Accurate measurement of muscle belly length in the motion analysis laboratory: potential for the assessment of contracture

Two-dimensional ultrasound imaging was combined with motion analysis technology to measure distances between remote anatomical landmarks. The length of the belly of the medial gastrocnemius muscle in five normal adults (nine limbs) was estimated using this technique. Our results in vivo were similar to the reported data for the lengths of muscles in cadavers, and were consistent with the expected relationship between muscle belly length and ankle joint angle. Experiments in vitro demonstrated that the accuracy of the device was better than 2 mm over 20 cm. Measurements on the same subject on different occasions showed that the results were repeatable in vivo. Rendering of the reconstructed volume of a foam phantom gave results comparable to photographic images. This validated technique could be used to measure muscle lengths in children with spastic cerebral palsy and indicate which muscles had fixed shortening, and to what extent.

Neuroleptic malignant syndrome in Kufs' disease

A patient with adult neuronal ceroid lipofuscinosis (ANCL; Kufs' disease) is described in whom neuroleptic malignant syndrome occurred, initially presenting as catatonic syndrome. Comprehensive neuroimaging studies were conducted including FDG-PET, IBZM-SPECT, and beta-CIT-SPECT, electrophysiological examinations and an ex vivo contracture test exposing muscle biopsy specimens to neuroleptics. Collectively the results argued for an involvement of the muscle in neuroleptic malignant syndrome at least in ANCL.

Arthroscopic treatment of post-traumatic elbow contracture

The purpose of this study was to evaluate range of motion and patient-reported outcome after complete arthroscopic release of post-traumatic elbow contracture. Fourteen consecutive patients who underwent elbow arthroscopy and capsular release were reviewed retrospectively at a minimum follow-up of 1 year. Pain and range of motion were measured. Patient outcome was assessed with the American Shoulder and Elbow Surgeons Elbow Assessment Form. Mean self-reported satisfaction on a visual analog scale was 8.4 out of 10. Only 6 patients continued to have pain, with a mean maximum pain score of 4.6 out of 10. Flexion increased from a mean of 117.5 degrees to 133 degrees, and extension improved from a mean of 35.4 degrees to 9.3 degrees. In those patients with a preoperative arc of motion less than 100 degrees (10 patients), the mean arc of motion improved from 69 degrees to 119 degrees. All patients had improved function after the procedure, with a mean self-reported functional ability score of 28.3 out of 30. There were no neurovascular complications. The improvement in range of motion and functional outcome compares favorably with open-release procedures. Combined with the potential benefits of improved joint visualization and low surgical morbidity, arthroscopic release of post-traumatic elbow contracture appears to be a reasonable alternative to open techniques.

[Hauptmann-Thannhauser muscular dystrophy and differential diagnosis of myopathies associated with contractures]

Hauptmann-Thannhauser muscular dystrophy is characterized by the clinical triad of early-onset contractures of elbow, Achilles tendons, and cervical spine, slowly progressive humeroperoneal muscle wasting and weakness, and life-threatening cardiac involvement with conduction blocks manifesting in the third decade. Hauptmann-Thannhauser muscular dystrophy is due to mutations in the LMNA gene affecting the nuclear envelope proteins lamin A and C. We present a 16-year-old German boy with typical muscular involvement and contractures and typical course of Hauptmann-Thannhauser muscular dystrophy due to the novel missense mutation R401C. The data of this family suggest a lower penetrance of muscular and especially cardiac symptoms than expected. Autosomal-dominant Hauptmann-Thannhauser muscular dystrophy and X-chromosomal Emery-Dreifuss muscular dystrophy are not clearly distinguishable by phenotypic criteria. Other muscular diseases associated with contractures and congenital or childhood onset are reviewed.

