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Volkmann Ischemic Contracture

BASICS

DESCRIPTION

- Pallor - Pulselessness - Paresthesia - Paralysis

- Decompression of the median nerve - High-risk areas: deep to the lacertus fibrosus (lacertus fibrosis), between the humeral and ulnar heads of the pronator teres, the proximal arch, and the deep fascial surface of the flexor digitorum superficialis, carpal tunnel (4)[B] - If contractures have occurred, treatment should focus on minimizing deformity and maximizing function of the upper extremity. - Treat mild contracture with - Serial splinting - Physical therapy - Tendon lengthening - Slide procedures

- Manage moderate contractures with - Slide procedures - Neurolysis - Extensor tendon transfers

An irreversible flexion contracture at the wrist following ischemic injury (most commonly from compartment syndrome):

  • Compartment syndrome occurs when the pressure within the closed compartment of a limb is elevated resulting in decreased perfusion; can occur from either internal swelling (as in a crush injury) or external constriction (tight cast or splint).
  • Volkmann contracture is a late sequela of the ischemic injury and is not part of an acute compartment syndrome.

EPIDEMIOLOGY

Incidence

  • Rare due to early detection of compartment syndrome and prophylactic fasciotomy.
  • 0.5% incidence in upper extremity pediatric long bone fractures.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Compression of the brachial artery leads to ischemic injury of the forearm flexors (primarily the flexor pollicis longus and the flexor digitorum profundus). If unrecognized, compartment syndrome develops leading irreversible myonecrosis, secondary fibrosis, scarring, and muscle contracture with resultant "claw-like " deformity of the wrist.
  • The neuromusculature of the forearm can tolerate ischemia for up to 4 hours; irreversible damage occurs after 8 hours.
  • Can be accompanied by median (more common) and/or ulnar nerve injury, with a resultant sensory neuropathy

Genetics

No known genetic predisposition

RISK FACTORS

Compartment syndrome associated with:

  • Trauma
  • Fracture, particularly supracondylar fractures of the humerus in children, distal radial fractures in adults
  • Arterial embolus
  • Burns
  • Muscle hypertrophy
  • Overly tight bandages/dressings
  • Tourniquet application
  • (Rare) snake (most often vipers) or insect sting (usually bee or wasp)

GENERAL PREVENTION

High clinical suspicion of compartment syndrome is required for early diagnosis and treatment (fasciotomy).

COMMONLY ASSOCIATED CONDITIONS

  • Displaced supracondylar humerus fracture and forearm fractures in children
  • A congenital variety occurs in newborns associated with skin lesions on the affected arm.
  • Distal radial fractures in adults
  • Myoglobinuria, metabolic acidosis

DIAGNOSIS

HISTORY

  • Trauma; fracture
  • Tourniquet use
  • Prior compartment syndrome
  • Arterial embolus
  • Burns
  • Muscle hypertrophy/overtraining of upper extremities
  • Overly tight bandages/dressings
  • Snake bite or insect sting (rare)

PHYSICAL EXAM

  • 5 Ps of compartment syndrome:PainPain with passive extension of fingers is an early sign.PallorPulselessnessParesthesiaParalysis
  • Mild contracture involves wrist flexors only.
  • Moderate contracture involves the following:Flexor digitorum profundusFlexor digitorum superficialisFlexor pollicis longusFlexor carpi radialisFlexor carpi ulnaris
  • Severe contracture involves both of the following:Wrist flexorsWrist extensors

DIFFERENTIAL DIAGNOSIS

Pseudo-Volkmann contracture secondary to tethering of the flexor digitorum profundus following reduction of forearm fracture.

DIAGNOSTIC TESTS & INTERPRETATION

Usually diagnosed clinically. Radiographs of humerus, elbow, and forearm, if concerned about fracture. Imaging can help identify risk for elevated compartment pressures (1)[B].

Diagnostic Procedures/Other

Measuring compartment pressures with an arterial line monitor, or with portable pressure measuring systems designed for this purpose (2)[B], provides diagnostic information.

Test Interpretation

Normal compartmental pressures are 0 to 8 mm Hg; critical pressure is ≥30 mm Hg. Compartment pressure >30 mm Hg, or a difference between diastolic blood pressure and compartment pressure of ≤20 mm Hg demand urgent decompressive fasciotomy (3)[B].

TREATMENT

GENERAL MEASURES

The only appropriate treatment for acute compartment syndrome is surgical release.

  • Failure to diagnose or treat compartment syndrome can lead to irreversible damage.
  • Prevention includes bivalving casts and removing tight dressings before compartment syndrome occurs.

MEDICATION

First Line

Analgesics

ISSUES FOR REFERRAL

Immediate surgical consultation

ADDITIONAL THERAPIES

Physical and occupational therapy improve range of motion and function in cases where contracture has occurred.

COMPLEMENTARY & ALTERNATIVE MEDICINE

Hyperbaric oxygen to improve tissue oxygenation and prevent further myonecrosis is currently being studied.

