Contracture

CONTRACTURE (from Latin contaminatio - defilement, infection), a rarely used term to denote the moment of infection, i.e., the introduction of an infective agent into the body (see Infection). In psychiatry, the term C. denotes incorrect word combination, when the beginning or end of one word is borrowed from the following word, e.g., "pletik zayazyayetsya" instead of "yazyk zapletayetsya" (tongue gets tangled). CONTRACTURES (from Latin contraho - I draw together), contractures represent forced positions of joints, either with sharp limitation of their mobility due to pathological disturbance of the elastic equilibrium of soft tissues having mechanical relation to the given joint. Causes of C. are numerous. Depending on which tissue was primarily affected, dermatogenous, desmogenous, myogenous, neurogenic, and artrogenic contractures are distinguished. Dermatogenous C. arise from burns, mainly in children and workers of metallurgical and chemical plants, as well as from traumatic defects of the skin. Desmogenous C. occur after inflammatory lesions of subcutaneous tissue. Such is, for example, torticollis developing after phlegmonous angina, contracture of fingers after phlegmon of the hand and forearm. A special form of desmogenous contracture is the so-called Dupuytren's contracture (see). Myogenous C. arise on the basis of acute and chronic inflammatory processes in muscles (purulent, fibrous, gummatous myositis), chronic intoxications (e.g., certain forms of rheumatic myositis), disturbances of local nutrition, an example of which is ischemic C. of Volkmann, on the basis of traumatic injuries to the muscle and finally due to habitual functional setting of the organ. An example of functional muscular C. is scoliosis with unequal length of legs, clubfoot on the side of the shortened leg or adduction of the knee and hip joints developing on the side of the longer leg. Neurogenic C. occur as a result of paralysis of various origins (see below), but may also be of hysterical and reflex origin. Examples of the latter are: adduction of the foot and toes due to pressure of calluses on richly innervated mucous and joint capsules, Bonnet's contracture of the limbs in lesions of the joint apparatus, contracture of the hand and fingers due to traumatic neuritis of the dorsal interosseous nerve (Turner). Artrogenic C. arise due to injuries of the ligamentous-capsular apparatus (bruises, sprains) and injuries to the articular ends of bones (dislocations, fractures), due to acute infection (e.g., acute articular rheumatism, gonorrhea), chronic infection (e.g., chronic rheumatism, tuberculous and syphilitic arthritis), as well as due to certain non-infectious degenerative processes (e.g., deforming arthritis, gout).-Most often C. are of acquired origin. However, congenital C. are also not rare [clubfoot (see), torticollis]. A special form of congenital C. are contractures of the hip, knee, and elbow joints, observed in combination with the so-called swimming or webbing membrane. Pathological anatomy. In any C., convex and concave sides are distinguished. On the convex side are located stretched, flaccid tissues, while on the concave side, conversely, wrinkled, increased-elastic tissues. At the beginning of C. formation, path.-anat. changes are concentrated b.ch. only in one definite layer of tissues; later, degenerative changes affect all other coverings of this area of the body. On the convex side, phenomena of atrophy, protein and fatty degeneration predominate, on the concave side - scar wrinkling. The speed with which path. changes in elastic properties occur is not the same in different tissues. Changes occur especially quickly in muscles and fasciae, then in the capsulo-ligamentous apparatus, more slowly - in the skin and even more slowly - in vessels and nerves. Depending on path. changes in elastic properties of the contracted tissues, the following 4 types of C. are distinguished. 1. C. with great and perfect elasticity: the joint is with difficulty stretched and upon cessation of external force returns completely to its path. position. 2. C. with great but imperfect elasticity: the joint is with difficulty stretched, but upon cessation of stretching retains the corrected position to a greater or lesser degree. 3. C. with small but perfect elasticity: the joint is easily stretched, but just as easily returns to its path. position. 