VOLKMANN’S ISCHEMIC VOLKMANN’S ISCHEMIC CONTRACTURECONTRACTURE

DR.KRISHNA MADHUKAR.DDR.KRISHNA MADHUKAR.DBHARATI HOSPITALBHARATI HOSPITAL

VOLKMANN’S ISCHEMIC VOLKMANN’S ISCHEMIC CONTRACTURECONTRACTURE

Definition :Definition : A condition which is characterized by ischemic necrosis of A condition which is characterized by ischemic necrosis of

the structures contained within the volar compartment of the structures contained within the volar compartment of the forearm associated with crippling contractures and the forearm associated with crippling contractures and varying degrees of neurologic deficit. varying degrees of neurologic deficit.

HISTORYHISTORY

1881, 1881, VolkmannVolkmann stated that paralytic stated that paralytic contractures that contractures that develop within a few develop within a few hours after injury are hours after injury are caused by arterial caused by arterial insufficiency or insufficiency or ischemia of muscles.ischemia of muscles.

HISTORYHISTORY1906, 1906, Hildebrand first used the term "Volkmann ischemic Hildebrand first used the term "Volkmann ischemic contracture"contracture" to describe the final result of any untreated to describe the final result of any untreated compartment syndrome.compartment syndrome.

1909,1909, Thomas Thomas found that paralytic contractures followed found that paralytic contractures followed severe contusions of the forearm without fractures.severe contusions of the forearm without fractures.

1914, 1914, MurphyMurphy reported that increased internal pressures reported that increased internal pressures in the deep compartments of the forearm due to in the deep compartments of the forearm due to hemorrhage and effusion in the muscles resulted in hemorrhage and effusion in the muscles resulted in ischemia.ischemia.

HISTORYHISTORY

1928, 1928, JonesJones concluded that concluded that Volkmann’s Volkmann’s contracture could be contracture could be caused by pressure caused by pressure from within, from from within, from without or both.without or both.

Volkmann’s ischemic Volkmann’s ischemic contracture is a late contracture is a late sequela of untreated or sequela of untreated or inadequately treated inadequately treated compartment syndrome compartment syndrome in which necrotic muscle in which necrotic muscle and nerve tissue are and nerve tissue are replaced with fibrous replaced with fibrous tissuetissue

ANATOMYANATOMY

At the entrance to the flexor At the entrance to the flexor compartment of the forearm, compartment of the forearm, the lacertus fibrosus fans the lacertus fibrosus fans medially from the biceps medially from the biceps tendon. tendon.

Beneath the lacertus fibrosus Beneath the lacertus fibrosus the brachial artery and median the brachial artery and median nerve pass to enter the flexor nerve pass to enter the flexor compartment.compartment.

ANATOMYANATOMYThe brachial artery divides into radial The brachial artery divides into radial and ulnar arteries.and ulnar arteries.

The radial artery courses superficially The radial artery courses superficially and is not crossed by any structure in and is not crossed by any structure in the forearm.the forearm.

The ulnar artery passes beneath the The ulnar artery passes beneath the pronator teres where it gives a major pronator teres where it gives a major branch, the common interosseus branch, the common interosseus artery.artery.

The common interosseus artery further The common interosseus artery further divides into volar and dosal divides into volar and dosal interosseus arteries.interosseus arteries.

ANATOMYANATOMY

The median nerve The median nerve accompanies the brachial accompanies the brachial artery beneath the artery beneath the lacertus fibrosus and lacertus fibrosus and enters the substance of enters the substance of the pronator teres the pronator teres passing between its passing between its humeral and ulnar heads.humeral and ulnar heads.

ANATOMYANATOMYCompartments of the Compartments of the forearm.forearm.

1.1. Superficial volar Superficial volar compartment.compartment.

2.2. Deep volar compartment.Deep volar compartment.

3.3. Dorsal compartment.Dorsal compartment.

4.4. Mobile wad of Henry.Mobile wad of Henry.

ETIOLOGYETIOLOGYSupracondylar fractures Supracondylar fractures of the humerusof the humerus in children in children is the most common is the most common precipitating injury.precipitating injury.

