style:normal;">hip contracture</div>
<div style="position:absolute; left:150px; top:120px;width:55px;text-align:left;font-style:normal;">knee contracture</div>
<div style="position:absolute; left:150px; top:165px;width:55px;text-align:left;font-style:normal;">“tiptoe” contracture of the ankle</div></div></td>
<td rowspan=2 ><div  class{{=}}speechbub style="position:relative;padding-bottom:25px;" >[[Image:DVC_Ch8_Page_77-3.png|170px|center|alt=the heel cord tightens when pushing on the toes]]
<div style="position:absolute; left:130px; top:-35px;width:125px;text-align:left;font-style:normal;">You can feel the tight ''cord'' here,</div>
<div style="position:absolute; left:55px; top:0px;width:95px;;text-align:left;font-style:normal;">when you push here</div></div>
</td></tr>

<tr valign=top>
<td style="padding-bottom:25px;">[[Image:DVC_Ch8_Page_77-1.png|200px|left|alt=Miguel crawls with a paralyzed leg]]</td></tr>
</table>
<table>
<tr>
<td style{{=}}"text-indent: -15px; padding-left: 25px;padding-right:25px;width:35%;">'''3.''' Because of the contractures, Miguel could not stand or walk, even with a brace</td>
<td colspan=2>
<div class{{=}}speechbub style="position:relative;padding-bottom:25px;clear:both;">[[Image:DVC_Ch8_Page_77-4.png|170px|center|alt=arrows point at Miguel's shortened muscles]]
<div style="position:absolute; left:39px; top:20px;width:125px;text-align:right; font-style:normal;">''shortened muscles causing hip contracture</div>
<div style="position:absolute; left:0px; top:90px;width:125px;text-align:right; font-style:normal;">''Shortened calf muscles cause a tight heel cord that keeps the foot in a ‘tiptoe’ position.</div>
<div style="position:absolute; left:245px; top:120px;width:170px;text-align:left; font-style:normal;">''Shortened muscles that bend the knee cause tight cords behind the knee. This keeps it bent.</div></div>
</td></tr>
</table>

Contractures develop whenever a limb or joint is not moved regularly through its full range of motion. This is likely when:

<table width=80%>
<tr valign=top>
<td style=width:50%;">
*a very weak or sick child is in bed for a long time</td>
<td><div style="position:relative;height:110px;">[[Image:DVC_Ch8_Page_77-5.png|200px|alt=arrow points to a child's contracture]]
<div style="position:absolute; top:70px; left:40px;">ankle contracture</div></div></td></tr>

<tr>
<td>
*a child with an amputation keeps joints bent</td>
<td><div style="position:relative;line-height:110%;">[[Image:DVC_Ch8_Page_77-6.png|150px|alt=arrows points to a child's contractures]]
<div style="position:absolute; top:85px; left:155px;width:120px;">hip contracture</div>
<div style="position:absolute; top:150px; left:155px;width:120px;">knee contracture</div></div>
</td></tr>

<tr>
<td>
*a paralyzed limb is kept bent or hanging</td>
<td><div class{{=}}speechbub style="position:relative;text-align:right;margin-left:50px;">[[Image:DVC_Ch8_Page_77-7.png|150px|right|alt=arrows points to a child's contractures]]
<div style="position:absolute; top:94px; left:-25px;width:90px;text-align:right;font-style:normal;">hip contracture</div>
<div style="position:absolute; top:143px; left:-25px;width:90px;text-align:right;font-style:normal;">knee contracture</div>
<div style="position:absolute; top:193px; left:-25px;width:90px;text-align:right;font-style:normal;">ankle contracture</div></div></td></tr>

<tr>
<td>
*a child has joint pain that prevents her from straightening her joints.</td>
<td rowspan=2><div class{{=}}speechbub style="position:relative;">[[Image:DVC_Ch8_Page_77-8.png|100px|alt=a child with contractures]]
<div style="position:absolute; left:177px; top:30px;width:120px;text-align:left; font-style:normal;">contractures in:<br>— neck<br>— shoulders<br>— back<br>— elbow<br>— wrists<br>— fingers<br>— hips<br>— knees<br>— ankles<br>— feet<br>— toes</div></div></td></tr>

<tr>
<td>
*a child is [[Disabled_Village_Children:Chapter_28:_Burns_and_Burn_Deformities|badly burned and the burned skin scars, or sticks together, around joints]].</td></tr>


</table>
=== Why is it important to know about contractures? ===
[[Image:DVC_Ch8_Page_78-1.png|150px|right]]
*Most contractures can be prevented through exercise and other measures. Yet in many communities, at least half of the children with physical disabilities already have contractures.
*Contractures make rehabilitation more difficult. Often they must be corrected before a child can walk or care for himself.
*Correction of contractures is slow, costly, and often very uncomfortable or painful.
*It is best not to let contractures develop, and if they do begin to develop, to correct them as soon as possible. Early contractures often can be easily corrected at home, with exercises and positioning. Advanced, old contractures are much more difficult to correct, and may require gradual stretching with plaster casts, or surgery.

