3. Introduction
• Volkmann contracture
– 19th century doctor Richard von Volkmann
• Classically associated with Supracondylar
fracture of the Humerus
• Any cause of compartment syndrome can
potentially result in VIC
4. Tight bandages/ dressings Muscle hypertrophy
Animal bites Neoplasms
Burns Bleeding into a compartment
( vascular injury, congenital,
or acquired disorder)
Intensive exercises Injections in the forearm
5. Etiology
• Result of prolonged ischemia
• Broad clinical spectrum
• Deformity and dysfunction
• Nerve dysfunction
7. Clinical and demographic profile Volkmann's ischemic
contracture presenting in Tigray (Ethiopia)
Abstract
Objective: Volkmann's ischemic contracture (VIC) represents the outcome of a
compartment syndrome, not adequately managed during the acute phase. It is still to
be found in the developing countries, while it is rarely present in the developed
countries. In this report we refer on our African experiences on VIC, because we
believe might be useful for last generation of Italian orthopedics which rarely have a
chance to see Volkmann's cases. Materials and Methods: AA report their 2-years
experience of 16 patients aged 7 to 17, presenting various entities of Volkmann's in
Tigrai. Results: in all patients there has been an acceptable recovery of hand function,
also although the difficulty to verify the outcomes because of the scarce overlapping
of the clinical status and different operations. Conclusions: attention shall be drawn to
the outcomes and a healthcare education is necessary in those villages where cures
are entrusted to the so called "traditional doctors" who are nothing more than "bone-
setters".
10. History & Physical
• Have typical history and physical exam
– Pain, Pallor, Pulselessness, parasthesias, &
paralysis
11. Classification
• Extent of muscle involvement and severity of
clinical disability
• Guides treatment & reconstruction planning
• Tsuge classification
12.
13.
14.
15. Evaluation of VIC patient
• Typically patients can be diagnosed with
history and physical
• Adjuncts: CPK, BUN, Cr., S. Electrolytes, UA, &
urine myoglobin, CB, &coagulation profile
• Measuring intra-compartmental pressure
• Imaging
17. Differential Diagnosis
• Dupuytren Contracture
– Progressive condition
• Pseudo VIC
– Inability to fully extend fingers due to mechanical
entrapment in patients with forearm fractures
18. Treatment & Management
• Removal of all dressings/casts/splints
• Elevation of the limb
• Correction of anemia
• Emergency fasciotomy
19. Prognosis
• Outcome of Fasciotomy for ACS leading to VIC
– Duration & intensity of Compartment syndrome
• Prognosis of established VIC
– FFMT substantial improvement in hand function
– Tendon lengthening causes recurrence of
contractures in many cases
21. Postoperative Care & Rehabilitation
• ACS incisions left open
• Dressing changes every 24-48 hrs.
• Delayed primary wound closure
• Rehab varies according to procedure
performed
22. Treatment
• Limitation in role of non-operative treatment
• Operative treatment
– Bone procedures
– Soft tissue procedures
23.
24. Bone Procedures
• Skeletal Shortening or fusions
– Matching skeletal length o shortened fibrotic
muscle
– Of concern in children because forearm is already
shortened by initial ischemic insult
– Useful for residual problems related to nerve
dysfunction or longstanding contractures not
amenable to soft tissue release
25. Bone Procedures
• Options of bony procedures
– Wrist fusion
– Trapeziometacarpal joint fusion
– Thumb MCP joint fusion
– Arthrodesis
• Chondrodesis
26. Soft Tissue Procedures
• Excision of infarcted muscle
• Fractional/ Z lengthening
• Muscle sliding procedures
• Neurolysis
• Tendon transfer
• Functional free-tissue transfer
27. Mild (localized) Type
(Deep Flexor Compartment without Neurologic Deficit)
• Failure to not respond to nonsurgical
management
• Muscle sliding
– Not combined with infarct excision or distal
release of pronator teres to correct pronation
contracture
• Limited approach reduces potential scarring
and vascular compromise
28. Moderate Type
(Deep and Superficial Compartment with Neurologic Deficit)
• Flexor muscle origin slide
• Characterized by Neurologic impairment
– Muscle slide is combined with neurolysis
• Thumb function
– Brachioradialis or ECRL to FPL
29. Moderate Type
• Reconstruction of Finger Flexion
– FFMT
– Tendon Transfer
• ECRL to FDP
• Biceps Brachi elongated with graft
• Brachioradialis, ECU, EIP
– Nerve Reconstruction
• Severe sensory impairment without recovery
30.
31.
