2. ďAcquired extension contracture of infancy or childhood.
ďLess common than flexion contracture.
ďF > M
ďInitially thought to be congenital, or secondary to progressive
idiopathic fibrosis of the vastus intermedius muscle
ďNearly all children, H/O serious illness in early infancy.
3. ETIOLOGY
ďRepeated IM inj in thigh during infancy.
ďAntibiotic, analgesics, antiepileptic.
ďAbscess
ďMuscle trauma
ďUnited fracture.
4. PATHOPHYSIOLOGY
ďVolume of drug inj in to young babies compresses the capillaries
& muscle fibres ď M. ischaemia ď fibrotic changes.
ďLocal M. necrosis at the site of inj.
ďIrritative nature of the drug.
ďCombined with severe underlying disease, poor nutrition &
prolonged recumbency.
5. ďMuscle fibrosis ď adherent to bone & deep fascia ď
dimple.
ďMuscle fails to develop with the bone ď flexion becomes
more & more restricted.
ďDelay between the inj & contracture always present.
ď# femur â Q adherent to callus â limit flexion.
6. CLINICAL FEATURES
ďPainless, progressive limitation of both active & passive knee
flexion with an extension contracture.
ďAffected knee is normal at birth.
ďParents note the childâs difficulty in squatting, kneeling,
sitting cross-legged, running, or climbing stairs.
ďWalks with limp due to straight knee or unstable quadriceps
gait.
7. ďDimple , which deepens with forced flexion of knee.
ďROM; Painless in the available arc.
ďAtrophy of thigh, absence of creases.
ďSubcutaneous hardness.
ďGenu- recurvatum in severe cases
ďHigh riding patella.
ďHabitual dislocation P in chronic case.
10. X ray
ďContracture â progressive displacement & hypoplasia of
patella, fragmentation of inf. Pole of patella.
ďSkeletal changes in distal femur articular surface points
anteriorly.
ďFemoral condyles gets flattened.
ďTibial dislocated anteriorly.
ďGross degenerative changes.
11.
12.
13. Differential diagnosis
ďC. genu recurvatum, Arthogryposis
ď cong. Short Q, present at birth @ with other
deformities.
ďCong. & habitual dislocation patella ď Q mech is relatively
short, ROM not affected.
ďPolio, myelomeningocele & NM disorders â unbalanced Q
action â extension deformities.
14. TREATMENT
ďEarly recognisation & prevention through passive ex. in
children receiving intramuscular inj.
ďPhysio / passive stretching ex [doubtful use]
ďAlways surgical release is necessary.
ďIndicated to prevent late changes in the condyles & patella.
15. Structures in contracture [Nicoll]
1) fibrosis of the vastus intermedius muscle tying down the
rectus femoris to the femur in the suprapatellar pouch and
proximally,
2) adhesions between the patella and the femoral condyles,
3) fibrosis and shortening of the lateral expansions of the vasti
and their adherence to the femoral condyles, and
4) actual shortening of the rectus femoris muscle
16. Sengupta â proximal release
ďDuring early stages
ďWhen no significant jt changes occurred
ďPrinciple âfibrosed muscles is in the upper lateral part of thigh
[inj]
ďUpper attachment of V.L is detached from its origin after
transversely cutting the fibrosed IT band.
ďFibrosed V. intermedius is erased from the femur.
17. ď Rectus femoris if fibrosed also to be released from its origin.
ď Advantages:
1. Eliminate extensor lag
2. Hemarthrosis
3. Performed at the site of the pathology
4. Postoperative mobilisation is quicker
5. High scar produces a more acceptable cosmetic result.
18. Thompson - Quadricepsplasty
ď When there is more extensive changes
ď success depends on
1) whether the rectus femoris muscle has escaped injury,
2) how well this muscle can be isolated from the scarred parts of
the quadriceps mechanism,
3) how well the muscle can be developed by active use.
19. ďRectus muscle released from vasti on both sides
ďFibrotic V. intermedius partially excised.
ďIntra-articular adhesions removed.
ďVasti are sutured with rectus keeping knee flexed.
ďRectus if contracted is elongated by V-Y plasty.
20. Postop
ďknee was immobilised in plaster at 50* for 2-3 days.
ďThe knee then placed in a CPM.
ďThis was followed by intensive physiotherapy.
ďStretching ex are continued throughout the growing period.
21. ďSupracondylar femoral osteotomy â when genu recurvatum
with degenerative changes developed in order to gain
flexion.
ďArthrodesis â if arthritis symptoms are severe.