<br>
For all these reasons...
{{openbox|The family of every child with disabilities should understand how contractures develop, how to prevent them, and how to recognize and correct them when they first begin.}}
<div id="muscle"></div>
=== Muscle imbalance &mdash; a major cause of contractures ===

When the muscles that bend or pull a limb in one direction are much stronger than those that pull it in the opposite direction, we say there is a muscle imbalance.  When paralysis, painful joints, or [[Disabled_Village_Children:Types_of_Cerebral_Palsy#1._MUSCLE_STIFFNESS_OR_.27SPASTICITY.27|spasticity]] cause a muscle imbalance, contractures are much more likely to develop.

<table width=100% frame=box cellpadding=10>
<tr>
<td style="width:50%;">'''WITHOUT''' MUSCLE IMBALANCE — CONTRACTURES LESS LIKELY</td>
<td valign=bottom style="line-height:110%;padding-right:50px;">muscles equally weak on both sides</td>
<td></td></tr>

<tr valign=top>

<td rowspan=2>A leg that is completely paralyzed is not very likely to develop contractures. The knee may even straighten more than is typical.</td>
<td>[[Image:DVC_Ch8_Page_78-2.png|220px|center|alt=a straight, weak leg without contractures]]</td>
<td></td></tr>

<tr>
<td valign=top style="padding-left:60px;line-height:110%;">no contracture</td>
<td></td></tr>
</table>
<div class{{=}}page-break></div>
<table width=100% frame=box cellpadding=10>
<tr valign=top>
<td colspan=3>'''WITH''' MUSCLE IMBALANCE — CONTRACTURES MORE LIKELY</td></tr>

<tr>
<td style="width:40%;padding-left:30px; padding-right:0px;line-height:110%;">''If the muscles that straighten the knee and lift the foot are very weak,</td>
<td colspan=2 style="padding-left:30px;padding-top:20px;" >Muscle imbalance causing contractures can result from spasms, or spasticity, that increase the pull of certain muscles (cerebral palsy and spinal cord injury).</td></tr>

<tr  valign=top>
<td><div class{{=}}speechbub style="position:relative; top:-30px;">[[Image:DVC_Ch8_Page_78-3.png|150px|right|alt=a leg with a muscle imbalance]]
<div style="position:absolute; width:125px; left:55px;top:105px;text-align:left;">''and the muscles that bend the knee and lower the foot are strong,''</div>
<div style="position:absolute; width:200px; left:55px; top:190px;text-align:left;">''contractures are very likely to develop.''</div></div></td>
<td><div  class{{=}}speechbub style="position:relative; line-height:110%;" aria-hidden{{=}}"true">[[Image:DVC_Ch8_Page_78-4.png|150px|left|alt=child with "knock-knee" contracture]]
<div style="position:absolute; width:160px; left:100px; top:160px;text-align:left;">“knock-knee” contracture&nbsp;of hips</div></div></td>
<td style="width:25%;">For example, the bent elbow and crossed legs of this child with spastic cerebral palsy can lead to contractures so that his legs cannot be spread apart or his elbow straightened.</td></tr>
</table>
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<br>
To check for muscle imbalance, test and compare the strength of the muscles that bend a joint, and of the muscles that straighten it (see [[Disabled_Village_Children:Testing_Range_of_Motion_of_Joints_and_Strength_of_Muscles#Muscle testing|Muscle testing]].)



{{Previous and next sections|Prevention_of_Polio|Examining the Child for Contractures}}
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[[en:Disabled_Village_Children:Chapter_8:_Contractures:_Limbs_That_No_Longer_Straighten]]
[[es:Disabled_Village_Children:Capítulo_8:_Contracturas:_Miembros_que_ya_no_se_enderezan]]
[[ru:Disabled_Village_Children:ГЛАВА_8:_Контрактуры:_Неразгибающиеся_конечности]]