“Syndrome of Contractures” According to Prof. Hans Mau; Problems of Shanks, Knees, Hips, Pelvis and Spine; Children, Adolescents, Adults, Diagnosis, Treatment“Syndrome of Contractures” According to Prof. Hans Mau; Problems of Shanks, Knees, Hips, Pelvis and Spine; Children, Adolescents, Adults, Diag

The problems of movement apparatus in children, youth and even adolescents aren’t connected with “a weakness of muscles” but with a shortening of muscles, tendons, and capsules which in orthopaedic literature is called “contracture” [1] [2] [3] [4]. The older way of thinking about the problem was based on the conviction that “weak muscles” cause and make problems; we, however, present on many examples that “restriction of movements” doing by shortening of soft tissues makes contracture and incorrect position of joints, body parts, the serious and frequent clinical problems.

Asymmetrical contractures of joints imply discrepancies in ranges of movements of separate joints (hip: left: right, knee: left: right, left: right sides of spine).They can be additionally influenced by Minimal Brain Dysfunctions (MBD).MBD-means sub-spasticity of various groups of muscles-mostly flexors of hip, flexors of knees, and flexors of feet.
The "left sided SofCD" is more common, as a result of the first position of the fetus during pregnancy, when the fetus is placed on his back on the left side of the mother's uterus.Such pregnancies occur in 85% -95% of all cases [14] [15].From the orthopaedic point of view, children with "Syndrome of Contractures and Deformities" has the dispositions to: infantile scoliosis, torticollis (wry neck), and dysplasia of the hip in form of development dysplasia of hip (DDH) according Klisic, mostly of the left hip because of the limited abduction of this joint (Figure 3(b)).In SofCD limited adduction of the right hip in their "extension position", in some cases even abduction contracture of this joint, play role in the development of the so-called idiopathic scoliosis, through "gait" and "permanent standing "at ease" on the right leg" (Figures 9-12).
Clinical symptoms of the "Syndrome of Contractures" are according Prof.

Material
During 8 years (2009-2017) authors examined 922 newborns and babies with symptoms of the SofCD.The diagnosis criteria were similarly like using by Prof. Hans Mau-the registration of clinical symptoms of asymmetries in position and in movement of head, neck, pelvis, hips, knees, feet.The control group consisted of 263 children presented by parents for examination, with no sign of the SofCD, but with others problems.In 2018 the material gathers 1033 cases.
Syndrome of contractures and its influence are on locomotors system [11] [16]- [24].In article we present the cases of SofCD and its influence on: 1) dysplasia of the hip; 2) wry neck (torticollis); 3) biomechanical etiology of the so-called idiopathic scoliosis; The dysplasia of the hips can be connected with 1) the Syndrome of Contractures and Deformities (SofCD), with 2) laxity of joints and with 3) disorders of the central nerve system witch influence the movement of hips.The dysplasia of the hips in babies with the SofCD shows a deficit of abduction of hips, mostly on the left hip (Figure 3(b)).The physiological treatment in this group of deformation is simple, easy and gives good results in relative short time.In therapy, as always, it is important to carry the child in full abduction and flexion of hips for over one year, as well to use orthopedic abduction devices (Figures 4-6).Unfortunately, in opposition to our recommendations, "wrongly educated" physiotherapists and rehabilitation   In some patients we use orthopedic abduction devices.For successful treatment and for full "restitutio ad integrum" we need months or sometimes years.
Children with dysplasia and laxity of joints need an especially long therapy.We 3) Next influences are connected with the function-"gait" and "standing".
Here we explain: during walking, restricted movement-not presented in the right hip is transmitted to the pelvis and to the spine as compensatory movement, which causes rotation distortion of inter-vertebral joints and stiffness of the spine; 4) The next cause is connected with permanent standing "at ease" on the right leg.As a result, appear the left convex lumbar curve in scoliosis II-nd epg and in I-st epg type.
In the new classification of the so-called idiopathic scoliosis there are three        2) vitamin D deficiency.
In such situations Blount disease can develop, it means varus in proximal part of shanks, in place of epiphysis and methaphysis.Primary Blount disease in every case is bilateral.In later years, one of the shanks, usually the left one, can correct itself spontaneously.The deformation of the right shank is durable and becomes bigger with time.Thus, one-sided deformity can be noticed in cases with the "Syndrome of Standing 'at ease' on the Right Leg" (new syndrome-see Literature).
All cases of Blount disease until 1981 in our Department had been operated.
In the 80' we found the conservative method of therapy.We "use" for this therapy, the Heuter-Volkmann law.According to this law, pathological changes of axes of lower extremities develop when "existing loading bigger than normal and primary varus of shanks is observed".If loading or overloading is not present spontaneously appears correction of axis.Since 1981 we recommended parents to carry children with varus deformity 10 or even 20 degrees for 2 -3 months, in some cases 4 months, until the shanks regain their normal axes.In this period the child shouldn't stand nor walk.To all cases of Blount disease we add vitamin D. After introducing such a conservative treatment, from 1981 until now, in all cases, in children aged from 1 to 2.5, the axes of legs come to normal.We emphasize that the age for such treatment is 1 to 2.5, in some cases-3 years.Older children have to be operated on, like before.