32. Severe Type
(Superficial and Deep Flexor Compartments, Extensor
Compartment, Severe Neurologic Deficits)
• Best treated with FFMTs
– Donor vessels: Radial or Anterior interosseous
• Severe Contractures: Double FFMT
33. Flexor Pronator Slide
• Incision: medial epicondyle to wrist
• Ulnar nerve mobilization
• Elevation flexor pronator mass
• Mobilize origin of FCU, FDP, & FDS from ulna
and interosseous membrane
• FPL released from origin
34.
35.
36. Flexor Pronator Slide
• Extent of Dissection
• Carpal tunnel
• Antecubital area
– Release helps correct deformity and prevents
median nerve compression
• Under-correction
• Ulnar nerve transposition ( anterior
subcutaneous position)
37. Free Functioning Muscle Transfer
• Microsurgical transplant off innervated muscle
• Perquisites
– Adequate passive range of motion of joints
– Some degree of protective sensibility
– Willingness to wait for reinnervation
– Extensive pre and post op physiotherapy
38.
39. FFMT
• Properties for donor muscle
– Expendable
– Common muscles: gracilis, ld, rectus femoris,
vastus lateralis
• Successful outcome at least grade 4 muscle
function
40. FFMT
• Vascular complications linked to poor
outcomes
– Monitoring of skin paddle alone inadequate
– Doppler monitoring
– Low threshold for exploration
– Dedicated microvascular surgery unit follow-up
• Postop Immobilization
42. Summary
• Early diagnosis and management of
Compartment syndrome
• Non-operative management viable only for
mild cases
• Possibility of progression from moderate to
severe
• Prolonged follow-up and rehabilitation
– Patient selection and motivation
43. References
• Elsevier . (2017). Green's Operative Hand
Surgery 7th Ed. . Philadelphia: Elsevier .
• Elsevier. (2018). Neligan Hand and Upper
Extremity 4th Edition. Philadelphia: Elsevier .
• Fasolo, L. C. (2021). Clinical and Demographic
Profile volkmann/s ischemic Contracture
Presenting in Tigray (Ethiopia). ACT Biomedica.
• Taqi, T. M. (2023). Volkman Contracture.
StatPearls.
Key precipitating events is ischemia of the forearm due to ACS
A condition in which there is an increase in intra-fascial pressure of any closed compartment in the body
This may occur due to two basic reasons a decrease in compartment size or an increase in the volume of the compartment
Intrinsic or extrinsic compartment syndromes
NB some literatures don’t limit the term VIC to just the presentation in the hand but most exclusively mention VIC as the ischemic fibrosis of anterior forearm muscles
Volkmann first described it in his paper on non-infective ischemic conditions off various fascial compartments in the extremities
Hildebrand first used the term to describe the final result of any untreated compartment syndrome
1909 Thomas paralytic contractures occurring as a result of severe contusions
Murphy reported increased internal pressure in deep compartment and effusion in muscles resulted in ischemia
VIC is also described as a sequelae acute arterial insufficiency of the limbs, emboli lodging in the arterial vasculature can also result in ischemia of the muscles resulting in limb contractures
End result of prolonged ischemia & associated with irreversible tissue necrosis established VIC has a different presentation
Spectrum is based on extent of muscle necrosis and degree of nerve injury
Unlike patients of ACS, VIC patients lack in pain and defining characteristic is deformity and dysfunction as a result of the ischemic event and resulting muscle scarring and fibrosis
Nerve dysfunction can occur as a result of the initial trauma, subsequent ischemia, or secondary to the fibrosis surrounding the nerves
As a result of muscle fibrosis and neurologic deficit distal to the site of ischemia patients will have deformity of the joints which is progressive and occurs over a period of weeks to months
In children the deformity will progress until they attain skeletal maturity, affected extremity is shortened due to tethering across physis
VIC is a relatively rare condition, most commonly presents after pediatric upper limb trauma
.105% of al orthopedic cases, with the majority of cases being males in 2nd and 3rd decade of life
Divided into 3 sections: arm, forearm, & hand
Principle bone the arm, humerus, connects ulna and radius (bones of the forearm) with the scapula
Forearm extends from elbow to the wrist with two groups of muscles flexor group and extensor group
Brachial artery courses down humerus, runs through the elbow and divides into two terminal branches with ulnar artery blood supply for the flexor group of muscles
A
Superficial: PT, PL, FCR, FDS, PL, & FCU
Deep: FPL, PQ, & FDP
Exception of FCU (Ulnar N.) all are innervated by median nerve with FDP having a dual supply
Both of these groups of muscles are involved in development of VIC
Most common associated injury with VIC of the forearm
Key signs and symptoms of compartment syndrome develop well before actual contracture and fibrosis o the muscles
Pain exacerbated by passive extension of hands and fingers of the affected limb, palpation of forearm also demonstrates firmness of tissues
Several classification systems exist for VIC of the forearm and are dependent on extent of muscle involvement and severity of clinical disability
Limitation of classification is the variability of clinical presentation
A, Cross-sectional representation of a mild Volkmann contracture (according to Tsuge classification) at the midforearm
level. B, Volar clinical appearance of mild Volkmann contracture. C, Lateral view appearance of mild Volkmann contracture. D, Mild contracture allows for full extension of the fingers when the wrist is positioned in volar flexion.
