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Fixed Flexion Deformity

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1) Fixed flexion deformity is when a joint is unable to fully extend due to soft tissue shortening or contracture, limiting its range of motion. Common sites include the hip, knee, elbow, and fingers. 2) Causes include trauma, inflammation, immobilization, neurological conditions, and degenerative changes. Prevention focuses on flexibility exercises, proper positioning, and early mobilization. 3) Management includes stretching, splinting, orthotics, medications to reduce spasticity, rehabilitation exercises, and sometimes surgery such as tendon lengthening or joint reconstruction.

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Dr. Md. Galib Raihan Phase-B Resident, Dept. of Physical Medicine & Rehabilitation Dhaka Medical College Fixed Flexion Deformity
Fixed Flexion Deformity
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. Flexion means bending the joint and extension means straightening it.
Deformity Deformity is derived from Latin word deformitatem meaning misshapen. Deformity determined by factors i. the extent to which deviate from the normal ii. symptoms to which give rise iii. the presence or absence of instability iv. the degree to which they interfere with function
Fixed deformity Fixed deformity - The term ambiguous. The 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
Fixed Flexion Deformity The joint is able to flex fully but not extend fully . At the limit of its extension it is still fixed in a certain amount of flexion. Flexion deformity and flexion contracture- synonymously used.
Classification of Contractures Trauma Inflammation Infection Immobilization Degenerative joint disease ( OA) Cartilage damage Capsular fibrosis 1. Arthrogenic contracture A. Intrinsic factor 1. Trauma ( Bleeding, oedema) 2. Inflammation (Polymyositis) 3. Degeneration ( Muscular Dystrophy) B. Extrinsic Factor 1. Spasticity (SCI, Stroke, cerebral palsy) 2. flaccid paralysis ( Muscle imbalance) 3. Mechanical ( Faulty position in bed) 2. Myogenic contracture Immobility Lack of ROM Mechanical position Type Primary cause Secondary cause Immobility Fibrosis Lack of stretch Faulty joint position
Contd Periarticular soft tissue ( Trauma, inflammation) Skin, subcutaneous tissue ( Trauma, burn, infection, systemic sclerosis) Tendon and ligament ( Tendinitis, bursitis, ligamentous tear and fibrosis) 3. Soft tissue contracture Type Primary cause Secondary cause Immobility
Common joint involved in fixed flexion contracture Lower extremity Hip Knee Upper extremity Elbow Proximal interphalangeal joint Wrist
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
Fixed Flexion Deformity of Hip Cause: Secondary to previous trauma Inflammatory condition Neurological condition eg. Cerebral palsy
Fixed Flexion Deformity of Elbow Fixed Flexion Deformity of Wrist Fixed Flexion Deformity of PIP
Clinical Presentation Insidious onset and asymptomatic. Unnoticed for extended periods Interferes with functional activity Often painful Alteration of gait pattern
Essentials of Assessment Etiology of the contracture, its natural course Pain Difficulties in mobility and transfers Activities of daily living (ADL) Hygiene Details regarding caregiver burden History
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 o Gait Neurological examination
Special Test Thomas Test: To assess fixed flexion deformity of hip
Normal Range Of Motion Hip joint Flexion 120 勇 Extension 5属 -20属 Knee joint Flexion 135 属 Extension 0 勇 Elbow joint Flexion 145属 Extension 0 勇 Wrist joint Dorsiflexion 75属 Palmar flexion 75属 Proximal IP joints Flexion 100属 MCP joints Flexion 90属
Performing ADL Eating Grooming Dressing upper body Dressing lower body Bathing Toileting Ambulation Transfer Functional Assessment
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
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.
Management Careful determination of predisposing factors Knowledge of involving joint component or tissue Particular attention to muscles crossing two joints Emphasizing joint stability Accurate measurement of ROM Analysis
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
Pain management- 損 Analgesic Control of spasticity 損 Muscle relaxant 損 Motor point or nerve blocks using phenol 損 Muscle injection of Botulinum toxin A or B Treatment of underlying disease Pharmacological management
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
Passive towel stretch Low-load, long-duration stretching
Orthosis Knee- Hinged ROM knee brace Elbow- ROM Elbow brace PIP joint- Dynamic PIP extension splint
Surgical Management Tenotomy Tendon lengthening Joint capsule release Joint reconstruction. Skin grafts or flaps Total joint replacement
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
Practice 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.
Fixed Flexion Deformity