[Dystrophic epidermolysis bullosa: surgical treatment of advanced hand deformities]

Dystrophic epidermolysis bullosa (Hallopeau-Siemens, recessive dystrophic epidermolysis bullosa) is a rare inherited disorder of the skin and mucosa, characterized by blistering in response to the slightest mechanical trauma. Healing is associated with scarring and the formation of contractures and milia. Following repetitive trauma (friction), this process leads to severe hand deformities with digits contracted in flexion, the thumb contracted in adduction and pseudo-syndactyly. In advanced cases (as described here), the hands show a mitten-like deformity and digits are encased in an epidermal "cocoon". This results in complete loss of function with major consequences for both the patient's (children's) daily life and their psychosocial development. We demonstrate the advantages of the (simplified) surgical procedure including "de-cocooning"/degloving, syndactyly-release, release of the thumb and the digital joint contractures and Kirschner-wire stabilization. Spontaneous epithelialisation of skin defects proved to be unproblematic and advantageous compared to skin transplantations, flaps, keratinocyte transplantations and other more ambitious procedures. Reviewing the published long-term results of other methods, we favour the procedure described because it simplifies and accelerates the overall treatment. From 1998 to 2001, we treated three children with recessive dystrophic epidermolysis bullosa and five hands were operated. A total number of 23 interventions was necessary (21 x using face masks, 2 x oral intubation). Pseudo-syndactyly (digits II - V, partially or totally) occurred in four hands after six to ten months. Flexion contractures of the digits occurred in two hands after eight to ten months. Limitating adduction contracture of the thumb occurred in two hands after eight to twelve months. Digital function (pinch and grasp) was actually preserved in two hands for 15 to 30 months. An active surgical approach is justified by the gain in functional improvement of the hand - even if only temporary - and, consecutively, by the positive effect on the child's development.

The reliability of a new device designed to assess gastrocnemius contracture

Gastrocnemius contracture may be a significant cause of many foot disorders. Gastrocnemius tension can be estimated clinically by measuring maximum ankle dorsiflexion during full knee extension. Such measurements, when made with currently available goniometric devices, are subject to high levels of intra- and inter-observer variability. We have designed a device to more consistently measure ankle dorsiflexion, using three dimensional tracking sensors on the leg and foot. The applied dorsiflexion torque is kept constant by a computer, and the computer also monitors hindfoot position to maintain a neutrally aligned foot during testing. Repeated measurements on 26 feet were taken to determine the consistency of the device. The correlation coefficient for the measurements was 0.96, indicating very low intra-observer variability. The standard deviation of the repeated measures was 2 degrees. Based on the 95% confidence interval, the device can be considered accurate to within 4 degrees. Given this accuracy, this instrument could be used to assess gastrocnemius tension, its role in foot pathology, and the effectiveness of surgical lengthening. Compared to other currently available measuring devices, this instrument is the most reliable in estimating ankle dorsiflexion, since it is capable of controlling hindfoot position and applied dorsiflexion torque, and it can be easily constructed by other laboratories.

Beals-Hecht syndrome

Beals-Hecht syndrome, also known as congenital contractural arachnodactyly, is caused by a defect in fibrillin as in Marfan syndrome. This syndrome is characterized by a multitude of clinical findings including arachnodactyly, narrow body habitus, scoliosis, congenital contractures, and external ear deformities. Restrictive lung disease may be associated with the severe scoliosis and thoracic cage abnormalities in this syndrome. We describe a child with Beals-Hecht syndrome and review the literature.

Multiple trigger fingers associated with geleophysic dysplasia

We report an infant with geleophysic dysplasia (MIM 231050) who developed multiple trigger fingers. The condition was progressive and distinct from trigger thumb, which is generally seen in infants without any underlying metabolic disease.

Reliability of heel-height measurement for documenting knee extension deficits

BACKGROUND

Heel-height difference has been used to detect subtle knee flexion contractures, but the effects of thigh circumference differences and patient positioning during testing have not been evaluated.

HYPOTHESIS

Differences in thigh circumference measurements and whether the patient's patellae are on or off the examination table during heel-height difference measurement will not affect the accuracy of detecting knee flexion contracture.

STUDY DESIGN

Prospective cohort study.

METHODS

Bilateral knee range of motion, prone heel-height difference with the patellae on and off the table, and thigh circumference at 5 and 15 cm proximal to the proximal pole of the patella were measured by one investigator on 50 consecutive patients who had undergone unilateral anterior cruciate ligament reconstruction.

RESULTS

A high degree of correlation was demonstrated between the heel-height difference and the standard range of motion measurement. Differences in thigh girth and patellar position did not statistically affect the accuracy of the heel-height difference as an indicator of knee flexion contracture.