Discussion
In etiology of deformities and illnesses of movement apparatus can play role the following causal influences: congenital, hormonal, coming from Central Nerve System-in children with MBD, but we must remember about very frequent influences going from the "Syndrome of Contractures and Deformities" (SofCD).
The asymmetries in SofCD-in position of part of the body of newborn and ba-  3) Only symmetry of movements and of function enables proper body growth.
This rule is especially important in prophylaxis of hip dysplasia and of scoliosis.
4) Effective treatment of small children with residual changes of SofCD should be considered an effective prophylaxis of insufficiency of the movement apparatus and as an important procedure against arthrosis of hips, knees, spine in older patients.
5) The aim of physiotherapy is to achieve symmetry of position, symmetry of movements of joints as well symmetry in development and growth.
6) For the treatment of older children we should use the stretching exercises to heal contracted (shortened) side or part of the body, and of region of joints but we never recommend strengthening exercises.

7)
In therapy and prophylaxis of the so-called idiopathic scoliosis we recommend the stretching exercises for right hips to obtain full movement, flexion-rotation exercises for spine, embryo position for rest and sleeping in the nights, and standing "et ease" only on the left leg, sport, especially exercises like karate, taekwondo, aikido, kung fu.
8) Additionally, in treatment we can use thermotherapy, magnetic fields, biodynamic (diadynamic), laser, and massages.Exercises in geothermal water are especially useful.

Figure 1 .
Figure 1.Three month old child; "Syndrome of Contractures and Deformities".1. Plagiocephalia.2. Right sided wry neck.3. Limited abduction of the left hip as a symptom of dysplasia in form of DDH. 4. Infantile scoliosis left convex.5. Moderate varus of shanks.

Figure 3 .
Figure 3.Typical "Syndrome of Contractures and Deformities".Child 1 month old.Changed axis of spine (scoliosis infantilis).Limited abduction of the left hip as symptom of dysplasia (DDH).

Figure 4 .
Figure 4. Improper way of carrying the child recommended by poorly educated orthopedic surgeons, physiotherapist, pediatricians (a).Proper way of carrying the child.Full abduction of the hips-the best prophylaxis for dysplasia (b).

Figure 5 .
Figure 5. Two month old child with typical Syndrome of Contractures and Deformities.Carrying the child in full abduction of the hips is the prophylaxis for dysplasia.Twisting child's head to the left side is the best therapy of left sided wry neck (b).

Figure 6 .
Figure 6.One year old child.Syndrome of Contracture and Deformities.Proper way of carrying the child in full abduction of the hips-the best method of therapy for dysplasia.Permanent rotation position of the head to the left side is the best method of therapy for the left sided wry neck.

3 )Figure 7 .Figure 8 . 1 ) 2 )
Figure 7. Two methods of treatment of hip dysplasia.(a) child with Weickert's trousers for walking.(b) child with spongy triangle.Walking in abduction is the best method for therapy of dysplasia in older children.The presented methods are better than orthopedic devices used when the child is laying down.

Figure 9 .
Figure 9. New classification.15 year old patient."S" scoliosis in I epg, 3D.Primary double curves.Connection with gait & standing "at ease" on the right leg.Specific model of hips movements.In development-first rotation deformity, next curves.Stiffness of spine.Progression.

Figure 10 .
Figure 10.New classification.10 year old patient."C" scoliosis in II/A epg.1D.Connection with standing "at ease" on the right leg.Specific model of hips movements.Flexible spine.No progression.

Figure 11 .
Figure 11.New classification.13 year old patient."S" scoliosis in II/B epg.2D or mix.Thoracic curve secondary.Connection with standing "at ease" on the right leg plus laxity of joints or wrong exercises in previous therapy.Flexible spine.No progression or a small one.

Figure 12 .
Figure 12.New classification.Two patients aged 18 and 20.Scoliosis "Ist" in IIIrd epg.Specific model of hips movements.Connection with gait only.2D or mix.Stiffness of spine.No curves or a small one.

Figure 15 .
Figure 15.Varus deformity of shanks-one-sided Blount disease.Left leg self corrected.Treatment of children aged 1 -3 years only by physiotherapy (look text).Older children-surgery.

4 . Conclusions 1 )Science 2 )
Every orthopedic surgeon and pediatric doctor, as well every physiotherapist, should be familiarized with the knowledge about the "Syndrome of Contractures and Deformities" (SofCD) based on Prof. Hans Mau's (Germany) experience.Karski Tomasz et al.DOI: 10.4236/ss.2019.10100435 Surgical Every newborn and baby with the SofCD should be treated very early by proper nursing and using of orthopedic devices, older children by stretching exercises in order to reach symmetry of joint movements of hips, knees, feet, and spine.