SURGERY/OTHER PROCEDURES

  • Emergent fasciotomy
  • Muscle viability can be determined intraoperatively via the 4 Cs.ColorConsistencyContractilityCapacity to bleed
  • Decompression of the median nerve
  • High-risk areas: deep to the lacertus fibrosus (lacertus fibrosis), between the humeral and ulnar heads of the pronator teres, the proximal arch, and the deep fascial surface of the flexor digitorum superficialis, carpal tunnel (4)[B]
  • If contractures have occurred, treatment should focus on minimizing deformity and maximizing function of the upper extremity.
  • Treat mild contracture withSerial splintingPhysical therapyTendon lengtheningSlide procedures
  • Manage moderate contractures withSlide proceduresNeurolysisExtensor tendon transfers
  • Severe contractures can be managed by salvage reconstructive procedures involving extensive debridement and scar tissue release.
  • Surgical complications: altered sensation/sensory loss within the wound (77%), dry skin (40%), pruritus (33%), discolored wounds (30%), swollen limbs (25%), recurrent ulceration (13%), muscle herniation (13%), pain (10%) (5,6)[B]

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Physical and occupational therapy to maximize limb function.
  • Follow-up with orthopedic surgeon to determine the need for surgical revision (6)[B].

PROGNOSIS

  • Prognosis depends on the degree of contracture, severity of the initial injury, and associated complications.
  • One long-term follow-up study showed the best results in patients who received a free vascularized muscle transplantation (6)[B].

COMPLICATIONS

  • Volkmann contracture can lead to irreversible loss of function.
  • Chronic pain, swelling, and loss of motion are common.

REFERENCES

11 McDonald S, Bearcroft P. Compartment syndromes. Semin Musculoskelet Radiol. 2010;14(2):236 " 244.22 Garner AJ, Handa A. Screening tools in the diagnosis of acute compartment syndrome. Angiology. 2010;61(5):475 " 481.33 Collinge C, Kuper M. Comparison of three methods for measuring intracompartmental pressure in injured limbs of trauma patients. J Orthop Trauma. 2010;24(6):364 " 368.44 Blomfield LB. Intramuscular vascular patterns in man. Proc R Soc Med. 1945;38(11):617 " 618.55 Fitzgerald AM, Gaston P, Wilson Y, et al. Long-term sequelae of fasciotomy wounds. Br J Plast Surg. 2000;53(8):690 " 693.66 Ultee J, Hovius SE. Functional results after treatment of Volkmann 's ischemic contracture: a long-term followup study. Clin Orthop Relat Res. 2005;(431):42 " 49.

ADDITIONAL READING

  • Blakemore LC, Cooperman DR, Thompson GH, et al. Compartment syndrome in ipsilateral humerus and forearm fractures in children. Clin Orthop Relat Res. 2000;(376):32 " 38.
  • Botte MJ, Keenan MA, Gelberman RH. Volkmann 's ischemic contracture of the upper extremity. Hand Clin. 1998;14(3):483 " 497.
  • Hardwicke J, Srivastava S. Volkmann 's contracture of the forearm owing to an insect bite: a case report and review of the literature. Ann R Coll Surg Engl. 2013;95(2):e36 " e37.
  • Hargens AR, Mubarak SJ. Current concepts in the pathophysiology, evaluation, and diagnosis of compartment syndrome. Hand Clin. 1998;14(3):371 " 383.
  • Lee SH, Han SB, Jeong WK, et al. Ulnar artery pseudoaneurysm after tension band wiring of an olecranon fracture resulting in Volkmann 's ischemic contracture: a case report. J Shoulder Elbow Surg. 2010;19(2):e6 " e8.
  • Prasarn ML, Ouellette EA. Acute compartment syndrome of the upper extremity. J Am Acad Orthop Surg. 2011;19(1):49 " 58.
  • Ragland RIII, Moukoko D, Ezaki M, et al. Forearm compartment syndrome in the newborn: report of 24 cases. J Hand Surg Am. 2005;30(5):997 " 1003.
  • Stevanovic M, Sharpe F. Management of established Volkmann 's contracture of the forearm in children. Hand Clin. 2006;22(1):99 " 111.

CODES

ICD10

  • T79.6XXA Traumatic ischemia of muscle, initial encounter
  • T79.6XXD Traumatic ischemia of muscle, subsequent encounter
  • T79.6XXS Traumatic ischemia of muscle, sequela

ICD9

958.6 Volkmanns ischemic contracture

SNOMED

  • Volkmanns contracture (disorder)
  • Volkmann's ischemic contracture following injury (disorder)

CLINICAL PEARLS

  • Volkmann ischemic contractures are most common in pediatric upper extremity fractures with associated compartment syndrome.
  • Early diagnosis and surgical decompression prevents this debilitating condition.
  • Early physical exam findings of compartment syndrome include pain out of proportion to injury and pain with passive extension of fingers.