The brachial artery may The brachial artery may get impinged on the get impinged on the sharp proximal fragment sharp proximal fragment against which it is held by against which it is held by lacertus fibrosus.lacertus fibrosus.

ETIOLOGYETIOLOGY

Hemorrhage and Hemorrhage and edema may further edema may further compress the brachial compress the brachial artery and the median artery and the median nerve in this region. nerve in this region.

ETIOLOGYETIOLOGY

Ischemia – Edema cycle as depicted by Eaton Ischemia – Edema cycle as depicted by Eaton and Greenand Green

ETIOLOGYETIOLOGYOther Causes :Other Causes :

1.1. Crush injuries.Crush injuries.

2.2. Prolonged external Prolonged external compression.compression.

3.3. Internal bleeding Internal bleeding (Hemophilia).(Hemophilia).

4.4. Burns.Burns.

5.5. Snake bites.Snake bites.

6.6. Intravenous regional anesthesia.Intravenous regional anesthesia.

ETIOLOGYETIOLOGY

Tolerance of tissue.Tolerance of tissue.

1.1. Muscle :Muscle : - functional impairment after 2-4 - functional impairment after 2-4

hours of ischemia.hours of ischemia. - Irreversible functional loss after - Irreversible functional loss after

4-12 hours.4-12 hours.

2. 2. Nerves :Nerves : - functional impairment after 30 - functional impairment after 30

mins of ischemia.mins of ischemia.

- Irreversible function loss after - Irreversible function loss after 12-24 hrs.12-24 hrs.

CLINICAL PICTURECLINICAL PICTUREAcute compartment Acute compartment syndrome (Impending syndrome (Impending Volkmann’s ischemic Volkmann’s ischemic contracture)contracture)

1.1. If If local compressionlocal compression is a the is a the cause :cause :

Pulses intact ( in early Pulses intact ( in early stages)stages)

Paresis Paresis Stretch painStretch pain Parasthesia (median nerve Parasthesia (median nerve

sensory zone commonly)sensory zone commonly) Good capillary filling. Good capillary filling.

CLINICAL PICTURECLINICAL PICTUREAcute compartment Acute compartment syndrome (Impending syndrome (Impending Volkmann’s ischemic Volkmann’s ischemic contracture)contracture)

2. If 2. If arterial injuryarterial injury is the is the cause :cause :

Stretch painStretch pain ParasthesiaParasthesia PulselessnessPulselessness Pallor ( or Cyanosis)Pallor ( or Cyanosis) ParesisParesis

CLINICAL PICTURECLINICAL PICTURE

Two point discriminationTwo point discrimination is more than 1 cm in the is more than 1 cm in the sensory zone of the sensory zone of the median nerve.median nerve.

Diminished perception of Diminished perception of vibratory sensevibratory sense of 256 of 256 cycles/sec stimulus.cycles/sec stimulus.

CLINICAL PICTURECLINICAL PICTUREMeasurement of Measurement of intracompatmental intracompatmental pressure :pressure :

1.1. Whitesides handheld Whitesides handheld pressure monitoring pressure monitoring system.system.

2.2. Wick catheter.Wick catheter.

3.3. Slit catheter.Slit catheter.

CLINICAL PICTURECLINICAL PICTURE

Evaluating the intracompartmental Evaluating the intracompartmental pressure.pressure.

- Range between Range between 10 – 20 mmHg10 – 20 mmHg below the diastolic below the diastolic pressure – cessation of blood flow is eminent.pressure – cessation of blood flow is eminent.

- 40 – 50 mmHg40 – 50 mmHg – muscle threatening compression and – muscle threatening compression and ischemia are present.ischemia are present.

- Pressure of Pressure of 30 mmHg or greater30 mmHg or greater – criterion for – criterion for fasciotomy.fasciotomy.

