VOLKMANN'S CONTRACTURE

Volkmann's contracture is a permanent shortening of the limb muscles. It is most commonly associated with injury to the upper forearm causing a clawlike deformity of the hand, fingers and wrist. It is the end result of an untreated compartment syndrome.With early and prompt diagnosing and treatment of compartment syndrome, Volkmann's contacture has fortunately become a relatively rare complication.  It can be severely disabling. Prompt treatment is essential to restore blood flow and reduce compartmental pressure. Permanent ischemic damage to muscle and nerve tissue occurs in 4-6 hours unless treated.

Pathophysiology

• Any process that leads to increased compartmental pressure can lead to a compartment syndrome and thus to ischemic contracture:
• Increase in interstitial tissue pressure
• Pressure increase in fascial compartment
• Tissue pressure rises above that of capillaries, opeing pressure.  This is followed by an additional increase in tissue pressure which exceeds the opening pressure of the veirns.  This causes venous congestion and an additional rise in tissue pressure. Finally, the aterial opening pressures are exceeded and all blood in-flow to the tissues stops.
• The rising tissue pressures lead to a lack of oxygenation and the accumulation of metabolic by-products whjich further damage the involved tissues.
• Severe injury to the deep tissues including distal nerves and muscles occurs.  The forearm muscles become ischemic and necrose'
• When the ischemia of the muscle tissure is left untreated, the muscles become fibrosed and contracted (Volkmnan's Contracture).

Related Anatomy

• Thigh, leg or foot - tibial shaft fractures
• Forearm - volar, dorsal and mobile wad
• Hand - hypothenar compartment, thenar compartment, adductor pollicis compartment, four dorsal interossei compartments, three volar compartments

Tsuge Classification of Forearm Contracture⁵

1. Mild – localized to deep flexor compartment
   • Contracture of profundus muscle, occasionally FPL and PT as well
   • Characterized by flexion contracture of long and ring fingers (occasionally index and small), possible contracture of thumb (FPL) and restriction to supination (PT)
   • Sensory disturbances in median nerve distribution
2. Moderate – deep flexor compartment with involvement of wrist flexors and FDS
   • Characterized by wrist held in flexed posture and hand in intrinsic minus
   • Sensory disturbances in median and ulnar nerve distribution
3. Severe – involvement of flexors and extensors
   • All flexors and pronators are involved with some involvement of extensors and intrinsics
   • Characterized by intrinsic minus
   • Sensory disturbances in median and ulnar nerve distribution
   • Long-standing cases lead to secondary fixed joint contractures

Incidence and Related Conditions

• Fracture, particularly displaced supracondylar fractures of the humerus in children or distal radius and tibial diaphysis fractures in adults
• Severe crush injury
• Prolonged compression (constrictive bandages, casts and Pneumatic Anti-Shock Garments)
• Restoration of blood flow to an ischemic limb
• Animal bites (insect bites, snake bites)
• Hematomas
• Severe thermal burns
• Injection of medicines such chemotherapy drugs and contrast dyes for imaging
• Excessive exercise (exertional compartment syndrome) - this is usually a transient comkpartment syndrome bought on by exercise and relieved by rest.

Differential Diagnosis

• Nerve injuries
• Arterial injuries

A right handed 34 y.o. male who sustained a crush injury to his right forearm 3 weeks ago.  He was initially seen at an outside facility where he was diagnosed with a comminuted and segmental radius and ulna fractures.  There was severe forearm swelling associated with his injuries. He was not admitted.  He was splinted and told to follow up with an orthopaedic hand surgeon but was lost to follow up.  He states that his pain was nearly unbearable during the first few days after the injury.  He took considerable pain medications to manage his pain.  The patient was finally sent at a second hospital.  His pain has subsided some but he can no longer actively flex/extend his fingers.  He was admitted and an emergency fasciotomy was performed.  There was significant necrotic muscle that had to be debrided. The same patient returned several years later to a third hosptial with stiff fingers held in a clawed posture.  He has no sensation to his arm and had very limited motor function in the forearm and hand.  He has muscular atrophy of his forearm compartments and dense fibrous tissue could be palpated.  He was diagnosed with a chronic Volkmann's contracture. 

• Functional impairment due to permanent loss of muscle and nerve tissue
• Fasciotomy can result in: altered sensation within the margins of the wound; dry, scaly skin, pruritus, discolored wounds, swollen limbs, tethered scars, ulceration, muscle herniation, wound related pain, and tethered tendons
• Scars from surgery can have long-term psychological effects on patients

• A difference in forearm length is common in the majority of patients treated for Volkmann's contracture in childhood
• Tendon lengthening has a lower success than other procedures
• Good hand function resulting from excision of fibrotic muscle tissue, neurolysis and tenolysis (sometimes combined with a tendon transfer) only in patients with sufficient remaining muscle tissue
• Substantial improvement of function associated with free vascularized muscle transplantation

• Tsuge Type 3 Volkmann ischemic contracture of the forearm is best treated with a free gracilis muscle transfer.^5,6,7
• The prerequisites for a successful free gracilis muscle transfer include good passive range of motion, reasonably intact sensation, and active finger, thumb and wrist extension.5,6,7
• Forearm muscles, listed in the order of their susceptibility to ischemia, are the flexor digitorum profundus, the flexor pollicis longus, flexor digitorum superficialis, the pronator, wrist extensors and brachioradialis.  Note the muscles closest to the bone are the most vulnerable. Also note the middle portion of each muscle is most sensitive to ischemia.5,6
• Forearm nerves, listed in the order of their susceptibility to ischemia, are the median and ulnar nerves. Only in very severe cases would the radial or posterior interosseous nerves be damaged in a Volkmann ischemic contracture.5,6
• A neonatal sentinel lesion is an eschar or bulla on the dorsoradial forearm caused by a compartment syndrome.  The size of the lesion correlates with the severity of the compartment syndrome.⁸
• Displaced supracondylar fractures in children can be complicated by a compartment syndrome which resilts in a Volkmann ischemic contracture.5

New Articles

1. 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):e36-7. PMID: 23484979
2. Agrawal H, Dokania G, Wu SY. Neonatal Volkmann Ischemic Contracture: Case Report and Review of Literature. AJP Rep 2014; 4(2):e77–e80. PMID: 25452886
3. Mubarak SJ, Carroll NC. Volkmann's contracture in children: aetiology and prevention. J Bone Joint Surg Br 1979;61-B(3):285-93. PMID: 479251
4. Holden CE. The pathology and prevention of Volkmann's ischaemic contracture. J Bone Joint Surg Br 1979;61-B(3):296-300. PMID: 479252
5. Green, David P. Green's Operative Hand Surgery: Volumes 1 and 2. Churchill Livingstone, 2010.
6. Manktelow RT, Zuker RM. The principles of functioning muscle transplantation: applications to the upper arm. Ann Plast Surg. 1989; 22:275-282.
7. Zuker RM, Bezuhly M, Manktelow RT. Selective fascicular coaptation of free functioning gracilis transfer for restoration of independent thumb and finger flexion following Volkmann ischemic contracture. J Reconstr Microsurg. 2011:27(7): 439-444.
8. Ragland R, Sharpe F.  Compartment syndrome in the newborn: report of 24 cases. J Hand Surg Am. 2005; 30(5): 997-100