4. C. with small and imperfect elasticity: the joint is easily stretched and comparatively well retains the corrected position. Correct accounting of the type of elasticity plays a large role in prognosis and choice of treatment method. The course of the disease depends on the primary cause that caused the contracture, on the affected joint and age of the patient. Symptoms consist of the contracture position of the joint, which in artrogenic C. is often thickened, to significant limitation and even complete impossibility of active and passive movements, to atrophic condition of surrounding tissues, especially sharply expressed in paralytic and tuberculous C., to shortening and lag in growth of the diseased limb. Old-standing C. are often combined with subluxation.-Diagnosis of the C. itself is easy, but diagnosis of the cause that caused the C. is often very difficult. And yet the choice of method of treatment depends largely on exact knowledge of the etiology of the condition. - Prognosis is in general the better, the younger the subject, the more pliable the tissues on the concave side of the C., the better the active muscular strength of the antagonists on the convex side of the curvature is preserved, and the earlier treatment of the C. is begun. The degree of mental development and endurance of the patient also plays a significant role, since treatment requires from his side patience and persistence, based on conscious attitude toward therapeutic measures. Prevention. To prevent traumatic, paralytic C., as well as C. on the basis of professional overexertion of individual muscle groups, massage, therapeutic gymnastics, electrization and thermal procedures, especially water procedures, are recommended in the presence of corresponding conditions. In the prevention of deformities of the arches of the foot and hammer toes, the greatest role belongs to rationally constructed footwear and orthopedic insoles. In inflammatory conditions of the musculature and joint apparatus, as well as in acute gouty attacks, the best method of combating threatening C. is timely immobilization of the limb in the position of physiological rest. In hopeless paralysis of individual muscles of peripheral or central origin, prevention of C. is possible by operation of neurolysis, nerve suture or anastomosis, as well as by transplantation of healthy muscles or their tendons. In extensive scars of the skin and musculature, in threat of desmogenous C. and contractures on the basis of traumatic and inflammatory lesions of joints, traction and reducing manipulations are indicated. In defects of the skin and tendons, timely transplantation of skin and plastic restoration of continuity of the tendon are necessary. To prevent ischemic C., observance of basic precautions when using Esmarch's tourniquet and avoidance of tight bandaging when applying circular plaster casts is required. To prevent development of artrogenic C. due to hemarthrosis occurring, for example, in bruises, dislocations and intra-articular fractures, puncture of the joint with aspiration of the extravasate is necessary. In some forms of dry adhesive arthritis, and according to Rosen - also in tuberculous arthritis, to prevent C., intra-articular injections of vaseline (Büdinger, Rovsing), 2-3% solution of pepsin (Raug) or intra-articular injections of several grams of sterile oil of Amygdal. dulcium should be tried. To prevent functional C. due to difference in length of the lower extremities, orthopedic footwear can be used primarily. In parallel, it does not hurt to try known conservative measures aimed at stimulating the growth of the lagging bone (smearing of the epiphyses with iodine, congestive hyperemia, scarification of the periosteum, etc.). In more severe cases - operative lengthening of the short leg, or shortening of the long leg, or finally both together. To prevent artrogenic contractures specifically of the knee joint, timely removal of damaged menisci, hypertrophied and degenerated plicae alares (disease of Hoffa) and restoration of integrity of torn cruciate ligaments is important. Treatment of C. consists of physical therapy procedures, methods of bloodless reduction and bloody operative interventions both on soft parts and on the skeleton. Physical therapy procedures very successfully restore nutrition and tone of weakened muscles. Physio-mechano-therapy is an obligatory addition to almost all other methods of treatment of C., first of all - paralytic, and gives the better effect, the earlier it is resorted to from the moment of occurrence of the contracture. The more the muscles are weakened, the more delicate the massage and therapeutic gymnastics techniques must be. Initial passive exercises are replaced by active ones, and the latter in turn are strengthened by introduction of resistance.

