Volkmann Ischemic Contracture Presentation and Treatment

Volkmann ischemic contracture or Volkmann contracture is a permanent shortening of forearm muscles which occur following injury and results in a claw-like deformity of the hand, fingers, and wrist.

Volkmann ischemic contracture is more common in children. A similar condition can occur in the foot.

It was first described by Richard von Volkmann in 1875. Volkmann described a contracture of the muscles of the wrist and fingers which followed tight bandaging of the arm in the treatment of fractures about the elbow. He believed that it was essentially due to ischemia of the muscles.

Overall, Volkmann contractures are rare, with an incidence of about 0.5%.

The condition occurs most commonly in children in the first 10 years of life, and follows injuries, particularly to the elbow, and especially those associated with pressure either internal or external.

Pathophysiology of Volkmann Ischemic Contracture

Volkmann contracture is usually seen in children with displaced supracondylar fractures of the humerus or forearm fractures. It results from severe injury to the deep tissues and muscles of the volar compartment secondary to increased compartmental pressures.

The usual occurrence is a vascular injury or arterial spasm following injury with a reflex spasm of the collateral circulation leads to ischemia is produced.

Muscle bellies are first affected [as they draw most blood] and in case of prolonged ischemia undergo infarction.

A similar spasm is seen following the lodgment of an embolus, and in fact, may result from any disturbance of the peripheral circulation.

During repair phase, the dead muscle is replaced by fibrosis.

Any process that leads to increased compartmental pressure can lead to a compartment syndrome.

This state can also be caused by infiltrated infusions are an iatrogenic cause of this state.

The relevant anatomy of Volkmann contracture includes the superficial and deep flexor muscles. Superficial flexor muscles that may be involved in this process are as follows:

• Pronator teres
• Flexor carpi radialis
• Flexor carpi ulnaris
• Flexor digitorum superficialis
• Palmaris longus

Deep flexor muscles that may be involved are as follows:

• Flexor pollicis longus
• Pronator quadratus
• Flexor digitorum profundus

The degree of contracture could be

• Mild – involving the wrist flexors.
• Moderate – involving most of the flexors especially flexor digitorum profundus, flexor digitorum superficialis, flexor pollicis longus, flexor carpi radialis, and flexor carpi ulnaris.
• Severe – involving both the flexors and the extensors.

History and Physical Examination

In the acute stage, also known as Volkmann ischemia, the clinical presentation includes pain, pallor, pulselessness, paresthesias, and paralysis. The symptoms usually begin within 1-24 hours of the injury. Severe Pain is the earliest sign.

Signs suggestive of increased compartmental pressure may be found on physical examination.

One of the reliable findings is pain accentuated by passive. Firmness or induration of the tissues often is noted on palpation. Pulselessness and paralysis are late findings.

An early intervention may reverse the condition. But a missed or neglected Volkmann ischemia would develop into Volkmann contracture resulting in permanent damage and deformity.

The complete process is over in the first 2 days, so the necessity for prompt initial treatment is very urgent.

After this period the swelling gradually disappears and the muscles become hard fibrosed and resistant. As the fibrosis increase, deformity becomes obvious—especially flexion of the fingers.

The fully developed picture is very characteristic –

• The wrist is flexed
• Fingers are extended at the metacarpophalangeal joints and flexed at the interphalangeal joints
• The forearm is often pronated and the elbow flexed

It could result in various degrees of the deformity:

Mil degrees are often brought to the consultant years after an injury to the elbow. The patient may be unable to extend the fingers completely but yet may possess a considerable range of movement when the wrist is flexed; indeed, it is usually possible to straighten the fingers completely with the wrist fully flexed.

The severe type, with the fully developed and characteristic attitude described above.

A severe type complicated by nerve involvement. Either the median or the ulnar may be coincidentally involved. The signs of nerve lesion would be present as well.

Differential Diagnosis

Pseudo-Volkmann contracture

Tethering of the flexor digitorum profundus secondary to fractures of the ulna occurs 2 days to 16 years after closed reduction of fractures of the shafts of the radius and ulna.

It can be prevented by a routine check of the passive range of motion after fracture reduction and repeat manipulation of the fracture when detected.

Surgical release may be needed in established cases.

Imaging

X-rays are done to evaluate bony injury in detail and assess the amount of displacement of supracondylar fractures and combined radial and ulnar fractures.

