Volkmann’s contracture

Volkmann’s contracture also called Volkmann ischemic contracture, is a deformity of the hand, fingers, and wrist caused by fibrosis and contracture of the forearm ¹. Volkmann’s ischemic contracture is caused by ischemic injury to the deep tissues enclosed in the tight unyielding osteo-facial compartments secondary to neglected acute compartment syndrome. Volkmann’s ischemic contracture may be associated with malunion or non-union of forearm fractures.

It is now well recognized that Volkmann ischemic contracture can develop from many different injuries, as long as the injuries cause swelling of the soft tissues that are contained in relatively nondistensible osseofascial compartments ². As a result of this swelling, intramuscular pressure is elevated to a magnitude sufficient to occlude capillary perfusion. The compartments with the least ability to expand are most severely affected by this ischemic insult. Because the deep flexor compartment of the forearm lies next to the bone, it is the first and most severely affected ³. Variable levels of necrosis and fibrosis, though to a lesser degree, may also be evident in the flexor digitorum superficialis and the superficially located muscles such as the wrist flexors. The muscle degeneration which follows is most marked in the middle, and its extent decreases peripherally, so that a so-called ellipsoid-shaped infarct ³ may be the end result. Nerve trunks running in the ischemic zone also suffer damage; this is initially caused by ischemia but is later aggravated by the subsequent muscle fibrosis.

Figure 1. Volkmann ischemic contracture

Footnote: Preoperative findings of the left hand. (A, B) The long finger shows severe flexion contracture, and the ring finger shows a mild flexion contracture with the wrist in the neutral position. (C) The flexion contractures of these 2 fingers are reduced with the wrist in the palmar flexion position.

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Volkmann’s ischemic contracture causes

Volkmann’s contracture occurs when there is a lack of blood flow (ischemia) to the forearm. This occurs when there is increased pressure due to swelling, a condition called compartment syndrome.

Injury to the arm, including a crush injury or fracture, can lead to swelling that presses on blood vessels and decreases blood flow to the arm. A prolonged decrease in blood flow injures the nerves and muscles, causing them to become stiff (scarred) and shortened.

When the muscle shortens, it pulls on the joint at the end of the muscle just as it would if it were normally contracted. But because it is stiff, the joint remains bent and stuck. This condition is called a contracture.

In Volkmann’s ischemic contracture, the muscles of the forearm are severely injured. This leads to contracture deformities of the fingers, hand, and wrist.

There are three levels of severity in Volkmann’s ischemic contracture:

• Mild – contracture of 2 or 3 fingers only, with no or limited loss of feeling
• Moderate – all fingers are bent (flexed) and the thumb is stuck in the palm; the wrist may be bent stuck, and there is usually loss of some feeling in the hand
• Severe – all muscles in the forearm that both flex and extend the wrist and fingers are involved; this is a severely disabling condition

Conditions that can cause increased pressure in the forearm include:

• Animal bites
• A forearm fracture
• Bleeding disorders
• Burns
• Excessive exercise
• Injection of certain medicines into the forearm
• Injury of the blood vessels in the forearm
• Surgery on the forearm

Sundararaj et al. ⁵, in his study of 196 cases of Volkmann’s ischemic contracture, reported that tight external splintage for supracondylar fractures of the humerus was the most common cause of the ischemic contracture. When considering individual injuries, supracondylar fractures were reported to be the major cause of ischemic contractures in studies by Reigstad et al. ⁶, Tsuge ⁷, Eichler ⁸, and Ultee ⁹. Fractures of the forearm bones were found to be the most common cause in a study performed by Chuang et al. ¹⁰, in which strategies for preventing Volkmann’s ischemic contracture were evaluated. Other rare causes mentioned in the literature ¹⁰ include intoxication, infusion of hypertonic dextrose extravenously, chemotherapy perfusion for therapy of malignant cancers, and following excision of congenital radioulnar synostosis.

Congenital Volkmann ischemic contracture

Congenital Volkmann ischemic contracture, also known as neonatal compartment syndrome, is a very rare condition ¹¹. In this age group there are only about 50 documented cases, all affecting an upper limb, even though it may occur in the lower limbs ¹².

The lesions are present at birth and characterised as bullae that quickly burst into deep ulcers evolving to necrotic areas ¹³. Later, muscular atrophy becomes evident with contraction and flexing of the fingers and claw-like hand position ¹⁴. This contraction is due to fibrosis and contracture of the flexing muscle, presenting at birth or developing during the first weeks ¹⁵. The histological characteristics are unspecified and the necrosis severity is related to ischemia duration ¹⁴. In the cases previously described, there is no evidence of compression in other anatomical regions ¹⁶. However, in the present case a few discreet skin lesions were detected in other regions that may be related to slight compression from conflict of intrauterine compartment ¹¹. The haemorrhagic cerebral lesion observed in the magnetic resonance was probably due to traumatic delivery. There is only one reported case of a preterm neonate with concomitant cerebral lesions due to vascular obliteration of the sylvian artery, probably due to vascular emboli consecutive to the death of a co-twin during pregnancy ¹⁷.