Cross-sectional representation of moderate Volkmann contracture (according to Tsuge classification) at the midforearm level. B, Patient with Tsuge moderate Volkmann contracture. With the wrist in a position of volar flexion, the fingers cannot be brought into full passive extension. C, Finger flexion contracture is worsened by the wrist being brought into a neutral position. D, Patient demonstrates
full active finger flexion.
A, Cross-sectional representation of severe Volkmann contracture (according to Tsuge classification) at the midforearm level. B, Patient with severe contracture with extensive intrinsic wasting secondary to neurologic involvement at the forearm
Intracompartmental pressure is considered abnormal when pressures are greater than 30- 40 mm hg and warrant immediate fasciotomy
Stryker tonometer
Near-infrared Spectroscopy (non invasive tool which measures O2 saturated hemoglobin
Imaging may be supportive in diagnosis of VIC but are not first line investigations
X-rays identify displaced supracondylar fractures of the humerus
CT & MRI can help narrow differential diagnosis of compartment syndrome unrelated to fractures of upper limb
US may also help exclude ACS
Mild localized type of contracture in which only parts of FDP are affected, commonly presents as flexion of a limited number of fingers, 2or 3, usually involving middle and ring fingers and sensory loss is minimal
Moderate: classic type of contracture in which FDP & FPL are involved. Superficial muscles such as FDS, FCU, & FCR may also be affected, fibrosis of these muscles leads to a typical claw hand picture which presents as flexion of all five digits as well as the wrist with sensor impairment in ulnar and median distribution being common
Severe: this type of contracture develops in extreme cases and presents as the involvement of both flexors and extensors. Results in severely distorted contractures with pronounced sensory deficits.
NB long standing moderate VIC have the potential of eventually developing into severe VIC
This is a condition characterized by permanent flexion of one or more fingers, with exact etiology unknown with risk factors: CLD, alcoholism, smoking prior trauma
Begins as thickening nodules in the palm later progressing to restriction of finger motion
A relatively rare condition: of note signs and symptoms of ischemia are absent
May be seen in pediatric age group patients due to tethering of FDP to a fractured ulna
NB some literatures don’t limit the term VIC to just the presentation in the hand but most exclusively mention VIC as the ischemic fibrosis of anterior forearm muscles
First step in management of ACS or early VIC is removal of all external compressive coverings, it is a basic but crucial step in halting development of VIC if extrinsic compartment syndrome is the prime culprit.
Casts may restrict compartment expansion by up to 40% and should always be removed, reduces pressure elevation by ~ 40-60%
Limb elevation reduces limb swelling but elevation beyond the level of the heart can also reduce limb perfusion and increase risk of ischemia
Allowing relative hypertension and correcting anemia can also slow down progression of ACS
Primary emergency treatment for ACS leading to VIC is fasciotomy, with decompression achieved by volar or dorsal approach
Median nerve needs decompression throughout its course especially in high-risk areas (deep to lacertus fibrosus, in the caprpal tunnel, and between the heads of pronator teres
Prompt fasciotomy within 4 hours leads to minimal sequelae
Prognosis in established cases vary from case to case nearly all patients suffering from a contracture during childhood end up with a relatively short limb
Overall tenolysis, neurolysis, tendon transfer procedure, and removal of necrotic muscle produce good hand function in those who have sufficient muscle remaining
NPW dressings may be applied if major arteries and nerves aren’t exposed,
Aseptic changes to prevent wound infection
Closure of wounds can be done 7-10 days after so that swelling sufficiently subsides
Immobilization in a cast or splint 2-4 weeks recommended with gradual use of limb started afterwards
Some benefit from therapy in stretching and splinting mild contractures
In children splinting is continued until skeletal maturity, moderate and severe contractures resist therapy
Varying types of procedures are used in the treatment of VIC ( bony and soft tissue management)
Skeletal shortening or fusions are frequently performed in conjunction with some soft tissue procedures
Soft tissue procedures include manipulation of muscles tendons and nerves
Shortening procedures shortening osteotomy of the radius and ulna and proximal row carpectomy
Of concern with these procedures is principal contracture is within the flexor compartment. Shortening of the forearm indiscriminately lengthens both flexor and extensor muscles while neglecting the predominant involvement of the contracture within the flexor compartment
In those failing nonsurgical treatment
Effective as long as good active finger flexion is present
Limited flexor slide may be done for mild deformity
Affecting only part of FDP
FDP originates solely from the ulna, flexor pronator mass does not have to be released from medial epicondyle and ulnar nerve doesn’t have to be transposed
