You are in: eMedicine Specialties > Orthopedic Surgery > TRAUMA Volkmann ContractureArticle Last Updated: Aug 26, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: John A Kare, MD, Assistant Professor of Emergency Medicine, Charles R Drew University of Medicine and Science/UCLA, Director of Research, Department of Emergency Medicine, Martin Luther King Jr/Charles R Drew Medical Center John A Kare is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Student Association/Foundation, and Emergency Medicine Residents Association Editors: Jeffrey L Visotsky, MD, Assistant Professor, Department of Clinical Orthopedic Surgery, Northwestern University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Samuel Agnew, MD, FACS, Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania Author and Editor Disclosure Synonyms and related keywords: Volkmann contracture, compartment syndrome, compartmental pressure, flexor contractures, fasciotomy, pseudo-Volkmann contracture, Volkmann ischemic contracture, supracondylar humeral fracture, distal humerus fracture, ischemic contracture INTRODUCTIONSection 2 of 12
  In 1881, Richard von Volkmann published an article in which he attempted to ascribe irreversible contractures of the flexor muscles of the hand to ischemic processes in the forearm. He believed that the problem was caused by massive venous stasis and simultaneous arterial insufficiency secondary to overly tight bandages. In 1906, Hildebrand first used the term "Volkmann ischemic contracture" to describe the final result of any untreated compartment syndrome, and he was the first to suggest that elevated tissue pressure may be causally related to ischemic contracture. In 1909, Thomas reviewed the 112 published cases of Volkmann ischemic contracture and found fractures to be the predominant cause. However, he also noted that tight bandages, an arterial embolus, or arterial insufficiency could also lead to the problem. Since then, much has been learned about the etiologies of Volkmann contracture, and more important, much has been learned about its preventive therapies. History of the ProcedureIn 1914, Murphy was the first to suggest that fasciotomy might prevent Volkmann contracture. He also suggested that tissue pressure and fasciotomy were related to the development of contracture. During World War II and subsequent years, many cases of Volkmann contracture occurred as a result of high-velocity gunshot wounds that caused fractures. Unfortunately, the arterial spasm accompanying the fracture was seen as the cause; therefore, more attention was directed to treating arterial spasm than to the need for fasciotomy. Surgical exploration of the artery often led to reversal of an acute impending compartment syndrome. It is now thought that this outcome occurred because vascular surgeons were actually performing limited fasciotomies during exposure of the vasculature. Appreciation of the importance of fasciotomy grew during the Vietnam War, and, in 1967, Chandler and Knapp suggested that long-term results might have improved if the surgeons had included routine fasciotomy with arterial repairs. Originally, most studies of ischemic contractures were focused on those of the upper extremity. In 1958, Ellis reported a 2% incidence of compartment syndrome with tibia fractures, and increased attention was paid to contractures involving the lower extremities. Initially, the focus was on the anterior compartment of the leg, but the work of Seddon, Kelly, and Whitesides in the mid-1960s demonstrated the existence of 4 compartments in the leg and the need to decompress more than just the anterior compartment. Since then, compartment syndrome has been shown to affect many areas of the body, including the hand, foot, thigh, and buttocks. FrequencyOverall, Volkmann contractures are rare, with an incidence of about 0.5%. Blakemore et al reviewed 978 consecutive upper-extremity long-bone fractures in children admitted to the hospital over a 13-year period.1 Thirty-three were noted to have a supracondylar fracture. Three (7%) developed a compartment syndrome requiring fasciotomies. In a subgroup analysis, 9 children had ipsilateral displaced, extension, supracondylar humerus fractures or displaced forearm fractures. In this subgroup, the prevalence of Volkmann contracture was 33%. EtiologyAny process that leads to increased compartmental pressure can lead to a compartment syndrome. For example, decreased compartment size with no change in volume results in increased pressure. This change can be secondary to closure of fascial defects, localized external pressure, or overly tight dressings. Many processes lead to increased compartment content without a corresponding increase in compartment volume, thereby increasing pressure. Bleeding into a closed compartment can be due to a major vascular injury or a bleeding disorder, congenital or acquired. 2 Increased capillary permeability can be due to exercise, burns, hypoalbuminemia, intra-arterial drugs, surgery, seizures and eclampsia, exercise, and trauma (without major vascular injury). Exercise, venous obstruction, and use of a long-leg brace can lead to increased capillary pressure. Muscle hypertrophy or neoplastic processes can increase the volume and, therefore, the pressure within a compartment. Finally, infiltrated infusions are an unfortunate iatrogenic cause. PathophysiologyVolkmann ischemic contracture is usually seen in children with displaced supracondylar fractures of the humerus or forearm fractures.3, 4, 5 It results from severe injury to the deep tissues and muscles of the volar compartment secondary to increased compartmental pressures.6 Three types of Volkmann contracture have been described: mild, moderate, and severe. The mild type involves wrist flexors. The moderate type involves injury to the flexor digitorum profundus, flexor digitorum superficialis, flexor pollicis longus, flexor carpi radialis, and flexor carpi ulnaris. The severe type involves both the flexors and the extensors. A variant of Volkmann ischemic contracture known as pseudo-Volkmann contracture has also been described