Of electrotherapeutic procedures, the most commonly used are galvanization and faradization of the muscles on the convex side of the curvature (contraindicated in spastic contractures). Of thermal procedures, local water baths from 35° to 40°. An even more active hyperemic agent is mud therapy, which has its indications for contractures both in a resort and non-resort setting. The most favorable results from mud therapy are obtained in rheumatic, toxic, and scar contractures, in contractures based on tenovaginitis and partly in desmogenic and ischemic contractures. Mechanotherapy is contraindicated after tuberculous contractures. In general, through physio-mechano-therapy, strengthening of weakened muscles on the convex side of the curvature is mainly achieved. To combat the excessively increased elastic resistance of tissues on the concave side of the contracture, methods of forced tissue stretching are used, and first of all, traction and redressation. For contracture of the upper extremity, traction is achieved by wearing portable apparatuses; on the lower extremity, they have to be used much less frequently. The acting force is a weight, less frequently elastic traction or a distraction screw. The best results are given by a small but continuously acting traction force. Weights exceeding 3-4 kg should be avoided; and to combat contractures in the acute stage of the disease, even weights exceeding 1/2-1 kg. Very good methods of traction are the drip method (Tregubov) and twisting (Mommsen). The drip method consists in that the stretching weight is a bucket into which water is automatically added or from which water is removed drop by drop. The technique of twisting consists in that above and below the contracted joint, a plaster cast is applied to each, and into each a rod is embedded at a right or acute angle; the free ends of the rods are connected by a double rope, which is gradually twisted by turns of a stick passed through it. For the treatment of specifically paralytic contractures of the fingers of the hand, a special bandage applied according to Momzen in the form of a lyre is used with success. The apparatus of Ermolaev should also be noted, designed specifically for the elimination of contracture of the knee joint. In some cases of contractures of tuberculous origin, it is possible to combat them through staged plaster casts, changed under deep anesthesia. The latter, excluding reflexes, allows the application of a new plaster with some reduction of the angle of contracture without the use of any violence. As a result, through 5-8 stages with a total duration of 3 to 6 months, significant correction is achieved, and sometimes complete elimination of the contracture. In more advanced non-tuberculous cases, when the resistance from the scarred tissues is very great, one has to resort to the modeling redressation of Lorenz, consisting in the careful plastic stretching of the contracted tissues. If correction cannot be achieved in one session, transition is made to staged redressation. The intervals between the stages correspond to periods of plaster immobilization and vary from one to several weeks depending on the 'adaptability' of the tissues. The method of modeling redressation is indicated in not too advanced cases of traumatic contractures and in the inactive stage of infectious contractures, except for syphilitic and tuberculous contractures, especially in scar contractures and in congenital clubfoot. Next follows a series of operative methods, accompanied by open incision of tissues. Transverse dermotomy is indicated in cases of rigid skin in old-standing contractures at an acute angle with scar changes in the tissues; these include in particular Moresten's plastic surgery of dermatogenous contractures, dermectomy, excision of skin and subcutaneous tissue, scarred as a result of burns and mechanical trauma. Unlike old-standing contractures, where plastic replacement of the defect is better postponed until the moment of complete healing of the operative trauma of deep tissues, which also always suffer in old-standing contractures, in purely dermatogenous contracture, immediate skin grafting to the site of the excised scar is indicated. A flap on a pedicle is more reliable than free plastic surgery. For the closure of extensive skin defects, plastic surgery according to Filatov is indicated. This should be kept in mind especially on the leg and foot, where the nutritional conditions for transplanted tissues are less favorable. Material for transplantation can often be obtained from the convex side of the contracture, after the elimination of which the stretched skin is gathered into an excess fold. Excision of scarred subcutaneous tissue and fascia of the palm, resp. sole, is the typical operation for Dupuytren's contracture of the fingers. Fasciotomy—incision of the fascia, most often the fascia lata: for flexion contracture of the hip joint—incision of fibers going from the anterior superior iliac spine (tractus ilio-tibialis); for flexion contracture of the knee joint—fibers going from the Waldeyer's tubercle of the iliac crest (tractus cristo-tibialis).—Similarly, supracondylar fasciotomy can eliminate the tendency to posterior dislocation of the tibia and at least prevent this deformity in redressation of flexion contractures of the knee. Besides such well-known methods as tenotomy, lengthening of muscles, their shortening, and myotenolysis, transplantation of muscle tendons is also used, which is the most common method of combating paralytic contractures. Three main methods are used: subfascial transplantation of tendon to tendon (method of Vulpius), subcutaneous transplantation of tendon under the periosteum (method of Lange), and transplantation under the periosteum, but with passage of the healthy tendon through the sheath of the paralyzed tendon (method of Biesalski-Mayer). Complete transplantation deserves preference over partial. In the method of Vulpius, the descending method of transplantation deserves preference over the ascending. Subfascial formation of a tunnel for passage of the transplanted muscles is not so physiological, but on the other hand, it is more natural than