Which expert please tell me what is gluteal myofascial contracture?

Gluteal muscle contracture syndrome is a clinical syndrome with unique gait and signs, which is caused by degeneration and contracture of gluteal muscle and its fascia fibers for many reasons, resulting in limited hip function. There have been many reports at home and abroad since the Valderrama report of 1970, but the reasons are not very clear. ?

What is the etiology and classification of 1?

1? 1 injection factor?

Most scholars believe that the disease is related to repeated injections in the buttocks, and the local formation of a lump after intramuscular injection is the performance of myofibrositis. Lloycl-Roberts and Thomas suggested that in the pathological examination of children with intramuscular injection, there were edema and bleeding at the injection site, which might lead to fibrosis, and then scar contraction led to contracture. In 1968, Williama reported that there was an inflammatory reaction at the injection site of antibiotics in animal experiments. Penicillin diluted by intramuscular injection of 2% benzyl alcohol has the largest reaction, which leads to degeneration and necrosis, leading to fibrosis. ?

1? 2 children's susceptibility factors?

1? 2? 1 immune factor. A large number of children received intramuscular injections, but only a few got sick. It was found that children with gluteal muscle contracture had immune regulation disorder, and TS cells were obviously low, which led to the relative hyperactivity of th cells. After receiving benzyl alcohol injection, the immune response caused by drug hapten can not be terminated in time, which is easy to cause immune damage. At the same time, serum IgG and c? 3 Reduce the circumstantial evidence provided for this purpose.

Human erythrocyte membrane has a receptor, which is a glycoprotein. Red blood cells can recognize and capture immune complexes in vivo through the adhesion of receptors on their membranes. 95% of the receptors in circulating blood are located on the erythrocyte membrane, so the main cell for people to remove immune complexes is red blood cells. The results showed that the activity of erythrocyte receptor and the level of erythrocyte membrane immune complex in children with gluteal muscle contracture were significantly lower than those in normal people, suggesting that the erythrocyte immune function of children was low and they could not adhere to and remove the immune complex produced after drug injection in time and effectively.

Connecting section method showed that there was immune complex deposition in the wall of small blood vessels of contracture gluteus muscle. Immune complex will damage the blood vessel wall, cause blood coagulation in the blood vessel and lead to tissue hypoxia, and then muscle cells will be damaged and fibroblasts will be activated, which will eventually lead to gluteal muscle fibrosis. ?

1? 2? 2 scar constitution?

1? 2? 3 genetic factors.

It has been reported abroad that 1 child has bilateral deltoid contracture and gluteal contracture, and his mother also has bilateral deltoid contracture, which can not be explained by intramuscular injection alone, and can be considered to be related to heredity. ?

1? 3 factors such as trauma and infection?

1? 3? 1 postoperative complications of congenital dislocation of hip. Several cases of bilateral congenital dislocation of hip joint have been reported in China. Gluteal muscle contracture was found 3 ~ 4 months after Salter osteotomy. ?

1? 3? 2 sequela of gluteal myofascial compartment syndrome?

1? 3? 3 Hip infection?

1? 4 idiopathic?

2 lesions?

2? 1 visual inspection? The appearance shows that there are depressions, lumps or fascia in the buttocks of the child. During the operation, red muscle fibers were replaced by gray-white fibrous tissue, especially on the greater trochanter of femur. Thickened fascia contractures and penetrates into some muscle fibers of gluteus maximus and gluteus medius to become grayish yellow, which can be mixed with normal muscle fibers. In severe cases, there are few normal muscle fibers. There is a fibrous contracture zone on the upper part of gluteus maximus, which is inconsistent in width, generally 2 ~ 7 cm, involving the whole layer of gluteus maximus, pale and inelastic, and is tendon-like tissue. ?

2? 2 Microscopic examination? Muscle cell atrophy can be seen in most contracture gluteus muscles, mostly local or peripheral, and the closer to the fibrotic site, the more obvious the atrophy is. The striations of muscle cells disappeared, the nucleus shrank and dissolved, and some of them formed homogeneous and unstructured substances. The fiber spacing between muscle cells and muscle bundles increases, forming fiber bundles, in which many fibroblasts can be seen. The number of intermuscular blood vessels decreased, the wall of the tube became thicker, the lumen was small and irregular, partially occluded, and neutrophils and lymphocytes infiltrated around the tube. ?

3 Clinical classification?

3? 1 divided into:?

① lump type: the buttocks can reach a knotted lump; ?

② Membrane type: flaky contracture of gluteal muscle fascia; ?

③ Band type: gluteal myofascial contracture. ?

3? According to the muscles involved, it can be divided into:?

① Simple gluteus maximus contracture type; ?

② Simple gluteus medius contracture; ?

