May 30, 2024

Volkmann’s Ischemic Contracture causes dysfunctional limb with varying amounts of deformity, stiffness, and paralysis as a result of ischemia leading to irreversible muscle and nerve damage

Pathophysiology is exact as compartment syndrome

Anatomy related to Volkmann's Ischemic Contrature
Anatomy related to Volkmann’s Ischemic Contrature

At the entrance of the flexor compartment, Lacertus fibrosis fan medially from the biceps tendon. Beneath lacertus fibrosis median nerve and brachial artery pass to enter the flexor compartment.

The brachial artery gives a branch to the radial artery (continue superficially ) and ulnar artery (passes beneath pronator teres) and median nerve also pass beneath lacertus fibrosis.

Volkmann’s Sign: Inability to actively extend finger (at IP and/or MCP joints) with/out flexing the wrist and passive extension of fingers possible only with wrist flexion. (It differentiate between deformities due to nerve palsy and intrinsic muscle contracture of long flexors)

In Supracondylar fracture: Brachial artery may get impingement on the sharp proximal fragment against which is held by lacertus fibrosis which is further compressed by hemorrhage and edema

Severe ischemia results in

  • Complete recovery
  • Gangrene (involves all tissue)
  • Middle course (contracture): selective muscle and nerve

Tolerance of tissue

TissueFunctional impairment after ischemiaIrreversible loss
Muscles2-4 hours4-12 hours
Nerves30 minutes12-24 hours

Deepest compartment: FDP (1st to get involved), FPL

In mild form: FDP of the ring and little finger

In severe form: All 4 digits

Less commonly: FDS, PT

Deformities in VIC

  • Elbow flexion
  • Forearm pronation
  • Wrist flexion
  • MCPJ extension
  • IPJ flexion
  • Thump flexion and adduction
  • Median and ulnar nerve neuropathy

Intrinsic muscle contracture vs Volkmann contracture

Intrinsic muscle contractureVolkmann Contracture
Intrinsic-plus deformityIntrinsic-minus deformity
Flexion: MCP JointHyperextension: MCP Joint
Extension: PIP JointFlexion: PIP Joint

Although the two entities may occur simultaneously, resulting claw hand deformity is determined by powerful extrinsic finger flexors

Classifications

Bunnell’s

  • Simple
  • Severe

Pedemonte

  • Classic
  • Useless

Merle D’ Aubigne

  • With claw hand
  • Without claw hand

Holder

  • Ischemia proximal
  • Ischemia at the same level

Seddon

  • Grade I: Ischemia
  • Grade II: Ischemia contracture
  • Grade III: Ischemia contracture with nerve involvement

Zancolli Classification

  • Type I: Contracture involving forearm muscle with normal intrinsic muscle
  • Type II: Contracture involving forearm muscle with paralysis of intrinsic muscles
  • Type III: Contracture involving forearm muscle with contracture of intrinsic muscle
  • Type IV: Combined type

Seddon (modified by Tsuge)

MildModerateSevere
Partially involved deep flexorsMostly involved FPL, FDP, and part of FDS, PTAll flexor muscles involved
Flexor contracture on one or more fingers which can be extended on hyper flexing wrist ( Often ring/ middle finger)Involvement of thumbWasting of all muscles seen
Resistance pronation contracture involving either pronator teres or quadratusMedian Nerve > Ulnar Nerve
(Decrease sensation in the median and ulnar nerve zones)
Neurological deficit (marked)
Proximal: Pronator teres
Middle: FDP
Distal: Pronator quardatus
Intrinsic minus hand Joint contracture seen

Management Options

Volkmann's Ischemic Contracture Management Outline
Volkmann’s Ischemic Contracture Management Outline

Before Surgery

Assessment of muscle group involved or spared (for tendon transfer), nerve involvement, and skin involvement

Duration of surgery:

The ideal time is to wait for 3 months (necrotic segment segregation and spontaneous recovery of muscle and nerve stops

Treatment Options for VIC

1. Acute Stage (< 24 hrs)

Manage like that of compartment syndrome

2. Sub-acute or delayed stage (24 hrs – 3/6 months)

  • To improve sensation and motor function and prevent stiffness and deformity
  • Mobilization and supervised physiotherapy
  • Surgery Indicated:
    • If there is neurological involvement
    • Failure of conservative treatment
    • Radiological evidence of fibrosis

Options:

  1. Neurolysis and displacement of the nerve from contracting cicatrix to subcutaneous plane\
  2. Excision of scar done
  3. If severe nerve damage:- Excision followed by grafting may be attempted

3. Established VIC

  • Mild
  • Moderate
  • Severe

Mild (Early)

  • Normal hand sensibility and strength: Conservative
  • An alternate passive and dynamic splint at 2 hours
  • At night, an Extension splint
  • The satisfactory outcome with early treatment

Mild (Severe)

  • Excision of infracted muscles
  • Lengthening the tendons

Moderate to severe (5 Phases)

  1. Release of secondary nerve compression
  2. Treatment of contracture
  3. Tendon transfer for substitution / reinforcement
  4. Free innervated muscle graft
  5. Salvage (Bone) surgery

Release of secondary nerve compression

  • Improvement is related to severity and duration
  • Signs of gradual recovery: 12 months

The median nerve can be constricted on:

  • Lacertus fibrosus
  • Two heads of pronator teres
  • Proximal arch of FDS
  • Carpal tunnel

Ulnar nerve compression

  • Low incidence
  • Between Ulnar and the humeral head of FCU

Radial nerve compression

  • Rare
  • Under tendinous origin of supinator (arcade of forhse)

Treatment of Contracture

Should be performed at the time of or subsequent to nerve decompression

Infract excisionFlexor tendon lengthening or excisionFlexor pronator slide
6 months of splitting by surgery (Seddon)Z-lengthening of FDP, FDS, FPL, PTMore effective infract excision
Post-operative immobilizationDisadvantages: weaknessRelease of origin of PT, FCR, PL, FDS, FPL, Humeral head of FCU
For involvement of multiple tendons

Disadvantages:

  • Ineffective for paralyzed muscles
  • Risk of recurrences
  • Decrease strength of grip, especially in flexion of the DIP
  • Some scar tissue is left behind
  • All flexors are treated as the same despite severe damage

Tendon transfer for substitution / reinforcement

Usually delayed till after nerve recovery

After maximal contracture correction

Phalen and Miller (1947)

  • Digital flexion and thumb opposition
  • ECRL-FDP, ECU-thumb opposition, EPB- ECU

Huber

Abductor digiti minimi quinti opponenplasty (thumb reconstruction)

Zancolli and Burkhalter

Extensor indices proprius opponenplasty

Parkes

FDS to FDP transfer

Transfer extensor tendon to flexors

Free muscle Graft

If no tendons are available for transfer

  1. Gracialis
  2. Lattismus dorsi
  3. Medial Gastrocnemius

Tendon lengthening are not preferred due to reconstruction and adherent to skin and each other

Salvage (Bone) surgery

Seldom necessary

  • Proximal or distal carpectomy
  • Radius and Ulnar shortening
  • Wrist or digital fusion