Deformities in Volkmann’s ischemic Deformities in Volkmann’s ischemic contracture.contracture.

Mild type :Mild type :

Deep flexors are partially Deep flexors are partially involved particularly, Flexor involved particularly, Flexor digitorum profundus.digitorum profundus.

Flexion contractures of one or Flexion contractures of one or more fingers which can be more fingers which can be extended on hyperflexing the extended on hyperflexing the wrist.wrist.

Resistant pronation Resistant pronation contracture involving either the contracture involving either the pronator teres or pronator pronator teres or pronator quadratus.quadratus.

Deformities in Volkmann’s ischemic Deformities in Volkmann’s ischemic contracturecontracture

Moderate type :Moderate type :

Involves most of the flexor Involves most of the flexor digitorum profundus, flexor digitorum profundus, flexor pollicis longus and part of pollicis longus and part of flexor digitorum superficialis.flexor digitorum superficialis.

Neurological deficit involving Neurological deficit involving median nerve more than ulnar median nerve more than ulnar nerve is present.nerve is present.

Deformity is intrinsic minus Deformity is intrinsic minus hand.hand.

Diminished sensations in Diminished sensations in median and ulnar nerve zones. median and ulnar nerve zones.

Deformities in Volkmann’s ischemic Deformities in Volkmann’s ischemic contracturecontracture

Severe type :Severe type :

All the flexor muscles are All the flexor muscles are involved.involved.

Neurological deficit is severe.Neurological deficit is severe.

Joint contractures are marked.Joint contractures are marked.

Wasting of forearm muscles .Wasting of forearm muscles .

MANAGEMENT – ACUTE COMPARTMENT MANAGEMENT – ACUTE COMPARTMENT SYNDROME (IMPENDING VIC)SYNDROME (IMPENDING VIC)

MANAGEMENT – ACUTE COMPARTMENT MANAGEMENT – ACUTE COMPARTMENT SYNDROME (IMPENDING VIC)SYNDROME (IMPENDING VIC)

Forearm fasciotomyForearm fasciotomy

Incision :Incision : A volar A volar curvilinear liberal incision curvilinear liberal incision medial to the biceps medial to the biceps tendon, crossing the tendon, crossing the elbow flexion crease at elbow flexion crease at an angle carring it distally an angle carring it distally to the palm to release the to the palm to release the carpal tunnel.carpal tunnel.

MANAGEMENT – ACUTE COMPARTMENT MANAGEMENT – ACUTE COMPARTMENT SYNDROME (IMPENDING VIC)SYNDROME (IMPENDING VIC)

Exploration must extend deeply to the FDP Exploration must extend deeply to the FDP and FPL.and FPL.

Necrotic muscle tissue is excised.Necrotic muscle tissue is excised.

Median nerve freed beneath the lacertus Median nerve freed beneath the lacertus fibrosus.fibrosus.

Ulnar nerve is freed and transplanted Ulnar nerve is freed and transplanted anteriorly.anteriorly.

Brachial artery must be inspected and Brachial artery must be inspected and decompressed.decompressed.

Surgical wound is left open for secondary Surgical wound is left open for secondary closure later when swelling subsibes.closure later when swelling subsibes.

Extremity suppoted with splint in funtional Extremity suppoted with splint in funtional position.position.

CONSERVATIVE MANAGEMENT CONSERVATIVE MANAGEMENT ESTABLISED DEFORMITIESESTABLISED DEFORMITIES

Robert Jones method Robert Jones method (1930s).(1930s).

Wooden tongue Wooden tongue

depressors were used to depressors were used to correct established correct established deformities gradually from deformities gradually from distal to proximal over a distal to proximal over a prolonged period of timeprolonged period of time..

CONSERVATIVE MANAGEMENT CONSERVATIVE MANAGEMENT ESTABLISED DEFORMITIESESTABLISED DEFORMITIES

Banjo splint :Banjo splint :

BBanjo splint used with rubber bands fastened to adhesive tape on the fingers permits the fingers to be exercised at all times and is most efficient.