Treatment of Volkmann Ischemic Contracture

Acute Stage

The goal of treatment is to restore adequate circulation before irreparable damage is done, thus to avert contracture deformities. In treatment, time is a major factor. The condition is a progressive one in which more damage is done. All measures favoring circulation generally are of the greatest value. These include elevation of the part, removal of any splint or circulation bandage, and the application of mild external warmth.

When the diagnosis has been determined with certainty, emergency fasciotomy is required to prevent progression to Volkmann contracture. Patients with compartment pressures exceeding 30 mm Hg should be taken for emergency fasciotomy.

When required arterial repair and fixation of the fracture should be carried as well.

The decompression is performed via the volar or the dorsal approach. Decompression of the medial nerve throughout its course is essential is taken especially deep to the lacertus fibrosus, between heads of the pronator teres, the proximal arch, and the deep fascial surface of the flexor digitorum superficialis and in the carpal tunnel.

Physical therapy and occupational therapy should be instituted at an appropriate time.

Established Volkmann Contracture

Once contracture has occurred, treatment depends on the degree of Volkmann contracture present.

Mild

• Dynamic splinting,
• Physical therapy
• Tendon lengthening
• Slide procedures

Moderate

Tendon slide, neurolysis of median nerve and extensor transfer procedures.

Severe

• Extensive debridement of damaged muscle
• Multiple scar tissue release
• Salvaging procedures
• Release of contracted tendons at the musculotendinous junction and tendon transfers at a later date.

The first in treatment is to prevent contractures and maintain a supple joint with a full range of movements, and so a splint is applied which make use of elastic traction to prevent the muscles contracting while at the same time permitting the joints of the fingers and wrist to be moved, if necessary passively, to prevent them from becoming stiff.

Operative Treatment

The operation should be preceded by a course of thorough stretching as described above.

Littlewood Operation

• Lengthening of all the shortened tendons
• Difficult in a young child
• Should be attempted only if the contraction is limited to one or two of the forearm muscles.

Maxpage Operation

• A muscle slide operation
• Flexor muscles are erased and dragged distally

Nerve Exploration

• When nerve does not recover by three months
• Median nerve and ulnar nerve are most involved

Tendon Transfers

The preferred transfers involve

• Brachioradialis to flexor pollicis longus to regain thumb motion
• Extensor carpi radialis longus to the flexor digitorum profundus for finger flexion

Prognosis

The prognosis will depend upon the stage at which treatment is instituted: the earlier it is undertaken, the better the prognosis likely to be. The outlook is grave in the severe types

References

• Erdös J, Dlaska C, Szatmary P, Humenberger M, Vecsei V, Hajdu S. Acute compartment syndrome in children: a case series in 24 patients and review of the literature. Int Orthop. 2010 Apr 18.
• Deeney VF, Kaye JJ, Geary SP. Pseudo-Volkmann’s contracture due to tethering of flexor digitorum profundus to fractures of the ulna in children. J Pediatr Orthop. 1998 Jul-Aug. 18(4):437-40.
• Blakemore LC, Cooperman DR, Thompson GH. Compartment syndrome in ipsilateral humerus and forearm fractures in children. Clin Orthop. 2000 Jul. (376):32-8.
• McGraw JJ, Akbarnia BA, Hanel DP. Neurological complications resulting from supracondylar fractures of the humerus in children. J Pediatr Orthop. 1986 Nov-Dec. 6(6):647-50.
• Botte MJ, Gelberman RH. Acute compartment syndrome of the forearm. Hand Clin. 1998 Aug. 14(3):391-403.
• Stevanovic M, Sharpe F. Management of established Volkmann’s contracture of the forearm in children. Hand Clin. 2006 Feb. 22(1):99-111.
• Wilson PD. Capsulectomy for the relief of flexion contractures of the elbow following fracture. 1944. Clin Orthop. 2000 Jan. (370):3-8.
• Sharma P, Swamy MK. Results of the Max Page muscle sliding operation for the treatment of Volkmann’s ischemic contracture of the forearm. J Orthop Traumatol. 2012 Aug 2.
• Ultee J, Hovius SE. Functional results after treatment of Volkmann’s ischemic contracture: a long-term followup study. Clin Orthop Relat Res. 2005 Feb. 42-9.