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Fixed Flexion Deformity

  • 1. Dr. Md. Galib Raihan Phase-B Resident, Dept. of Physical Medicine & Rehabilitation Dhaka Medical College Fixed Flexion Deformity
  • 3. 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. Flexion means bending the joint and extension means straightening it.
  • 4. Deformity Deformity is derived from Latin word deformitatem meaning misshapen. Deformity determined by factors i. the extent to which deviate from the normal ii. symptoms to which give rise iii. the presence or absence of instability iv. the degree to which they interfere with function
  • 5. Fixed deformity Fixed deformity - The term ambiguous. The 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
  • 6. Fixed Flexion Deformity The joint is able to flex fully but not extend fully . At the limit of its extension it is still fixed in a certain amount of flexion. Flexion deformity and flexion contracture- synonymously used.
  • 7. Classification of Contractures Trauma Inflammation Infection Immobilization Degenerative joint disease ( OA) Cartilage damage Capsular fibrosis 1. Arthrogenic contracture A. Intrinsic factor 1. Trauma ( Bleeding, oedema) 2. Inflammation (Polymyositis) 3. Degeneration ( Muscular Dystrophy) B. Extrinsic Factor 1. Spasticity (SCI, Stroke, cerebral palsy) 2. flaccid paralysis ( Muscle imbalance) 3. Mechanical ( Faulty position in bed) 2. Myogenic contracture Immobility Lack of ROM Mechanical position Type Primary cause Secondary cause Immobility Fibrosis Lack of stretch Faulty joint position
  • 8. Contd Periarticular soft tissue ( Trauma, inflammation) Skin, subcutaneous tissue ( Trauma, burn, infection, systemic sclerosis) Tendon and ligament ( Tendinitis, bursitis, ligamentous tear and fibrosis) 3. Soft tissue contracture Type Primary cause Secondary cause Immobility
  • 9. Common joint involved in fixed flexion contracture Lower extremity Hip Knee Upper extremity Elbow Proximal interphalangeal joint Wrist
  • 10. 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
  • 11. Fixed Flexion Deformity of Hip Cause: Secondary to previous trauma Inflammatory condition Neurological condition eg. Cerebral palsy
  • 12. Fixed Flexion Deformity of Elbow Fixed Flexion Deformity of Wrist Fixed Flexion Deformity of PIP
  • 13. Clinical Presentation Insidious onset and asymptomatic. Unnoticed for extended periods Interferes with functional activity Often painful Alteration of gait pattern
  • 14. Essentials of Assessment Etiology of the contracture, its natural course Pain Difficulties in mobility and transfers Activities of daily living (ADL) Hygiene Details regarding caregiver burden History
  • 15. 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 o Gait Neurological examination
  • 16. Special Test Thomas Test: To assess fixed flexion deformity of hip
  • 17. Normal Range Of Motion Hip joint Flexion 120 勇 Extension 5属 -20属 Knee joint Flexion 135 属 Extension 0 勇 Elbow joint Flexion 145属 Extension 0 勇 Wrist joint Dorsiflexion 75属 Palmar flexion 75属 Proximal IP joints Flexion 100属 MCP joints Flexion 90属
  • 18. Performing ADL Eating Grooming Dressing upper body Dressing lower body Bathing Toileting Ambulation Transfer Functional Assessment
  • 19. 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
  • 20. 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.
  • 21. Management Careful determination of predisposing factors Knowledge of involving joint component or tissue Particular attention to muscles crossing two joints Emphasizing joint stability Accurate measurement of ROM Analysis
  • 22. 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
  • 23. Pain management- 損 Analgesic Control of spasticity 損 Muscle relaxant 損 Motor point or nerve blocks using phenol 損 Muscle injection of Botulinum toxin A or B Treatment of underlying disease Pharmacological management
  • 24. 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
  • 25. Passive towel stretch Low-load, long-duration stretching
  • 26. Orthosis Knee- Hinged ROM knee brace Elbow- ROM Elbow brace PIP joint- Dynamic PIP extension splint
  • 27. Surgical Management Tenotomy Tendon lengthening Joint capsule release Joint reconstruction. Skin grafts or flaps Total joint replacement
  • 28. 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
  • 29. Practice 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.