subcutaneous. However, subcutaneous passage of the muscle is technically the simplest and, as experience shows, also gives excellent clinical results. One can proceed to muscle transplantation no earlier than 3 years after paralysis. Waiting longer than 3 years without progressive improvement leads to secondary trophic disturbances of the musculature, and consequently to a clear disadvantage for plastic purposes. An exception in the sense of a longer waiting period with operation can be made only for children under three years of age, since children of this age poorly tolerate sequential treatment and their tendons are too thin for plastic manipulations. Of more recent methods, the operation of transplantation of muscle attachment points according to the method of Soutter-Putti, Campbell, and Silverskiold can be mentioned, the method of muscle doubling according to Baron, the method of long artificial tendons according to Lange, the method of replacing paralyzed muscles with rubber strips according to Stracker, restoration of retinacula for displaced tendons (Krukenberg, Haberer, Spitzy), and restoration of the normal topography of the displaced musculature (Fridland). As for neuroplastic methods of treatment of contractures, they all have the great disadvantage that if the operation is unsuccessful, not only does the function of the paralyzed muscles not recover, but the remaining muscles often suffer, which after such neuroplastic intervention become less suitable for subsequent myoplastic combinations than before. The failure of nerve plastic surgery depends mainly on that in the cross-sections of mixed nerves, sufficient coincidence of like fibers does not occur, i.e., motor with motor and sensory with sensory; incorrectly fused fibers are lost for function. Therefore, Erlacher and Heineke recommend, if topographic-anatomical conditions allow, transplantation of a healthy nerve directly into the paralyzed muscle. Even more favorable prospects are offered by the recently developed method of muscle neurotization by Erlacher: a small piece (from 2 to 8 cm³) on a pedicle from a healthy muscle is excised and sutured into a cleft of the refreshed paralyzed muscle. Already after a month, restoration of normal electrical excitability can be observed in the latter, occurring due to neurotization of the paralyzed muscle by means of the conductors of the transplant from the healthy muscle. Neurectomy and neurectomy are popular methods in the treatment of spastic contractures. Such is the operation of Stoffel—excision of motor branches from the thickness of the main nerve trunk or resection of nerve branches directly before their entry into the spastically contracted muscle, partial resection of nerve trunks according to Wreden, the operation of Forster—section of the posterior (sensory) roots; recently proposed by Rovl, ramicotomy sympathica, the operation of sectioning sympathetic rami communicantes, and the old operation of Lorenz-Selig—section of the n. obturatorii in spastic contracture of the adductor muscles of the thigh.

Considering tropho-reflex contractures as a result of chronic neuritis, Turner and his school (Novotelnov) showed that under these conditions neurectomy can also give a significant therapeutic effect. To this same category belong the methods of neurotripsis and 'chemical sectioning' of nerves in reflex contractures. Examples are the various measures proposed for clubfoot: crushing the peroneal nerve, freezing it with ethyl chloride vapors (Meyer), injecting novocaine into the peroneal and tibial nerves (Spitzy), into the bellies of the contracted muscles (Engelmann), and finally into the capsule of the contracted joint (Lorenz, Ziegner). Among the operative methods on the diaphysis of tubular bones, first place belongs to osteotomy. It renders invaluable services in the treatment of those arthrogenic contractures where there are contraindications for intervention on the joint itself; therefore primarily in tuberculous contractures of the hip joint, especially in advanced cases when one can no longer expect a therapeutic effect from traction. At the present time, successful attempts have been made to perform osteotomy for paralytic, flexion contractures of the knee with the aim of its recurvational installation—a method that has certain advantages over arthrodesis of the knee from the point of view of the dynamics of the latter (Novotelnov). The difficulties encountered in the union of the osteotomized ends of bones after eliminating rectangular and acute-angled contractures, as well as the tendency of the knee joint to subluxation during redressive correction of its flexion contracture, served as the impetus for the development by Vreden of an original method—the operation of metaplasia. The latter consists in the femur being sawn through at the border of the metaphysis and epiphysis, then from the central end of the femur first a transverse saw cut halfway through the diameter of the femur, then a longitudinal blow of a chisel removes a piece of bone; after this an incision is made in the femoral metaphysis with the calculation that the axis of the femur inserted into this incision and the axis of the tibia form one straight line. In severe contractures, in the rigidity of wrinkled, scarred tissues, and especially in significant tension of large vessels and nerves (this applies mainly to the elbow and knee flexors), as well as in congenital contractures with a webbed, resp. 