ESTABLISHED VOLKMANN’S ISCHEMIC ESTABLISHED VOLKMANN’S ISCHEMIC CONTRACTURE - MANAGEMENTCONTRACTURE - MANAGEMENT

Muscle sliding operation of flexors of Muscle sliding operation of flexors of

forearm.forearm.

Inglis & CooperInglis & Cooper

Williams & HaddadWilliams & Haddad

INGLIS & COOPERINGLIS & COOPER

Incision on the medial aspect of volar side of the Incision on the medial aspect of volar side of the arm 5 cm proximal to medial epicondyle and arm 5 cm proximal to medial epicondyle and distally to midpoint of forearm over the ulna.distally to midpoint of forearm over the ulna.

INGLIS & COOPERINGLIS & COOPER

Ulnar nerve is identified, released from the cubital tunnel and protected.Ulnar nerve is identified, released from the cubital tunnel and protected.

Tendinous origins of muscles on the medial epicondyle are cut.Tendinous origins of muscles on the medial epicondyle are cut.

Flexor carpi ulnaris and Flexor digitorum profundus are completely released Flexor carpi ulnaris and Flexor digitorum profundus are completely released from the medial epicondyle and ulna.from the medial epicondyle and ulna.

INGLIS & COOPERINGLIS & COOPER

Lacertus fibrosus is divided along with any remaining Lacertus fibrosus is divided along with any remaining portions of the flexor muscle origin.portions of the flexor muscle origin.

Ulnar nerve is trasposed anteriorly.Ulnar nerve is trasposed anteriorly.

WILLIAMS AND HADDADWILLIAMS AND HADDAD

Medial aspect of arm and forearm anterior to the Medial aspect of arm and forearm anterior to the medial epicondyle of the humerus, beginning 5 medial epicondyle of the humerus, beginning 5 cm proximal to the elbow extending distally to 5 cm proximal to the elbow extending distally to 5 cm proximal to the wrist. cm proximal to the wrist.

WILLIAMS AND HADDADWILLIAMS AND HADDAD

Structures anterior and medial to the elbow are Structures anterior and medial to the elbow are exposed.exposed.

WILLIAMS AND HADDADWILLIAMS AND HADDAD

Lacertus fibrosus is divided.Lacertus fibrosus is divided.

Origins of the superficial flexors are released from the medial Origins of the superficial flexors are released from the medial epicondyle.epicondyle.

Origin of flexor digitorum superficialis is released from radiusOrigin of flexor digitorum superficialis is released from radius

WILLIAMS AND HADDADWILLIAMS AND HADDAD

Origin of Flexor carpi ulnaris is released from olecronon.Origin of Flexor carpi ulnaris is released from olecronon.

Common origin of flexor carpi ulnaris and flexor Common origin of flexor carpi ulnaris and flexor digitorum profundus are released from ulna.digitorum profundus are released from ulna.

WILLIAMS AND HADDADWILLIAMS AND HADDAD

Origin of flexor digitorum profundus is released Origin of flexor digitorum profundus is released from volar aspect of ulna and interosseous from volar aspect of ulna and interosseous membrane.membrane.

WILLIAMS AND HADDADWILLIAMS AND HADDAD

Origin of flexor digitorum profundus to the index Origin of flexor digitorum profundus to the index finger is released from radius.finger is released from radius.

WILLIAMS AND HADDADWILLIAMS AND HADDAD

Ulnar nerve is transplanted anteriorly into Ulnar nerve is transplanted anteriorly into brachialis muscle.brachialis muscle.

AFTER SURGERYAFTER SURGERY

Sutures are removed after 3 weeks.Sutures are removed after 3 weeks.

Extension hand splint should be worn for Extension hand splint should be worn for 3 months.3 months.

Occupation and physiotherapy should be Occupation and physiotherapy should be continued until desirable function is continued until desirable function is attained.attained.

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