CONCLUSION

Heel-height difference is a valid method of documenting knee flexion contractures. Compared with traditional goniometer assessment, this test is a more meaningful and easier way for detecting subtle knee flexion contractures of less than 10 degrees.

[Isolated finger flexion caused by continuous muscle fiber activity]

We report two patients who presented with progressive involuntary flexion of fingers. Both of them were women (Case 1 and 2 were 23 year old and 86 year old, respectively), and developed involuntary finger flexions, particularly of the ring and little fingers, following a localized pain of their hands and forearms. The other neurological findings were not present. There was no abnormal finding in their serum, and anti-voltage-gated potassium channel antibodies were negative. Nerve conduction velocity studies revealed no obvious peripheral neuropathy or conduction block. EMG studies revealed continuous muscle fiber activities only in the flexor digitorum superficialis muscles in both patients. Additionally, in Case 1, neuromyotonic discharges at frequencies of 100-200 Hz were recorded only from the flexor digitorum superficialis muscle. The present findings are likely to be similar to those of a novel form of focal neuromytonia reported recently as 'isolated finger flexion'.

Isolated gastrocnemius tightness

BACKGROUND

Contracture of the gastrocnemius-soleus complex has well-documented deleterious effects on lower-limb function in spastic or neurologically impaired individuals. There is scarce literature, however, on the existence of isolated gastrocnemius contracture or its impact in otherwise normal patients. We hypothesized that an inability to dorsiflex the ankle due to equinus contracture leads to increased pain in the forefoot and/or midfoot and therefore a population with such pain will have less maximum ankle dorsiflexion than controls. We further postulated that the difference would be present whether the knee was extended or flexed.

METHODS

This investigation was a prospective comparison of maximal ankle dorsiflexion, as a proxy for gastrocnemius tension, in response to a load applied to the undersurface of the foot in two healthy age, weight, and sex-matched groups. The patient group comprised thirty-four consecutive patients with a diagnosis of metatarsalgia or related midfoot and/or forefoot symptoms. The control group consisted of thirty-four individuals without foot or ankle symptoms. The participants were clinically examined for gastrocnemius and soleus contracture and were subsequently assessed for tightness with use of a specially designed electrogoniometer. Measurements were made both with the knee extended (the gastrocnemius under tension) and with the knee flexed (the gastrocnemius relaxed).

RESULTS

With the knee fully extended, the average maximal ankle dorsiflexion was 4.5 degrees in the patient group and 13.1 degrees in the control group (p < 0.001). With the knee flexed 90 degrees, the average was 17.9 degrees in the patient group and 22.3 degrees in the control population (p = 0.09). When gastrocnemius contracture was defined as dorsiflexion of < or = 5 degrees during knee extension, it was identified in 65% of the patients compared with 24% of the control population. However, when gastrocnemius contracture was defined as dorsiflexion of < or = 10 degrees, it was present in 88% and 44%, respectively. When gastrocnemius-soleus contracture was defined as dorsiflexion of < or = 10 degrees with the knee in 90 degrees of flexion, it was identified in 29% of the patient group and 15% of the control group.

CONCLUSIONS

On the average, patients with forefoot and/or midfoot symptoms had less maximum ankle dorsiflexion with the knee extended than did a control population without foot or ankle symptoms. When the knee was flexed 90 degrees to relax the gastrocnemius, this difference was no longer present.

CLINICAL RELEVANCE

These findings support the existence of isolated gastrocnemius contracture in the development of forefoot and/or midfoot pathology in otherwise healthy people. These data may have implications for preventative and therapeutic care of patients with chronic foot problems.

Heterogeneity in fetal akinesia deformation sequence (FADS): autopsy confirmation in three 20-21-week fetuses