The specific cause for congenital Volkmann ischemic contracture is still unknown, but is consensual that the ischemic lesion is caused by an increase in intracompartmental pressure ¹⁸. The average diastolic pressure of the newborn is approximately 40 mm Hg or less ¹³. Therefore, even small increases in intracompartmental pressure may rapidly compromise muscular perfusion ¹³. At this age group, it seems to be the result of external intrauterine compression, for which several situations may be responsible such as instrumental deliveries, difficult extractions, foetopelvic incompatibility, inadequate limb positioning, oligohydramnios, amniotic band or umbilical cord constriction and twin pregnancy ¹⁸. Other factors that may lead to difficult extractions and initial intrauterine injury are mother’s diabetes, prolonged membrane rupture, pre-eclampsia, premature birth, uterine anomaly and excessive weight gain on the mother ¹⁸. The administration of psychotropic medication during pregnancy, such as narcoleptics and benzodiazepines, has been considered as a risk towards foetal hypomotility and abnormal intrauterine positioning ¹². Intrinsic factors to the newborn include hypercoagulability states ¹³. However, some studies show that there is a predominant involvement of the extensor muscles, a superficial muscular group, which is suggestive that the initial injury is due to external direct compression instead of vascular alterations ¹⁹. Even though there may be some associated factors, there are reported cases in which both pregnancy and delivery presented with none of the above related factors  ¹³. Side effects of oseltamivir use during pregnancy are poorly documented, rendering it hard to evaluate its implication, but it seems not to be involved ²⁰.

When the lesions are recent, ideally during the first 24 hour, fasciotomy is the choice treatment as it allows a reduction in intracompartmental pressure and arterial reperfusion ²¹. However, this diagnosis is rarely taken in consideration immediately. In a study of 24 cases, fasciotomy during the first 24 hour was limited to a single occurrence, the only one to evolve with no complications ¹³. At a later stage, other surgical treatments are needed including devitalised tissue debridement and skin grafting, nerve decompression, scar revision, contractures release and angular deformity correction ¹³. The timing of these procedures depends on age, limb size and surgical goals ¹³.

Volkmann’s ischemic contracture symptoms

Symptoms of Volkmann’s contracture affect the forearm, wrist, and hand. Symptoms may include:

• Decreased sensation
• Paleness of the skin
• Muscle weakness and loss (atrophy)
• Deformity of the wrist, hand, and fingers that causes the hand to have a claw-like appearance

Volkmann’s contracture complications

Untreated, Volkmann’s contracture results in partial or complete loss of function of the arm and hand.

Volkmann’s contracture diagnosis

Your health care provider will perform a physical exam, focusing on the affected arm. If your doctor suspects Volkmann’s contracture, detailed questions will be asked about past injury or conditions that affected the arm.

Tests that may done include:

• X-ray of the arm
• Tests of the muscles and nerves to check their function

Volkmann’s contracture treatment

The goal of treatment is to help people regain some or full use of the arm and hand. Volkmann’s contracture treatment depends on the severity of the contracture ²²:

• For mild contracture, muscle stretching exercises and splinting the affected fingers may be done. Surgery may be needed to make the tendons longer.
• For moderate contracture, surgery is done to repair the muscles, tendons, and nerves. If needed, the arm bones are shortened.
• For severe contracture, surgery is done to remove muscles, tendons, or nerves that are thickened, scarred, or dead. These are replaced by muscles, tendons, or nerves transferred from other body areas. Tendons that are still working may need to be made longer.

Up to now, a variety of therapeutic techniques for Volkmann’s contracture, such as splinting ²³, excision of the affected muscle ²⁴, muscle sliding ²⁵, tendon lengthening ²⁶ and free muscle transplantation ²⁷, have been reported.

Tension-reduced early mobilization is one of the rehabilitation methods usually applied following tendon rupture reconstruction ²⁸. In this method, the distal stump of the ruptured tendon is transferred to the tendon to the adjacent finger. Afterward, if the ruptured tendon is the flexor tendon, the tension-reduced position is maintained by taping the affected finger to the volar side of the adjacent finger, and the immediate active motion of the fingers is allowed. Using this method, active finger range of motion (ROM) exercise can be performed under a tension-reduced condition of the tendon suture site. Good clinical results have been reported using this method ²⁸.

Concerning the timing of surgery, Seddon ²⁹ recommended waiting for at least 3 months for evidence of spontaneous recovery in the forearm muscles before surgical treatment. Tsuge ³⁰ recommended waiting for more than 5 or 6 months as function of the hand and fingers was gradually restored with the recovery of the degenerated muscles. However, Chuang ³¹ advocated exploration within 3 weeks of injury, since debridement of infarcted muscles can prevent the fibrotic compression responsible for further nerve damage.

Volkmann’s contracture prognosis

How well a person does depends on the severity and stage of Volkmann ischemic contracture at the time treatment is started.

Outcome is usually good for people with mild contracture. They may regain normal function of their arm and hand. People with moderate or severe contracture who need major surgery may not regain full function.

References

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