'swimming' membrane, one has to resort to shortening the diaphysis of the tubular bone by means of wedge-shaped or even trapezoidal resection. Mikulicz and Henle in their time proposed to remove pieces up to 4 vershoks long from the radius and ulna in order to achieve relative lengthening of the finger flexors in ischemic contractures and thereby to restore to the muscles part of their motor function. Henle achieves the same thing by shortening the hand at the expense of partial removal of the carpal bones. Resection of individual bones of the posterior and middle sections of the foot is one of the methods of treating congenital, traumatic and partly paralytic contractures. Resection of the heads of the metatarsal bones and phalanges is one of the ways of eliminating hallux valgus, digitus quintus varus and hammer toes. In contractures arising from a difference in the length of the lower limbs, besides myoplastic measures aimed at eliminating the contracture itself, a number of osteoplastic operations also come to the aid. Some of them have in mind lengthening the short leg, others, on the contrary, shortening the long limb. To the first group of operations belong oblique osteotomy followed by prolonged traction of the limb with heavy weights (best of all by means of a Steinman nail) or segmental osteotomy performed according to the principle of Bayer's tendon lengthening. For the same purpose Vreden performs oblique osteotomy on the femur and, having distracted the fragments by 4-5 cm with a Lorenz screw, fixes them with a Lane plate. To the second group of operations belong: shortening of the leg by means of resection or by means of oblique osteotomy with longitudinal approximation of the fragments. Even more can be gained in equalizing the length of the limbs if the resected piece of bone from the longer leg is transferred to the osteotomy gap of the shorter leg. The development of methods relating to this, begun by Codivilla, at the present time has been greatly enriched by the works of a number of authors. Considerable lengthening of the leg can also be achieved by means of arthrodesis of the foot in the equinus position (plantar flexion), according to Vladimirov or Abraganov, which for the patient in all respects is more advantageous than functional contractures of the hip and knee joints on the side of the longer leg. Professional contractures. The cause of professional contractures most often lies in chronic trauma: in repeated overexertion of the musculature, pressure and bruising of various body tissues; further in sharp fluctuations in the temperature of the environment and other harmful factors. Alcoholism, excessive smoking, chronic malaria, syphilis, as well as all other intoxications and infections predispose to the development of professional contractures. Sometimes—and this should be kept in mind—intoxications and infections are in themselves a sufficient cause for contractures, the occurrence of which is facilitated by the presence of professional harmful factors. In such cases to decide which of the causes predominates is often not only difficult but also impossible.—Burns as a cause of contractures are most often observed in workers dealing with caustic reagents, fire and molten metal or mineral, i.e., in chemists, stokers, smelters, foundry workers and glassblowers. Injuries in the form of deep cuts, observed mainly in shoemakers, tailors, carvers and generally in persons working with sharp instruments, also sometimes lead to myogenic and neurogenic contractures. Falling from a great height and the collapse of heavy loads (cargo, lumps of earth) on a worker, causing damage to the skull and spine, are the cause of the most severe spastic contractures and contractures of antagonists in flaccid paralyses. Their victims are mainly roofers, masons, diggers and miners. For certain professions are characteristic traumatic ruptures of certain muscles. For example, rupture of the occipital muscles is most often observed in porters carrying loads on their backs; of the lumbar muscle—in workers in the iron industry, forced to lift from the floor at times unwieldy lumps of metal (Ropke); of the extensor of the big toe—in drummers; of the Achilles tendon—in some professional athletes, namely—tennis players and football players (Kuttner, Grassheim); of the biceps brachii—in discus throwers or others, even if only small weights. All these injuries, as well as ruptures of the knee menisci, very common in miners, circus jumpers and football players, not promptly eliminated by proper treatment, can also lead to professional contractures. As for the chronic factors, first place here is occupied by repeated functional overexertion. It is caused by a forced posture, asymmetrical movements or frequent and prolonged tension of any particular small group of muscles. These include the so-called static scolioses of office workers, arising from incorrect sitting at a desk; scolioses of typesetters, sculptors (Gocht), seamstresses (Lehmann) and violinists from one-sided movements; kyphoses of porters, millers, blacksmiths and miners from lifting and carrying weight on the back; kyphoses of clerks, shoemakers, weavers and tailors due to the constantly bent position at work, which most sharply affects tall persons and those suffering from nearsightedness. To this same group belongs the unique myo-arthrogenic contracture of the hand, the so-called 'claw hand' ('main en crochet' of the French), developing on the basis of the usual grasping of the tube in glass blowers (Poncet) and the habitual grasping of work tools in persons engaged in heavy physical labor: in carpenters (Pichler), gardeners, nail makers (Vernois) and basket weavers (Teleky). The question of the professional nature of Dupuytren's contracture is still not resolved (see Dupuytren's contracture).—Frequent repeated movements of the fingers of the hand or the hand, serving as a source of irritation for the tendon sheaths, cause professional tenosynovitis (see), which in turn often lead to limitation of movement and contractures. Chronic functional overexertion leads to pathological disturbances not only in the musculature but also in the nervous system, which reacts to this kind of professional harmfulness with spasmodic contractures, a classic example of which is writer's cramp (see) and other professional coordinator neuroses. Special mention is deserved by contractures observed as a result of professional pressure on nerve trunks. These contractures have a flaccid-paralytic character. Such lesions were observed in the area of the ulnar nerve in engravers from professional pressure on the elbow (Remak), in the area of the radial nerve in porters (Weber); paralysis of the popliteal nerves, especially the peroneal, was observed in bridge builders and asphalt pavers due to compression of these nerves in the popliteal fossa, caused by professional standing on the knees or squatting (Ott, Bernhardt, Remak).