To correct tightness of the flexors provided there is adequate remaining strength in the flexors
Neurolysis for both ulnar and median nerves
Separate incision for carpal tunnel release may be needed
Depending on functional deficits tendon transfer can be combined with flexor origin slide (staged/simultaneous procedure)
Extensor indicis proprius can be used for thumb opposition at a later date
When flexors are weak or absent FFMT may produce a better functional result than a tendon transfer
ECRL to FDP is the best option it is synergistic and easy to relearn
The secondary options lack sufficient excursion to match the flexor muscles but in the absence of other options they can provide some improvement,
If there is minimal FDS involvement this muscle can be used as a donor to FDP
Densely scarred atrophic nerve or avascular nerve requires resection back to fascicles that appear healthy followed by sural nerve grafting to restore protective sensation in the hand
End to end anastomosis for radial and AIP, or end to side procedures when using the brachial artery
Donor motor nerve is the AIN which is resected back to healthy fascicles
Final outcomes may be improved by: tendon transfer, nerve graft reconstruction, and late osseous reconstructive procedures
Approach can be volar or Ulnar: incision begins on medial distal arm and continues to ulnar border of forearm up to the wrist
Ulnar nerve should be identified and mobilized for several centimeters proximal and distal to the medial epicondyle
Including proximal release at arcade of Struthers
Intermuscular septum b/n brachialis and triceps is excised to prevent kinking of ulnar nerve after transposition
Flexor pronator mass elevated off the medial epicondyle, preserving the medial collateral ligament and elbow joint capsule
Inadvertent joint capsule rupture should be repaired
Dissection is carried out above Periosteum toward the radius
Posterior interosseus artery a branch of common interosseous supplies extensor compartment and its protection is mandatory
AIN is found in this area and deserves special attention,
Wrist & fingers are manipulated throughout procedure to to see if there is improvement in contracture
FIGURE51.15 A, Diagram of surgical incision for flexor origin slide. B, Schematic diagram of deeper layer of dissection for flexor origin
slide. C, Ulnar incision with ulnar nerve identified and mobilized. Flexor pronator mass elevated from the medial epicondyle with preservation
of the medial collateral ligament and elbow joint capsule. D, Dissection proceeds in a radial direction with protection of the interosseous
arteries. E, Complete release heralded by full finger wrist extension with the wrist held in extension. FCR, Flexor carpi radialis; FDS, flexor
digitorum superficialis; PL, palmaris longus; PT, pronator teres.
Dissection often needs to be carried down to the level of the wrist, to release adhesions between the flexor tendons and pronator quadratus before achieving full correction
If necessary carpal tunnel should be opened and tendon adhesions released in this area
Lacertus fibrosus and superficial fascia in this area are often tight and contribute to residual elbow flexion contracture
Also can tether superficial flexors of the wrist and fingers leading to incomplete correction of the wrist and fingers
Hand is casted in position of forearm supination with wrist and fingers in full extension with immobilization continued for a period of 6 weeks to allow flexor pronator to heal adequately to its new origin
Compressed between the two heads of pronatoor teres
Slight under correction addressed by postop splinting may decrese the reduction in muscle power resulting from the muscle slide
Reserved for those having severe functional impairment who are not candidates for tendon or nerve transfers to areas devoid of function following muscle loss
Donor muscle units must provide both adequate power and excursion to be functionally useful
NB a donor muscles ability to generate given force is proportional to its cross sectional area and excursion is related to length and orientation of its muscle fibers
Properties
Expendable: donor muscle should ideally result in minimal morbidity or functional deficit at donor site after harvest
Following FFMT close monitoring is important, and skin paddle monitoring is inadequate because muscle is more metabolically active than skin and is therefore more intolerant of ischemia, by the time ischemic changes are seen in a skin paddle muscle may be irreparably injured
Hourly monitoring in for the first 48 hours following this monitoring can be decreased to every 4 hours since likelihood of postoperative thrombosis is less after the first 48 hours.
Immobilization varies from weeks to early passive motion protocol with tendon compression and tenodesis exercises
Lead to increased postop range of motion and decreased need for postop tenolysis procedures
A difficult problem to address
Nerve reconstruction is done when there is absent sensory and motor function or a clearly necrotic nerve intraop
Some sensory recovery can be expected but motor recovery is less predictable
If not restored with neurolysis or reconstruction, transfer from dorsal sensory branch of radial nerve to ulnar digital nerve of the thumb and radial digital nerve of index finger should be considered for restoration of sensate pinch