Fetal akinesia deformation sequence (FADS) is a rare condition characterized by intrauterine growth retardation (IUGR), congenital limb contractures, pulmonary hypoplasia, hydramnios and craniofacial abnormalities. The present report comprises an autopsy study of three fetuses to illustrate the variable clinical manifestations and neuropathological findings. Fetus 1 had arthrogryposis and no movement on fetal ultrasound examination. Aborted at 21 weeks, the fetus showed micrognathia, bilateral joint contracture with pterygia at the elbow and axilla. Growth retardation and pulmonary hypoplasia were not major features. Neuropathologic examination revealed anterior horn cell loss and lateral corticospinal tract degeneration in spinal cord, with marked muscular atrophy. Fetus 2, 20 weeks' gestation, had fetal akinesia, nuchal thickening, left pleural effusion, and Dandy-Walker malformation on ultrasound examination. Autopsy showed low-set ears, ocular hypertelorism, cleft palate, flexion contractures with pterygia over axilla, elbow and groin, pulmonary hypoplasia, Dandy-Walker malformation, unremarkable spinal cord and skeletal muscle. Fetus 3, 21 weeks' gestation, was aborted for fetal akinesia, neck and limb webbing and severe arthrogryposis. At autopsy, similar facial abnormalities, contracture and pterygia in neck and multiple major joints were found. Borderline pulmonary hypoplasia and severe lumbar scoliosis were also present. The brain, spinal cord and muscle were unremarkable. In these three fetuses, the prenatal ultrasound and autopsy findings were characteristic of FADS. Neurogenic spinal muscular atrophy was the basis of fetal akinesia in Case 1. Dandy-Walker malformation was present in Case 2, but the pathogenetic mechanism of fetal akinesia was not clear as spinal cord and muscle histology appeared normal. The etiology of akinesia was undetermined in Case 3; no extrinsic or intrinsic cause was identified.

Winchester syndrome

Winchester syndrome was first described in 1969 and since then nine patients have been reported in the literature. The syndrome is characterized by short stature, coarse face, corneal opacities, generalized osteolysis and progressive painful arthropathy with joint stiffness and contractures of distal phalanges in combination with skin changes. The etiology is unknown. Parental consanguinity supports autosomal inheritance. The diagnosis is based on clinical and radiological manifestations. We describe a case in a 7-year-old Pakistani boy.

[Arthroscopic therapy in limited mobility of the elbow joint]

Limitation of elbow mobility constitutes a grave problem for therapy. Arthroscopy offers a therapeutic option, but in cases of loss of motion poses a considerable challenge to the operative technique. Placement of the portals already carries an increased risk of neurovascular lesions due to the altered anatomy and reduced distension capacity of the joint. Thus, particular significance attaches to the standardized arthroscopic procedure for localization and placement of the cannulas, intra-articular assessment, differentiated evaluation of the dorsal joint regions, and operative tactics for transsection of cicatrization, removal of loose bodies, and excision of osteophytes. If extra-articular factors are involved in the genesis of the limited motion, arthroscopic treatment often does not achieve the desired result. It is therefore considered propitious to differentiate the causes of the loss of motion during clinical examination with imaging diagnostics, in particular to determine those caused by extra-articular elements. If, however, individually localized intra-articular adhesive bands or loose bodies are responsible, the prognosis for arthroscopic management is clearly more favorable. Patients with minor loss of motion (> 15 degrees) profit more from the arthroscopic operation than those with a extension or flexion deficit of more than 30 degrees.

[Radiological diagnosis in contracted elbow joint. Value of CT and MRI]

A contracture of the elbow joint is a challenge for diagnostic radiology. Radiographs remain the method of choice for primary diagnosis, however, diagnostic confidence can be limited if periarticular ossifications or contracture do not permit evaluation of the whole joint. In these cases, CT or MRI can be used for specific diagnostic problems. Additional multiplanar or three-dimensional reformations can be used by the orthopedic surgeon for planning the surgical procedure. MRI has a great advantage in allowing visualization of muscles, capsula-ligamentous complex and articular cartilage. The main disadvantages are duration of examination time and artifacts. CT is superior in terms of spatial resolution and visualization of bony structures. MRI and CT examinations of the elbow will increase with the number of minimal invasive surgical procedures. Protocols must therefore be optimized with attention to positioning, sequence selection and image processing. This article reviews the current standards of high resolution imaging with CT and MRI, including arthrographic techniques. The pros and cons of both methods are discussed in the setting of a contracture of the elbow joint.