The most severe forms of contracture of the extremities (primarily as a result of damage to the radial nerve) can also occur as a result of professional intoxications, for example, lead poisoning. Arthrogenic contractures of rheumatic origin are a frequent phenomenon among workers whose labor takes place in cold and damp conditions, therefore among laundresses, dyers, tanners, felt boot makers, bricklayers, as well as among masons and peasants who are often forced to work under sharp fluctuations in weather, in the wind and in the rain. Prevention of professional contractures consists first of all in sanitary-hygienic measures of a general nature, which exclude the possibility of traumatic injuries as 'accidents'. Attention should be paid to the correct position of the body during work; the correct position of the body facilitates the coordination of movements, which at the same time increases the quantity and quality of production. Production processes that require the worker to perform particularly fatiguing, monotonous, and asymmetrical movements should be mechanized. 'Charging' and 'corrective' gymnastics are especially recommended. Self-massage is also an excellent preventive measure. The other preventive measures, as well as the treatment of professional contractures, do not differ in any way from the prevention and treatment of non-professional contractures. These measures are very numerous and are carried out on the basis of the general principles of orthopedics.

M. Fridland. Contractures neurogenic. The basis of neurogenic contractures lies in specific physicochemical processes that disrupt the ionic equilibrium and colloidal state in the muscle. In contractures, action currents, increased gas exchange, thermal 93 production, and glycogen consumption are not found in the muscle. The feeling of fatigue is also absent. However, with more refined methods, minimal action currents and even a slight increase in gas exchange have been detected. Therefore, some, for example Spiegel, now recognize that the difference between contracture and normal voluntary contraction is rather quantitative. In any case, contractures are attributed to the sarcoplasm, which in the normal state is assigned not a kinetic but a fixing function. The prerequisite for contracture is the integrity of the corresponding elementary reflex arc. Regarding the participation of centers and pathways for tone, see Decerebration, Tone, Nucleus ruber. Contractures occur with lesions of the pyramidal, extrapyramidal systems, meninges, in some infections and poisonings, with irritation of the centripetal limb of the reflex arc; regarding contractures with cerebral lesions of the pyramidal system, see Hemiplegia, Wernicke-Mann type of contractures; there also about early and late contractures. With spinal lesions of the pyramidal pathways, contractures usually have an extensor character, as an exception - flexor (see Protective reflexes). According to Ferster, pyramidal contracture is the result of an increase in the subcortical 'fixation reflex' as well as the stretch reflex, i.e., resistance of the muscle to stretching, for example, by the force of gravity. According to recent works by Rademaker, the significance of lesions of the pyramidal pathways in the genesis of contracture is usually overestimated, since for its occurrence it is necessary to have simultaneous lesions of subcortical and other pathways. Apparently, the corticobulbar pathways play a major role in this (Kleist, experiments by Warner and Olmsted). Pyramidal contracture is found in brain agenesis, Little's disease, hemorrhages or softening in the brain, porencephaly, hydrocephalus, diffuse or lobar sclerosis, after post-infectious encephalitis, especially in children, with tumors, gliosis, myelitis, spondylitis, lateral sclerosis, multiple sclerosis, etc. Extrapyramidal contracture is especially sharply expressed with lesions of the substantia nigra and pale nucleus (globus pallidus). It differs from pyramidal, springy contracture by its 'plasticity,' or waxiness. Chronaxia in pyramidal contracture is below normal. Therefore, the difference in chronaxia of antagonists increases even more. In extrapyramidal contracture, the chronaxia of flexors approaches that of extensors. Extrapyramidal contracture usually affects the proximal parts of the extremities, the muscles of the