③ Complex contracture of gluteus maximus and gluteus medius (including gluteus minimus contracture). ?

4 clinical manifestations?

["JP3"] This disease is often bilateral, and unilateral is rare. It is also reported that there are more men than women. 「JP」？

4? 1 Hip dysfunction? The patient's hip joint rotation and adduction are limited. When standing, the lower limbs rotate outward and cannot be completely close together. Walking often has an outer eight, a swinging gait and a quick jump. When you sit down, your legs can't be together, your hips are separated in a frog posture, and it is difficult for one thigh to lean on the other (cross-legged test). When squatting, the knees of the light person are separated first, and then they are together after squatting (circle sign). In severe cases, you can only squat in abduction and supination. When squatting, the hips are in abduction and rotation position, the knees can't be together, and the heels don't touch the ground, showing a frog style. ?

Physical examination found that there was a skin depression in the upper part of the buttocks, which was more obvious when the buttocks were adducted, and the buttocks could feel tight. The lower limbs are in abduction and external rotation, and the adduction and internal rotation of hip joint are limited. The flexion of hip joint in neutral position of lower limbs is limited, and the affected hip must be abduction and external rotation, so that the affected hip can be fully flexed back to the original sagittal plane after being pulled out for half a turn. Bouncing sensation of greater trochanter of femur. Ober sign positive. ?

4? 2 pelvic deformation?

If the course of disease is long, the acetabular floor may protrude to the pelvic cavity, forming Otto's pelvis. Children with gluteal muscle contracture have greater trochanter epiphysis. Children with bilateral asymmetric gluteal muscle contracture may have pelvic tilt and secondary lumbar scoliosis. The anterior superior iliac spine on the severe side is lower than that on the mild side, and the distance from the umbilicus to the ankle on the severe side is longer than that on the mild side, while the distance from the greater trochanter to the ankle on both sides is equal. ?

4? 3 auxiliary inspection?

X-ray examination results are mostly reported as normal. The X-ray study of children with contracture by Fang Lunguang and Han Jingming found that CE angle increased (X=36? 62), the neck shaft angle increased (X= 153) and the femoral head index decreased (X=0? 44)。 Early operation is helpful to the recovery of the above secondary changes during postoperative follow-up. Preoperative CT cross-sectional scan of gluteus contracture showed that the density of inflammatory lesions decreased in the early stage, and many groups of muscle bundles accumulated with the development of the disease in the later stage. Muscle fibers are replaced by connective tissue, which shows that the muscle volume decreases, the density increases, the myofascial space widens, and finally the scar forms a rope shadow. Scanning can determine the location, scope and severity of lesions and provide valuable clinical data. ?

5 gluteal muscle contracture grading?

5? 1 Fernandez division?

According to the 90 external contracture angle of hip flexion: mild: <15; Moderate:15 ~ 30; Severity: > 30. ?

5? 2 Wuhan Children's Hospital adopts the following standards for grading?

What is the clinical score of gluteal muscle contracture?

Past medical history: Repeated gluteal muscle injection [JY]1min?

Symptoms: [ZK (] abnormal gait (figure-eight gait) [JY] 1?

Can't cross your legs [JY]1minute?

Knees together, squatting is limited [JY]1minute [ZK】]]?

Signs: [ZK (] limited hip flexion or 90 apart knees [JY]1?

Ober sign is positive [JY]1min?

Knee circle sign or hip bounce [JY]1minute?

Pelvic malformation or pseudolimb unequal length [JY] 1 min [ZK]]?

X-ray: [ZK (] acetabular index decreased [JY]1min?

Femoral neck shaft angle increases [JY] 1 min [ZK]]?

According to the score, gluteal muscle contracture was graded: mild: 3 ~ 4 points; Moderate: 5 ~ 7 points; Severity: 8 ~ 10. ?

6 surgical treatment?

6? 1 local anatomy?

The muscle fibers of gluteus maximus inclined downward from the inside out. The fibers in the upper half extend into the iliotibial tract, and the fibers in the lower half also extend into the iliotibial tract. The deep fiber stops at the thick line of musculoskeletal gluteal muscle, and its proximal edge is connected with iliotibial tract. There is a gap parallel to the longitudinal axis of femur, which can be used as a sign of loosening. It can be exposed only by cutting the proximal edge of gluteus maximus and the junction of iliotibial tract, and the sciatic nerve is under its deep medial fascia. It is safe and simple to free gluteus maximus on its surface. ?

6? 2 surgical incision?

At present, most operations are carried out along the arc incision of the posterior upper rotor, which clearly shows the position of the main contracture site and ensures the smooth operation; Moreover, it is released in this part, mainly tendon contracture tissue release, with less surgical trauma and less bleeding; It is safe to release the gap between the upper and posterior surfaces of femur, which can avoid damaging sciatic nerve. The incision can also extend downward appropriately. Small incision, incision along iliac spine and straight incision were used in the early stage, but they were rarely used because the exposure was not ideal and it was difficult to completely release them. S-shaped incision is rarely used because of its big trauma, much bleeding and unsightly appearance. ?

