Volkmann Contracture

Introduction
Increased osseofascial compartment pressure leads to  decreased
perfusion
May lead to irreversible muscle and nerve damage
May occur anywhere that skeletal muscle is surrounded by fascia,
but most commonly
leg
forearm (details below)
hand (details below)
foot
thigh
buttock
shoulder
paraspinous muscles
Pathophysiology
local trauma and soft tissue destruction> bleeding and
edema > increased interstitial pressure > vascular
occlusion > myoneural ischemia
Causes

trauma
fractures (most common)
 distal radius fractures in adults
 supracondylar humerus fracture in children
crush injuries
contusions
gunshot wounds
tight casts, dressings, or external wrappings
extravasation of IV infusion
burns
postischemic swelling
bleeding disorders
arterial injury
Outcomes
may lead to
loss of function
Volkmann ischemic contracture
neurologic deficit
infection
amputation
Anatomy
Forearm compartments 3 in total
volar
 most commonly affected
dorsal
mobile wad (lateral)
 rarely involved
 muscles
 brachioradialis 
 extensor carpi radialis longus 
 extensor carpi radialis brevis 
Hand compartments 10 in total
hypothenar
thenar
adductor pollicis 
dorsal interosseous (x4) 
volar (palmar) interosseous (x3) 
Presentation
Symptoms 
pain out of proportion to clinical situation is usually
first symptom
may be absent in cases of nerve damage
difficult to assess in

 polytrauma 
 sedated patients
 children
Physical exam
pain w/ passive stretch of fingers 

most sensitive finding

paraesthesia and hypoesthesia
indicative of nerve ischemia in affected compartment
paralysis
late finding
full recovery is rare in this case
palpable swelling
tense hand in intrinsic minus position 

 most consistent clinical finding

peripheral pulses absent

late finding
amputation usually inevitable in this case
Evaluation
Radiographs
obtain to rule-out fracture
Compartment pressure measurements 
indications
 polytrauma patients
 patient not alert/unreliable
 inconclusive physical exam findings
relative contraindication
 unequivocally positive clinical findings should prompt emergent operative interventionwithout need
for compartment measurements
threshold for decompression
 controversial, but generally considered to be

 absolute value of 30-45 mm Hg

 within 30 mm Hg of diastolic blood pressure (delta p)
o intraoperatively, diastolic blood pressure may be decreased from anesthesia
• if delta p is less than 30 mmHg intraoperatively, check preoperative diastolic pressure and follow
postoperatively as intraoperative pressures may be low and misleading 
Treatment
Nonoperative
indications
 exam not consistent with compartment syndrome
 delta p > 30

Operative
emergent forearm fasciotomies 
 indications
 clinical presentation consistent with compartment syndrome
 compartment measurements with absolute value of 30-45 mm Hg
 compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
o intraoperatively, diastolic blood pressure may be decreased from anesthesia
• must compare intra-operative measurement to pre-operative diastolic pressure
emergent hand fasciotomies 
 indications
 clinical presentation consistent with compartment syndrome
 compartment measurements with absolute value of 30-45 mm Hg
 compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
o intraoperatively, diastolic blood pressure may be decreased from anesthesia
• must compare intra-operative measurement to pre-operative diastolic pressure
Surgical Techniques
 Forearm
emergent fasciotomies of all involved compartments 
approach
volar incision     
o decompresses volar compartment, dorsal compartment, carpal tunnel

• incision starts just radial to FCU at wrist and extends proximally to medial epicondyle
• may extend distally to release carpal tunnel
dorsal incision 
o decompresses mobile wad
• dorsal longitudinal incision 2cm distal to lateral epicondyle toward midline of wrist

technique
volar incision
o open lacertus fibrosus and fascia over FCU
o retract FCU ulnarly, retract FDS radially
o open fascia over deep muscles of forearm
dorsal incision

o dissect interval between EDC and ECRB

o decompress mobile wad and dorsal compartment
post-operative
leave wounds open 
o wound VAC
o sterile wet-to-dry dressings
repeat irrigation and debridement 48-72 hours later
o debride all dead muscle

o possible delayed primary wound closure

o VAC dressing when closure cannot be obtained
• follow with split-thickness skin grafting at a
later time 
Hand
emergent fasciotomies of all involved compartments
approach  
 two longitudinal incisions over 2nd and 4th metacarpals  
 decompresses volar/dorsal interossei and adductor compartment
 longitudinal incision radial side of 1st metacarpal 
 decompresses thenar compartment
 longitudinal incision over ulnar side of 5th metacarpal
 decompresses hypothenar compartment

technique
 first volar interosseous and adductor pollicis muscles are decompressed through blunt
dissection along ulnar side of 2nd metacarpal

post-operative
 wounds left open until primary closure is possible
 if primary closure not possible, split-thickness skin grafting is used
Complications
Volkman's ischemic contracture 
irreversible muscle contractures in the forearm, wrist and
hand that result from muscle necrosis
contracture positioning

 elbow flexion
 forearm pronation
 wrist flexion
 thumb adduction
 MCP joints in extension
 IP joints in flexion
classification
Volkman's ischemic contracture 
 type of forearm ischemic contracture resulting from 
brachial artery injury usually associated w/ 
supracondylar frx of humerus;
    - may see loss of motor & sensory function,
however, classic involvment is w/ anterior interosseous
branch of median nerve;
 pathology:
           - contracture results from insufficient arterial perfusion &
venous stasis followed by ischemic degeneration of muscle;
           - irreversible muscle necrosis begins after 4-6 hrs;
           - resulting edema impairs circulation, leads to forearm
comapartment syndrome, which propagates progressive muscle
necrosis;
           - muscle degeneration is most affected at the middle third
of muscle belly, being most severe closer to bone;
                  - there is less involvement toward the proximal &
distal surfaces;
           - necrosis of the muscle with secondary fibrosis that may
develop followed by calcification in its final phase;
anatomy
           - distal to lacertus fibrosus brachial artery branches
into radial & ulnar artery;
           - radial artery is superficially located, whereas
ulnar artery is deeply situated, traversing deep to 
pronator teres muscles;
           - ulnar artery gives rise to the common interosseous
artery, which divides immediately into anterior & PIN
branches;
           - flexor digitorum longus and the 
flexor pollicis longus muscles derive their blood supply
thru anterior interosseous artery;
pathoanatomy:
           - infarct has ellipsoid shape w/ its axis along anterior interosseous
artery & its central point slightly above middle of the forearm;
           - therefore, the muscles most dependent on the anterior interosseous
artery (FDP, FPL, FDS, and the pronator teres;
                  - FDP and FDS muscles become contracted and are replaced by
scar, which leads to wrist flexion contracture and clawing of the fingers;
           - in addition to muscle necrosis, there will also be injury to the median
 and ulnar nerves leading to high ulnar nerve and median nerve palsy;
           - fingers:
                  - may lie in intrinsic minus position (due to high nerve palsy)
                  - alternatively, the fingers may lie in an intrinsic plus position
(MP's flexed, PIP extended), if there has been a concomitant  
compartment syndrome of the hand resulting
                  in intrinsic contracture;
Management:
    - proper initial splinting of hand in the function
position;
    - release of forearm flexors;
             - muscle slide
             - tendon lengthening;