spine. The postures in it often correspond to preformed subcortical automatisms, which are also found in hyperkineses (see). It is found in Parkinson's disease, epidemic encephalitis, arteriosclerotic muscular rigidity, pseudosclerosis, or Wilson's disease, syphilis or tumors of the striatal system, etc. Contractures that appear in meningitis (see) and subarachnoid hemorrhages are caused by irritation of the roots, enhancement of the tonic neck reflexes of Magnus and Klein. They cause opisthotonus, the Kernig symptom. Related is the contracture of the muscles of the spine in sciatica (see), leading to scoliosis. The muscle form of torticollis (see) has a different pathogenesis, depending on the unilateral contracture of the neck muscles. In addition to root origin, it can depend on labyrinth disease (labyrinthine reflex on the neck) or on lesions of the striatal system. Radiculitis after infectious diseases sometimes causes contractures, for example, lateral deviation of the fingers (coup de vent). The question of the pathogenesis of contractures after military injuries (acrodystonia, 'frozen' hand) caused great discussion. Some explained these contractures by the effect on the elementary reflex arc, others by irritation of subcortical, in particular thalamic centers; Gierlich even admitted a reflex lesion of the pyramidal pathways. Others reduced this 'reflex' contracture to hysterical. O. Kalischer identified it with contracture of the facial muscles after facial nerve paralysis (see below). Along with the nerve, the accompanying vessel is often affected. Therefore, sometimes traumatic contracture is reduced to ischemic. Greater significance may have the lesion of the perivascular plexus and disruption of the autonomic innervation of the muscle sarcoplasm. The latter explanation is most satisfactory also in relation to sequential contracture of the facial muscles after facial nerve paralysis. Since such 'secondary' contracture often occurs when paralysis was accompanied by pain, some recognized it as reflex; others attributed importance to the overexcitation of the facial nerve nucleus. It is incorrect to associate it with electrization: it also appears in untreated cases. Extremely painful contractures are found in tetanus (trismus, sardonic laughter, dysphagia, opisthotonus), as well as in strychnine poisoning, when the contracture attacks resemble the hysterical arc de cercle. They are caused by irritation of the centers of the brainstem. In tetany, temporary attacks of painful contracture occur in the distal ends of the extremities. Voluntary movements become impossible or difficult, passive movements encounter an obstacle, sometimes insurmountable; the muscles are dense, sometimes hard as stone. In sleep, in a warm bath, after an Esmarch tourniquet (10-15 min.), light massage, under chloroform, after injection of alcohol, novocaine, iontophoresis with magnesium, contractures often decrease. Contracture can be hemi-, para-, or monoplegic; it can affect the muscles of the face, neck (tricollis), trunk (opisthotonus), lower jaw (trismus), abdomen, extremities. In hysteria, contractures are observed either in the form of attacks or sometimes persistent. The latter differ from organic ones in that they can pass under the influence of hypnosis: the basis of hysterical contracture is physical or psychological trauma. Chronaxia in it is not changed, as in organic contracture. The postures in hysterical contracture are often affected and different from those in organic contracture.-Finally, true contractures should be distinguished from false, or pseudo-contractures of ischemic and myogenic origin; some acute forms of myopathy accompanied by fibrous degeneration of the musculature can also be included here. False contractures should also include those fixations in polyneuritis that depend on the predominance of antagonists, which can later also turn into retraction of tendons. Such false contractures can be easily differentiated under chloroform. In them, tendon reflexes are never elevated.-The prognosis and treatment of true contractures depend on the underlying disease. Temporary relief is sometimes given by warm baths, light massage, injection of novocaine into the muscle, iontophoresis with magnesium. Sometimes it is necessary to resort to the severing of the posterior roots or peripheral nerves (see above).

