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
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
| Tissue | Functional impairment after ischemia | Irreversible loss |
| Muscles | 2-4 hours | 4-12 hours |
| Nerves | 30 minutes | 12-24 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 contracture | Volkmann Contracture |
|---|---|
| Intrinsic-plus deformity | Intrinsic-minus deformity |
| Flexion: MCP Joint | Hyperextension: MCP Joint |
| Extension: PIP Joint | Flexion: 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)
| Mild | Moderate | Severe |
|---|---|---|
| Partially involved deep flexors | Mostly involved FPL, FDP, and part of FDS, PT | All flexor muscles involved |
| Flexor contracture on one or more fingers which can be extended on hyper flexing wrist ( Often ring/ middle finger) | Involvement of thumb | Wasting of all muscles seen |
| Resistance pronation contracture involving either pronator teres or quadratus | Median 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
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:
- Neurolysis and displacement of the nerve from contracting cicatrix to subcutaneous plane\
- Excision of scar done
- 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)
- Release of secondary nerve compression
- Treatment of contracture
- Tendon transfer for substitution / reinforcement
- Free innervated muscle graft
- 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 excision | Flexor tendon lengthening or excision | Flexor pronator slide |
| 6 months of splitting by surgery (Seddon) | Z-lengthening of FDP, FDS, FPL, PT | More effective infract excision |
| Post-operative immobilization | Disadvantages: weakness | Release 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
- Gracialis
- Lattismus dorsi
- 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