Restrictive dermopathy: case report, subject review with Kaplan-Meier analysis, and differential diagnosis of the lethal congenital contractural syndromes

We report on a 34-week-old infant with restrictive dermopathy (RD), a rare lethal genodermatosis, characterized by an abnormal skin growth and differentiation with thin, tightly adherent skin that causes a dysmorphic face, generalized flexion joint contractures, and respiratory insufficiency. Kaplan-Meier analysis of 32 previously well-described infants affected with RD showed a median survival of 132 hours. Lethal congenital contractural syndromes, including Pena-Shokeir phenotype, cerebro-oculo facio-skeletal syndrome, and lethal multiple pterygium syndrome, should be considered first in the differential diagnosis. Other lethal contractural syndromes are discussed.

Do associated reactions in the upper limb after stroke contribute to contracture formation?

OBJECTIVE

To establish (1) whether associated reactions could contribute to contracture formation and (2) whether the presence of spasticity was essential for their expression, after stroke.

SUBJECTS

Subjects were 24 hemiparetics within 13 months of a stroke, unselected for contracture or spasticity.

MAIN OUTCOME MEASURES

Associated reactions were identified by the presence of muscle activity in the affected biceps brachii and quantified as the amount of affected elbow flexor torque produced during a moderate contraction of either the contralateral biceps brachii or the contralateral quadriceps muscles. Contracture was measured as loss of elbow joint range of motion and spasticity as the presence of abnormal reflex activity.

RESULTS

Associated reactions were present in at least one testing condition in seven subjects. During contractions of the contralateral biceps brachii, the median amount of elbow flexor torque produced was 0.39 (interquartile range, IQR 2.5) Nm while during contractions of the contralateral quadriceps muscle it was 0.19 (IQR 1.6) Nm. Associated reactions were not associated with contracture (p = 0.39) which was present in over half of the subjects. The incidence of associated reactions was about the same as that of spasticity, but the two were not related (p = 0.61).

CONCLUSIONS

Even though associated reactions were present in 29% of the subjects during moderate contraction of the contralateral muscles, they were not large, nor were they associated with contracture or spasticity, suggesting that this phenomenon is not usually a major problem for everyday function after stroke.

Factors influencing ambulation in myelomeningocele: a cross-sectional study

A consecutive series of 53 children with myelomeningocele (mean age 7.6, range 3.2 to 11.4 years) was assessed in order to see if the children with motor paresis of the lower limbs achieved the expected level of ambulation, and if not, to identify possible causative factors. Methods used were clinical examination of orthopaedic and neurological status, information from medical reports, and documentation of orthoses use. Functional skills were documented and energy expenditure was examined. Thirty-one of 53 children had reached the expected ambulation considered possible according to their motor paresis, whereas 22 of the 53 performed worse than expected. Balance disturbances, occurrence of spasticity in knee and hip joints, and number of shunt revisions made differed significantly between the groups that achieved and did not achieve expected ambulation. Functional skills of mobility differed significantly between two muscle-function levels in children who had walking ability. Energy expenditure was higher in the non-achieving group than in the group who achieved expected ambulation in each of the muscle-function levels. Results show that children with similar muscle paresis exhibit different ambulatory function. This indicates the importance of a close analysis of other factors which may cause ambulation to deteriorate in order to predict future ambulation in children with myelomeningocele.

Deltoid contracture: MR imaging features

AIM

To describe the magnetic resonance imaging (MRI) features of deltoid contracture and compare these findings with the operative and histological findings and to determine the utility of MRI for diagnosis and treatment planning.

PATIENTS AND METHODS

Retrospective review of clinical and imaging in six patients with deltoid contracture, as well as the operative and histological findings of four operated patients.

RESULTS

Magnetic resonance imaging clearly demonstrated the intramuscular fibrous bands of the deltoid as a homogeneously hypointense area with distinctive margins on T1-, T2- and T2*-weighted images. Operative findings were exactly consistent with the findings observed by MRI.

CONCLUSION

Deltoid contracture is best evaluated with MRI which facilitates visualization of the intramuscular fibrous bands being pathognomonic of this entity and may provide information useful in treatment planning.