M. Krol. Litr.: Abraganov A., New operative method for lengthening of the lower extremity, New Surgical Archive, vol. VI, book 4, 1925; Vreden R., Treatment of spastic contracture of the hand in children's hemiplegia by partial resection of nerves, Herald of Surgery, vol. IV, books 10-11, 1924; idem, Operative treatment of contractures and ankyloses of the knee joint, Orthopedics and Traumatology, vol. II, books 4-5, 1928; Vriis S., Treatment of spinal cord paralysis in children, Kazan, 1913; Golyanitsky I., Introduction to social pathology of surgical diseases, Moscow, 1925; idem, Surgical occupational diseases, Moscow, 1927; Ermolaev G., On the question of treatment of flexion contractures of the knee joint, Orthopedics and Traumatology, vol. I, books 2-3, 1927; Khefer N., On the question of treatment of Volkmann's contracture, New Surgical Archive, vol. VII, no. 26, 1925; Krause N., On the physiology and pathophysiology of the fascia lata, Herald of Surgery, 1927, books 28-30; Lowy J., Occupational diseases, Moscow, 1925; Novotelnov S., Operative treatment of reflex contractures in classic fractures of the radius, Orthopedics and Traumatology, vol. I, books 2-3, 1927; idem, On the question of operative reconstruction of a paralyzed leg, ibid., vol. III, books 1-2, 1929; Poritsky S., On the question of conservative treatment of contractures of the hip and knee joints, ibid., vol. II, books 1-2, 1928; Frumin I., On the question of operative treatment of spastic paralyses, ibid., vol. I, books 2-3, 1927; Fridland M., Prevention and treatment of contractures of the extremities, excluding spastic ones, XXI All-Russian Congress of Surgeons 1929 (printed); Khakhutov T., Method of operative lengthening of the extremity, Herald of Surgery, vol. IV, 1924; idem, 5 variants of methods for operative lengthening of the lower extremity, Orthopedics and Traumatology, 1929, book 4; Abbot L., Operative lengthening of tibia and fibula, J. of bone and joint surgery, vol. IX, 1927; Brinkmann E., Contribution to muscular neurotization, Arch. f. orthopadische u. Unfall-Chirurgie, Vol. XXV, 1927; Erlicher Ph., The technique of orthopedic intervention, Vienna, 1928; idem, On the current state of nerve surgery, Orthopedics and Traumatology, vol. I, books 2-3, 1927; Foerster O., Flaccid and spastic paralysis (Handbook of normal and pathophysiology, ed. by A. Bethe, G. Bergmann et al., Vol. X, Part 2, 1927, lit.); Lange F., Silk tendons and silk joint ligaments, Munch. med. Wochenschr., 1928, no. 1; Oehlecker F., Operative shortening of the leg, Centralbl. f. Chir., 1926, no. 20; Paule E., Development, present and future of joint surgery, ibid., no. 14; Spiegel E., The tonus of the skeletal musculature, Berlin, 1927; Stracker O., Alloplasty in amputations, Arch. f. orthopadische u. Unfall-Chirurgie, Vol. XXV, 1927. (from Latin contra-against and latus-side), reflexes caused by irritations of the opposite side of the body. Contralateral can be both tendon, periosteal, and skin reflexes. The so-called P. Marie's contralateral reflex is particularly well-known among deep contralateral reflexes: with the patient lying on his back with knees extended and spread apart, percussion of the patellar tendon on one side causes contraction of the adductors of the thigh on the other side. According to P. Marie's calculations, this reflex occurs in 57% of cases of pyramidal paralysis and thus has certain diagnostic value. The same effect can be achieved with periosteal irritations in cases of heightened reflex excitability: by percussion of the medial condyle of the femur, the surface of the tibia, the bones of the pelvis, and sometimes even the bones of the foot (its medial edge). Great principal interest is represented by crossed protective reflexes. They have been studied in detail by physiologists (especially Sherrington) in animals with severed spinal cord: the flexor reflex of the directly irritated leg is accompanied by the extensor reflex of the other leg. These reflexes can also be observed in humans in paraplegia, rarely in a fully expressed form, more often in an abortive form: a shortening protective reflex on one side is accompanied by plantar flexion of the toes on the other side. Occasionally, the crossed Babinski reflex is also observed.

REFLEXES

v*, P. Marie's reflex occurs in 57% of cases of pyramidal paralysis and thus has certain diagnostic value. The same effect can be achieved with periosteal irritations in cases of heightened reflex excitability: by percussion of the medial condyle of the femur, the surface of the tibia_g the bones of the pelvis, and sometimes even the bones of the foot (its medial edge). Great principal interest is represented by crossed protective reflexes. They have been studied in detail by physiologists (especially Sherrington) in animals with severed spinal cord: the flexor reflex of the directly irritated leg is accompanied by the extensor reflex of the other leg. These reflexes can also be observed in humans in paraplegia, rarely in a fully expressed form, more often in an abortive form: a shortening protective reflex on one side is accompanied by plantar flexion of the toes on the other side. Occasionally, the crossed Babinski reflex is also observed.