6? 3 surgical method?

Can be simply divided into the following categories:

① Excision of gluteal muscle contracture zone: This operation is traumatic, bleeding, easy to damage sciatic nerve, leaving a cavity after operation, and the release is not complete, especially in severe cases, the gluteal muscle contracture zone is large, for fear of damaging sciatic nerve, and the medial contracture zone is not completely removed, which affects the curative effect. So it has been used less now. ?

② Gluteal contracture band amputation: The operation is simple and minimally invasive. In severe cases, the curative effect is often not ideal because the tension part of gluteus maximus tendon plate can not be released. ?

③ Gluteus contracture band cutting and gluteus maximus stopping point releasing: The posterior edge of fascia lata, the lower edge of gluteus maximus contracture band and the lower part of gluteus maximus tendon plate can be exposed by using an arc incision above the greater trochanter. The surgical incision is small and minimally invasive, and the pathogenic factors can be fully solved in the surgical field, and the curative effect is satisfactory. ?

6? 4. Introduce the surgical treatment of gluteal muscle contracture by taking the arc approach behind the greater trochanter as an example.

① Disinfection sheet: The child lies on his back, lifts his lower limbs, and leaves his hips from the operating table. The disinfection sheet is made according to bilateral hip surgery. After laying the sheets, the child should be able to turn left and right, flex and extend the hip joint on the operating table without polluting the operating field. ?

② Anesthesia: Ketamine basic anesthesia. ?

③ Surgical release: The child takes a semi-lateral position, with the surgical side facing upwards, and moderately flexes and adducts with the affected hip joint, which makes the fibrous cord tense. In most cases, there are fibers in the upper gluteus muscle, iliotibial tract on the surface of gluteus medius muscle and gluteus myofascial contracture in front of tensor fascia lata, which are the main release sites of the disease. Make an arc cut 2 cm behind the big rotor, about 4 ~ 8 cm long. Incision of skin and subcutaneous tissue can expose the contracture and thickening of denatured fibrous tissue in the deep surface of the incision. Incision of iliotibial tract on the surface of gluteus medius muscle, backward.

To the edge of gluteus maximus, the gluteus maximus-iliotibial tract space behind the greater trochanter of femur can be clearly exposed, and the index finger can be inserted to guide, and the contracture tissue can be provoked and released one by one with vascular forceps. Release tensor fascia lata and its superficial gluteal fascia forward as needed. At this point, most situations can be completely liberalized. If it is released near or in the middle of gluteal muscle, it can be found that the anatomical level is unclear, the trauma is great and there is much bleeding. Be careful about gluteal muscle contracture. If there is partial septal contracture in muscle fibers, contracture fibrotomy is feasible. In most cases of fibrous contracture, lengthening surgery should be performed to preserve hip abduction function, keep hip joint stable and avoid flexion gait. ?

④ Relaxation degree: The range of motion achieved: the adduction and pronation positions were about 10 respectively, and the hip joint flexed from the straight position to more than 120.

. Or check that the flexion of the hip joint is 90 and the adduction of the hip joint is greater than 30 when Ober sign is checked; Hip adduction in hip extension position is greater than 10, and hip flexion test can end the operation without rebound in extreme adduction and internal rotation position. You can put your finger into the incision tissue to explore whether there is any contracture zone and cut it accordingly. ?

⑤ Postoperative treatment: After stopping bleeding completely, rotate membrane drainage or negative pressure drainage tube to suture superficial subcutaneous fascia and skin. After operation, the local gauze pad was fixed with pressure for 24 ~ 48 hours. The stitches were removed 2 weeks after operation. ?

7 postoperative complications?

7? 1 local hematoma formation?

It is related to incomplete hemostasis during operation and poor drainage after operation. Local swelling after hematoma formation, persistent pain, easy to cause infection; Hematoma compression can cause skin ischemia and necrosis at the edge of incision. Therefore, the bleeding should be stopped completely during the operation, and rotational drainage and local pressure dressing should be carried out after the operation. Use necessary hemostatic drugs after operation. If hematoma is found, treat it as soon as possible. ?

7? 2 infection?

It is related to the poor treatment of aseptic principle during operation and the formation of hematoma after operation. ?

7? 3. Incomplete remission or recurrence of symptoms?

Incomplete symptom relief is related to incomplete release or soft tissue tension. Recurrence may be related to incomplete amputation of contracture tissue and relative shortening with development, or to delayed functional exercise and scar re-adhesion after operation. ?

7? 4 incision scar?