Clinical and molecular genetic spectrum of autosomal dominant Emery-Dreifuss muscular dystrophy due to mutations of the lamin A/C gene

Emery-Dreifuss muscular dystrophy (EDMD) is characterized by early contractures of the elbows and Achilles tendons, slowly progressive muscle wasting and weakness, and life-threatening cardiomyopathy with conduction blocks. We recently identified LMNA encoding two nuclear envelope proteins, lamins A and C, to be implicated in the autosomal dominant form of EDMD. Here, we report on the variability of the phenotype and spectrum of LMNA mutations in 53 autosomal dominant EDMD patients (36 members of 6 families and 17 sporadic cases). Twelve of the 53 patients showed cardiac involvement exclusively, although the remaining 41 all showed muscle weakness and contractures. We were able to identify a common phenotype among the patients with skeletal muscle involvement, consisting of humeroperoneal wasting and weakness, scapular winging, rigidity of the spine, and elbow and Achilles tendon contractures. The disease course was generally slow, but we observed either a milder phenotype characterized by late onset and a mild degree of weakness and contractures or a more severe phenotype with early presentation and a rapidly progressive course in a few cases. Mutation analysis identified 18 mutations in LMNA (i.e., 1 nonsense mutation, 2 deletions of a codon, and 15 missense mutations). All the mutations were distributed between exons 1 and 9 in the region of LMNA that is common to lamins A and C. LMNA mutations arose de novo in 76% of the cases; 2 of these de novo mutations were typical hot spots, and 2 others were identified in 2 unrelated cases. There was no clear correlation between the phenotype and type or localization of the mutations within the gene. Moreover, a marked inter- and intra-familial variability in the clinical expression of LMNA mutations exists, ranging from patients expressing the full clinical picture of EDMD to those characterized only by cardiac involvement, which points toward a significant role of possible modifier genes in the course of this disease. In conclusion, the high proportion of de novo mutations together with the large spectrum of both LMNA mutations and the expression of the disease should now prompt screening for LMNA in familial and sporadic cases of both EDMD and dilated cardiomyopathy associated with conduction system disease.

Isolated finger flexion: a novel form of focal neuromyotonia

Two almost identical elderly women are described who presented with gradually progressive painless involuntary flexion of the ring and middle fingers over 12 months, leading eventually to contractures. The flexion deformity persisted during sleep and was the sole neurological abnormality. Both patients had advanced chronic obstructive pulmonary disease and were on long term salbutamol and oxygen. Neurophysiological studies indicated that this was due to neuromyotonia mainly involving flexor digitorum superficialis muscles without evidence of underlying peripheral neuropathy, proximal conduction block, or generalised neuromyotonia. Voltage gated potassium channel antibodies were negative. The clinical and neurophysiological picture remained static over a 2 year follow up period. It is suggested that this is a novel form of acquired focal neuromyotonia and speculate both on its cause and distribution.

Contribution of thixotropy, spasticity, and contracture to ankle stiffness after stroke

OBJECTIVES

Increased resistance to stretch of muscles after stroke may be the result of centrally mediated neural factors such as spasticity or local, peripheral factors such as muscle contracture or thixotropy. The aim was to investigate evidence for an abnormal thixotropic response and compare this with two other factors-contracture and spasticity-which could potentially contribute to muscle stiffness after stroke.

METHODS

Thirty patients with stroke whose calf muscles were assessed clinically as stiff and 10 neurologically normal subjects were recruited. To measure thixotropy, their calf muscles were stretched through two cycles after two prestretch conditions: one in which the muscles were maintained in a shortened position and one in which they were maintained in a lengthened position. Spasticity was defined as the presence of tonic stretch reflexes in relaxed muscles. Contracture was defined as being present when maximum passive ankle dorsiflexion fell at least 2 SD below the mean value of the control subjects.

RESULTS

Both controls and patients with stroke exhibited a thixotropic response but this was no greater in the patients than the controls. About one third of the patients displayed muscle contracture and most exhibited spasticity. Contracture made a significant contribution (p=0.006) to the clinical measure of calf muscle stiffness while spasticity made a significant contribution (p=0.004) to the laboratory measure of calf muscle stiffness.

CONCLUSIONS

Measuring thixotropy at the level of joint movement was sufficiently sensitive to determine the thixotropic response in both neurologically normal subjects and patients impaired after stroke. The thixotropic response was not higher than normal after stroke, suggesting that whereas thixotropy may produce enough immediate resistance to impede movement in those who are very weak, it is not a substantial contributor to long term muscle stiffness. Contracture did significantly contribute to muscle stiffness, supporting the importance of prevention of contracture after stroke. Spasticity contributed to muscle stiffness only when the limb was moved quickly.