Definition:

Hip flexion contracture is a common problem in patients who have sustained trauma about the hip. The iliopsoas muscle is the main deforming force; however, contraction of the hip capsule and surrounding soft tissue may also contribute.

Description:

A flexion contraction is a flexed joint that cannot be straightened actively or passively. It is therefore a chronic loss of joint motion as a result of structural changes in the muscle, tendon, ligaments. In the case of hip flexion contracture, hips that remain flexed for a long period of time are more likely to develop flexion contracture. This condition may also be associated with weakness of hip extensors, spasticity of the hip flexors or an inflamed hip joint capsule. Consequently, shortening of the hip flexor muscles and capsular ligament is observed.

Rehabilitation strategies for a fully extendable hip include stretching hip flexor muscles along with capsular ligaments and strengthening hip extensor muscles which will not be an option in infants. The main aim will be stretching of the hip flexors.

Contractures in infants

 Joint contractures in children may be classified into the congenital and acquired, and these classes divided again according to whether the contracture is intrinsic or extrinsic. In the intrinsic class the limitation of movement is due to structures of the joint itself, particularly the fibrous tissues round it; in the extrinsic contractures the limiting structures are outside the joint, most usually being muscles, though occasionally webbing of the skin is responsible.

1.      Congenital contractures

Contractures due to abnormal pressure. Long-continued pressure on a limb has the same effects if it occurs before birth as it is generally recognized. These effects seem to be due to an interference with the normal blood circulation, particularly the venous return, which of course would become obstructed at a much lower pressure than the arterial. This increased pressure may be either mechanical, due to the uterine structures not expanding at the correct rate to keep pace with the expansion of the growing foetus; or hydraulic, due to increased tension of the amniotic fluid. Though increased tension of this fluid is usually associated with increase in its amount (that is to say hydramnios) increased tension may be present without increased amount, and increased amount without increased tension.

There are two results of this obstruction:

• The muscles naturally fail to develop
• There is a thickening and stiffening of the fibrous tissues around the joints, which is not easy to explain.

The study of contractures of this kind involves the investigation of the mechanical conditions of the pregnancy that produced them. This line of research is neglected in the present very fragmented state of medicine, as it involves the territory of two definitely divided and firmly “closed shops”, those of orthopaedics and obstetrics. It will be found by anyone undertaking it that the results confirm the working hypothesis upon which it is based.

Hydraulic compression would, of course, affect all four limbs equally, the effects being more severe the further the tissues involved lie from the pump of the heart. A significant proportion of these children will be found to have pregnancy histories of hydramnios; and often they emerge from the uterus stiffened in a form that could only be possible in a cavity of abnormal size; e.g. with extended hips.

Those, on the other hand, who have developed in a cavity too small for them will have the compression effects confined to those parts which are unsheltered; most often, of course, the legs and feet. Usually the arms escape, being sheltered by the huge foetal head; but rarely they may be caught in the “wooden soldier” position, straight down alongside the body. The mothers give pregnancy histories of the kind that may be expected, these being particularly valuable if they have experience of a normal pregnancy for comparison. They are small in the later months, often remarking that “all the neighbours were surprised when I had a baby”; and, in addition, nearly always are very uncomfortable.

Treatment:

Treatment of contractures of this type consists mainly in cherishing and pre- serving the deficient muscles. The mistake is not infrequently made of attacking such structural deformities as flexed wrists and knees without considering that the real trouble is not the structural deformity, but the lack of function. These joints respond very badly to manipulations followed by immobilization in plaster of Paris; though it is possible to improve the position in this way the deformity steadily recurs, while the immobilization has inevitably weakened the muscles.

Leaving out such rare and intractable conditions as webbing of the limbs at the elbows and knees, the important contractures in children are those which are due to malposition in utero, that is to say that the child has been lying in an abnormal position. Two of the three stock varieties of moulding deformities of the feet, club-foot and metatarsal varus, belong to this category; the third, metatarsal valgus, is due to mechanical compression in the normal position. The most important member of the first class is congenital, postural scoliosis, due to the child lying with the spine bent sideways in utero. The amount of the contractures in this condition can be best demonstrated by X-rays taken in three positions. It is urgently necessary to diagnose and correct this deformity before the child begins to sit up and walk; or else the combination of body weight and unbalanced muscular action will cause a rapid and accelerating increase of the curve into the most intractable and crippling condition of idiopathic scoliosis.

2.      Acquired contractures

 The most important of these contractures are due to unbalanced muscular action. This can be due to lack of movement in the hip joint caused by early severe illness, immobilisation and limitation of the infants movements. Obstruction of blood circulation to the muscles can also occur outside the uterus when the baby is born and placed in similar positions for an extended period of time. This often occurs when infants are hospitalised and forced to lie in a certain position due to possible health benefits or IV drips. Joint development depends on the functionality of surrounding muscles and therefore great care and attention should be given to restore proper function in an infant which will ensure normal development.

The most common muscles involved are the iliopsoas, rectus femoris, sartorius and iliacus. Due to the fact that that these contractures are only acquired after birth, if they are spotted and treated early on the infant should be able to develop and function normally. The treatment process can be challenging and multiple sessions might be necessary. Conservative treatment is usually recommended depending on the severity of the contracture. Surgery is indicated if infant does not respond to conservative care.

Tips:

• Stretch your baby’s hip muscles as shown by your doctor
• Do bicycle exercises with both of your baby’s legs
• Swaddle your baby’s legs into a straight position to keep the hip joint extended
• Place slight pressure in your baby’s groin where the contracture is as shown by doctor and hold for 10 seconds. You can repeat this multiple times a
• Do not place baby onto that side but rather try and place on opposite side majority of the
• Encourage baby to use the leg by frequently touching and moving the leg