Although the skin edge was well matched during operation, most children left large scars at the incision after operation. Considering its scar constitution. Therefore, some people think that scar constitution should be regarded as a manifestation of gluteal muscle contracture syndrome. ?

7? 5 Middle gluteal muscle weakness?

Most patients with gluteus medius amputation can have swinging gait after operation. With the passage of postoperative time, scar tissue connects the stump of gluteus medius muscle, and the myasthenia of gluteus medius will eventually disappear. ?

7? 6 Intraoperative arterial bleeding?

It's rare, but it needs special attention. When releasing the fascia of gluteus maximus under the greater trochanter, it is easy to encounter small branches from the inferior gluteal artery, which can be avoided by careful separation or ligation. Accidental cuts should be reliably sutured to stop bleeding. ?

8 postoperative functional exercise?

After contracture release, it can recur because of gluteal muscle re-adhesion. Therefore, active exercise and functional exercise are adopted after operation to overcome blink sign and frog leg sign, prolong the residual contracture tissue, improve the obstacle of limb unequal length and prevent the re-adhesion of the broken end of iliotibial tract of tensor fascia lata.

It is very important to consolidate the release effect. ?

8? 1 step? Good limb position 6 hours after operation: take off the pillow and lie flat, wrap your knees together with bandages, put a soft pillow under your knees, bend your hips 60 degrees, bend your knees 30 degrees and fix them for 24 hours. Observe the bleeding of the wound. If there is little bleeding or drainage, pull out the drainage tube and start functional exercise. ?

Within 24 ~ 48 hours after operation, assist and guide the patient to cross his lower limbs in bed, flex and adducte his hip joints, and practice sitting up, three times a day, 30 minutes/time. ?

48 hours after operation, help the child get out of bed and walk, one step at a time: hold out his chest, lift his shoulders horizontally, walk in a straight line and cross his lower limbs. Three times a day, 30 minutes each time. ?

3 ~ 4 days after operation, on the basis of gradual walking, hip abduction and squat exercises were gradually increased: feet together, hands raised horizontally,

Heels should not leave the ground, and the back should be straight. 3 times/day, repeat exercise 200 times. ?

On the 7th day after operation, on the basis of correcting abnormal gait, leg exercises were performed (crossing your legs). When crossing your legs, you sit in an armchair, your back is close to the backrest, one leg straddles your knee, crosses the other leg, and your left and right legs cross, and you actively stretch by swinging your hips left and right. Three times a day, 30 minutes each time. The above-mentioned functional exercises should be carried out step by step to prevent the bleeding incision from cracking due to excessive activity. ?

8? 2 Pre-discharge guidance?

On the basis of consolidating the above functional exercises, do knee joint functional exercises after discharge. These methods are as follows:

① Sit, bend your hips and knees, then separate your hips outward to the greatest extent, and make your feet relatively close together in front.

Press the inside of the knee joint with your hand, and try to put your legs together and restore. Repeat 5 times. ?

② In supine position, the hip and knee of one affected limb flexed, then fell inward to the maximum position, and then fell outward to the maximum position and reset. Repeat 5 times alternately left and right. ?

③ Standing posture, feet are separated back and forth, the front knee joint is flexed, the rear knee joint is straightened, hands are pressed against the front knee joint, and the body slowly leans forward for 5 seconds. Restore. Repeat 5 times alternately from left to right, and insist on doing it for 6 ~ 2 months after discharge. Squatting and sitting up freely are the standards of self-care. ?

9 efficacy evaluation?

The effect of operation is closely related to age, illness and complete release. The following indicators can be used to judge the curative effect:

2. Nursing care of patients with gluteal muscle contracture 2004-11-2710: 43: 02

Gluteal muscle contracture mostly occurs in children, mainly due to gluteal muscle fiber contracture after long-term repeated drug injection, resulting in abnormal hip function. Surgery to completely release and remove contracture tissue is the most effective treatment. Due to the large wound and more bleeding, it is necessary to closely observe the bleeding of the wound after operation. In addition, correct posture and proper functional exercise after operation are also important measures to improve the function of hip joint. Common nursing problems include: ① fear; ② Self-care defects; 3 pain; ④ Bedsore may occur; (5) Potential complications-more bleeding in the wound; ⑥ Lack of knowledge: Exercise knowledge in special posture and function.

First, fear

Second, self-care defects

Third, pain.

All the above 1 ~ 3 refer to the relevant contents in the General Standard Nursing Plan for Orthopedic Patients.

Fourth, there is the possibility of bedsore.

Related factors:

1 The operation wound is large, and the local blood circulation of buttocks is affected.

2 local compression.

The main manifestations: the skin of sacrococcygeal and costal arch turns red, dark and even necrotic.

Nursing goal: The patient has no bedsore.