in the literature. This is due to tethering of the flexor digitorum profundus secondary to fractures of the ulna. It has been described to occur 2 days to 16 years after the closed reduction of fractures of the shafts of the radius and ulna. None of the patients had nerve palsies or undue pain after reduction of the fractures.7 A routine check of the passive range of motion of all fingers immediately after closed reductions of fractures of the radius and ulna is recommended. If muscle tethering is detected, repeat manipulation of the fracture is required to release the muscle. If unsuccessful, surgical release through a small incision should be attempted to normalize the length, excursion, and function of the flexor digitorum profundus. Function can be restored by untethering the muscle and its tendons from the ulnar fracture by means of early manipulation or late localized myotenolysis. ClinicalThe clinical presentation of Volkmann contracture includes what is commonly referred to as the 5 Ps. These are pain, pallor, pulselessness, paresthesias, and paralysis. Pain is the earliest sign. On physical examination, pain accentuated by passive stretching seems to be the most reliable finding. Firmness of the tissues often is noted on palpation. Pulselessness and paralysis are late findings. Induration of the forearm is another useful diagnostic finding. INDICATIONSSection 3 of 12
Some argue about which compartment pressure readings are indications for fasciotomy. However, most agree that patients with compartment pressures exceeding 30 mm Hg should be taken to the operating room for emergency fasciotomy. RELEVANT ANATOMYSection 4 of 12
The relevant anatomy of Volkmann contracture includes the superficial and deep flexor muscles. Superficial flexor muscles
Deep flexor muscles
Related eMedicine topic: CONTRAINDICATIONSSection 5 of 12
There are no absolute contraindications to immediate decompression for Volkmann contracture in the acute setting. WORKUPSection 6 of 12
Imaging Studies
TREATMENTSection 7 of 12
Medical therapyInitial treatment for Volkmann contracture consists of removal of occlusive dressings or splitting or removal of casts. Analgesics are the mainstay for symptomatic relief in chronic cases. Surgical therapyEmergency fasciotomy is required to prevent progression to Volkmann ischemic contracture. Decompression is performed via the volar or dorsal approach. Medial nerve decompression throughout its course is essential, especially in high-risk areas, including deep to the lacertus fibrosus; between the humeral and ulnar heads of the pronator teres, the proximal arch, and deep fascial surface of the flexor digitorum superficialis; and in the carpal tunnel.8, 9, 10, 11 Once contracture has occurred, treatment depends on the type of Volkmann ischemic contracture present. In the mild type, dynamic splinting, physical therapy, tendon lengthening, and slide procedures are used to improve function. In the moderate type, tendon slide, neurolysis (M and U), and extensor transfer procedures are used. The severe type requires more extensive and radical intervention. Extensive debridement of damaged muscle with multiple releases of scar tissue and salvaging procedures often are required. Severe contractures require the release of contracted tendons at the musculotendinous junction and tendon transfers performed at a later date. The preferred transfers involve the brachioradialis, which often is transferred to the flexor pollicis longus to regain thumb motion. For finger flexion, the extensor carpi radialis longus commonly is transferred to the flexor digitorum profundus. If no motor function is present secondary to muscle necrosis and fibrosis, free muscle can be used for transplantation. Intraoperative detailsMuscle viability in Volkmann contracture can be assessed by using what commonly is referred to as the 4 Cs: color, consistency, contractility, and capacity to bleed. Follow-upBoth physical therapy and occupational therapy are vital to the improvement of range of motion and the return of function in patients with Volkmann contracture. COMPLICATIONSSection 8 of 12
Complications related to fasciotomies for Volkmann contracture include the following12, 13:
The appearance of the scars can affect patients. In one study, 23% kept the wound covered, 28% changed hobbies, and 12% changed their occupation.12 OUTCOME AND PROGNOSISSection 9 of 12
Cubitus varus, or gunstock deformity, is the most common complication in Volkmann contracture. This results in the loss of the carrying angle of the upper extremity. Cubitus varus has been reported in as many as 25-60% of patients. The rate depends on the management. With the use of percutaneous pinning, the rate of this complication has decreased to less than 10%. With valgus or varus deformities in the coronal plane, remodeling is unlikely, if at all possible. Nerve injuries occur in 7% of cases, with common involvement of the radial, median, and ulnar nerves. Most deficits are seen at the time of injury. Fortunately, neuropraxias resolve with conservative management.14 Motor function returns at 7-12 weeks, followed by the recovery of sensation, which may take more than 6 months. Reportedly, 10% of children with supracondylar fractures temporarily lose the radial pulse. Fortunately, this most often is due to swelling and not to direct brachial artery injury. Reducing the fracture usually helps to return the arterial flow. FUTURE AND CONTROVERSIESSection 10 of 12
Current research is aimed toward reperfusion of the ischemic extremity. Some have advocated the use of hyperbaric oxygen to improve the oxygenation of the tissues and to prevent further myonecrosis.15 Early detection and prevention are still important in preventing severe disability. Frequent repeat examinations are required. Miniature transducer-tip catheters may allow continuous and accurate measurements of intracompartmental pressures.6 Other noninvasive techniques for Volkmann contracture are currently under investigation. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Article Last Updated: Aug 26, 2008 | |||||||||||||||||||
