Fixed Flexion Deformity

There are few presentation about fixed flexion deformity. It will help anyone understanding the topic.

1. Dr. Md. Galib Raihan Phase-B Resident, Dept. of Physical Medicine & Rehabilitation Dhaka Medical College Fixed Flexion Deformity

2. Flexion and Extension Flexion and extension are movements that take place within the sagittal plane and involve anterior or posterior movements of the body or limbs. F lexion means bending the joint and extension means straightening it .

3. Deformity Deformity is derived from Latin word deformitatem meaning ‘misshapen’. ‘Deformity ’ determined by factors the extent to which deviate from the normal symptoms to which give rise the presence or absence of instability the degree to which they interfere with function

4. Fixed deformity Fixed deformity - The term ambiguous. T he arc of movement is limited in one direction but movement in the opposite direction is full or even increased. It means that one particular movement cannot be completed. Variety: Fixed flexion deformity Fixed extension deformity Fixed abduction deformity Fixed adduction deformity

5. Fixed Flexion D eformity The joint is able to flex fully but not extend fully . A t the limit of its extension it is still ‘fixed’ in a certain amount of flexion. Flexion deformity and flexion contracture - synonymously used.

6. Classification of Contractures Immobility Lack of ROM Mechanical position Type Primary cause Secondary cause Immobility Fibrosis Lack of stretch Faulty joint position

7. Contd … Type Primary cause Secondary cause Immobility

8. Common joint involved in fixed flexion contracture Lower extremity Hip Knee Upper extremity Elbow Proximal interphalangeal joint Wrist

9. Fixed Flexion Deformity of Knee Cause: Osteoarthritis Cerebral Palsy Hip joint injuries Rheumatoid arthritis After knee operations(Total arthroplasty ) Ankle pathologies Polio Tendon transfers Stiffness- post fractures of knee joint Scar tissue

10. Fixed Flexion Deformity of Hip Cause: Secondary to previous trauma Inflammatory condition Neurological condition eg . Cerebral palsy

11. Fixed Flexion Deformity of Elbow Fixed Flexion Deformity of Wrist Fixed Flexion Deformity of PIP

12. Clinical Presentation Insidious onset and asymptomatic. Unnoticed for extended periods Interferes with functional activity Often painful Alteration of gait pattern

13. E ssentials of Assessment E tiology of the contracture, its natural course Pain Difficulties in mobility and transfers Activities of daily living (ADL) Hygiene Details regarding caregiver burden History

14. Physical Examination Musculoskeletal system: Look Joint shape, size, symmetry and position Edema, effusion or deformity of the joints Skin thickening , scar Feel Swelling and tenderness Move Range of motion Active Passive Precise tool – Universal goniometer Gait Neurological examination

15. Special Test Thomas Test : To assess fixed flexion deformity of hip

16. Normal Range Of Motion Hip joint Flexion 120 ͦ Extension 5° -20° Knee joint Flexion 135 ° Extension ͦ Elbow joint Flexion 145° Extension ͦ Wrist joint Dorsiflexion 75° Palmar flexion 75° Proximal IP joints Flexion 100° MCP joints Flexion 90°

17. Performing ADL Eating Grooming Dressing upper body Dressing lower body Bathing Toileting Ambulation T ransfer Functional Assessment

18. Diagnostic Studies Laboratory studies - no blood markers or laboratory studies Imaging – Radiologic studies ( eg . x-rays, bone scans )-(bony deformities , heterotopic ossification, fractures, dislocations, ankylosis ) Diagnostic ultrasound - soft tissue structures, fibrotic changes Magnetic resonance imaging - soft tissue pathology

19. Limitations of Physical Function Upper extremity flexion contracture interferes with activities of daily living such as reaching, dressing, grooming , eating, and the performance of fine motor tasks. Disability for instrumental activities of daily living including driving. Interference with mobility . Hip and knee flexion contractures alter gait pattern. Increased energy expenditure . Reduced participation in hobbies, social activities, and athletic activities . Multiple upper and lower limb joint contractures exacerbate disability.

20. Management Careful determination of predisposing factors K nowledge of involving joint component or tissue Particular attention to muscles crossing two joints Emphasizing joint stability Accurate measurement of ROM Analysis

21. Prevention is the heart of flexion contracture management In healthy individual Flexibility exercise three times a week for 10 to 15 min Stretch of two jointed muscles Yoga Pilates In individual at risk for contracture Range of motion exercises ( active or passive) with terminal stretch Proper positioning in bed, wheel chair Splinting, casting Early mobilization, ambulation Resisting exercise to opposing muscles Continuous passive motion (CPM) Prevention

22. Pain management- Analgesic C ontrol of spasticity Muscle relaxant Motor point or nerve blocks using phenol Muscle injection of Botulinum toxin A or B Treatment of underlying disease Pharmacological management

23. Rehabilitation Passive range of motion exercises with terminal stretch Low-load, long-duration stretching Dynamic splinting or serial casting immediately after passive stretching Gait training Therapeutic heating modalities Hot packs Therapeutic ultrasound Hydrotherapy Paraffin baths Therapeutic Exercise

24. Passive towel stretch Low-load, long-duration stretching

25. Orthosis Knee- Hinged ROM knee brace Elbow- ROM Elbow brace PIP joint- Dynamic PIP extension splint

26. Surgical Management Tenotomy Tendon lengthening Joint capsule release Joint reconstruction. Skin grafts or flaps Total joint replacement

27. Cutting edge concepts and practice In animal model, radiofrequency treatments successful. High torque and long-duration static stretching- most effective. Low level laser therapy ( LLLT) Local vibration therapy Possible treatment modalities but Therapeutic ultrasound Not yet elucidated in literature Intra articular injection of substance P inhibitor- post-traumatic joint contractures

28. P ractice “Pearls ” Prevention is the key. Appropriate positioning in bed is a simple yet effective preventative measure . One should avoid placing pillows under the knees while supine to prevent knee flexion contractures. Prone lying can force the hip into extension to prevent hip flexion contractures. Avoiding immobilization of elbow for more than 3 weeks can prevent elbow flexion contracture.