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Volkmann¶s ischemic contracture
Volkmann's ischemic contracture is caused by compartment syndrome leading to muscle and nerve necrosis in the forearm. It is characterized by contractures and neurological deficits. The condition typically results from untreated injuries that increase forearm compartment pressure, blocking blood flow. Clinical signs include pain, paresthesia, loss of pulses, and contractures. Treatment involves urgent fasciotomy to release pressure if compartment syndrome is present. Established contractures may be treated conservatively or with muscle sliding procedures like Inglis-Cooper or Williams-Haddad to release contracted flexor muscles and tendons.
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Volkmann¶s ischemic contracture
- 1.
- 2. VOLKMANN’S ISCHEMIC CONTRACTURE •Definition :A condition which is characterized by ischemic necrosis of the structures contained within the volar compartment of the forearm associated with crippling contractures and varying degrees of neurologic deficit.
- 3. • HISTORY • 1881,Volkmann stated that paralytic contractures that develop within a few hours after injury are caused by arterial insufficiency or ischemia of muscles.
- 4. • HISTORY • 1906,Hildebrandfirst used the term "Volkmann ischemic contracture“ to describe the final result of any untreated compartment syndrome. • 1909, Thomas found that paralytic contractures followed severe contusions of the forearm without fractures. • 1914, Murphy reported that increased internal pressures in the deep compartments of the forearm and effusion in the muscles resulted in ischemia.
- 5. • 1928,Jones concluded that Volkmann’s contracturecould be caused by pressure from within, from without or both.
- 6. • Volkmann’s ischemic contractureis a late sequelae of untreated or inadequately treated compartment syndrome in which necrotic muscle and nerve tissue are replaced with fibrous tissue .
- 7. ANATOMY • At theentrance to the flexor compartment of the forearm , lacertus fibrosus fans medially from the biceps tendon. • Beneath the lacertus fibrosus the brachial artery and median nerve pass to enter the flexor compartment.
- 8. ANATOMY • The brachialartery divides into radialand ulnar arteries. • The radial artery courses superficially and is not crossed by any structure in the forearm. • The ulnar artery passes beneath the pronator teres where it gives a branch, the common interosseus artery. • The common interosseus artery further divides into volar and dosal interosseus arteries.
- 9. ANATOMY • The mediannerve accompanies the brachial artery beneath the lacertus fibrosus and enters the substance of the pronator teres passing between its humeral and ulnar heads.
- 10. ANATOMY • Compartments ofthe forearm. • 1. Superficial volar compartment. • 2. Deep volar compartment. • 3. Dorsal compartment. • 4. Mobile wad of Henry.
- 11. ETIOLOGY • Supracondylar fractures ofthe humerus in children is the most common precipitating injury. • The brachial artery may get impinged on the sharp proximal fragment against which it is held by lacertus fibrosus.
- 12. ETIOLOGY • Hemorrhage and edemamay further compress the brachial artery and the median nerve in this region.
- 13. ETIOLOGY • Ischemia ±±Edema cycle as depicted by Eaton and Green
- 14. ETIOLOGY • 1. Crushinjuries. • 2. Prolonged external compression. • 3. Internal bleeding (Hemophilia). • 4. Burns. • 5. Snake bites. • 6. Intravenous regional anesthesia
- 15. TOLERANCE OF TISSUE •1. Muscle :- • Functional impairment after 2-4 hours of ischemia. • Irreversible functional loss after 4-12 hours. • 2. Nerves :- • Functional impairment after 30 mins of ischemia. • Irreversible function loss after 12-24 hrs.
- 16. CLINICAL PICTURE • Acutecompartment syndrome (Impending Volkmann’s ischemic contracture) • 1. If local compression is the cause : • Pulses intact ( in early stages) • Paresis • Stretch pain • Parasthesia (median nerve sensory zone commonly) • Good capillary filling.
- 17. CLINICAL PICTURE • Acute compartmentsyndrome (Impending Volkmann’sischemic contracture) • 2. If arterial injury is the cause : • Stretch pain • Parasthesia • Pulselessness • Pallor ( or Cyanosis) • Paresis
- 18. CLINICAL PICTURE • Twopoint discrimination is more than 1 cm in in the sensory zone of the median nerve. • Diminished perception of vibratory sense of 256cycles/sec stimulus.
- 19. CLINICAL PICTURE • Measurement ofintracompatmental pressure : • 1. White sides handheld pressure monitoring system. • 2. Wick catheter. • 3. Slit catheter.
- 20. CLINICAL PICTURE • Evaluatingthe intracompartmental pressure. • Range between 10 ± 20 mmHg below the diastolic pressure - cessation of blood flow is eminent. • 40± 50 mmHg - muscle threatening compression and ischemia are present. • Pressure of 30 mmHg or greater - criterion for fasciotomy.
- 21. Deformities in Volkmann’sischemic contracture • Mild type : • Deep flexors are partially involved particularly, Flexor digitorum profundus. • Flexion contractures of one or more fingers which can be extended on hyperflexing the wrist. • Resistant pronation contracture involving either the pronator teres or pronator quadratus.
- 22. Deformities in Volkmann’sischemic contracture • Moderate type : • Involves most of the flexor digitorum profundus, flexor pollicis longus and part of flexor digitorum superficialis. • Neurological deficit involving median nerve more than ulnar nerve is present. • Deformity is intrinsic minus hand. • Diminished sensations in median and ulnar nerve zones.
- 23. Deformities in Volkmann’sischemic contracture • Severe type : • All the flexor muscles are involved. • Neurological deficit is severe. • Joint contractures are marked. • Wasting of forearm muscles .
- 24. MANAGEMENT - ACUTECOMPARTMENT SYNDROME (IMPENDING VIC)
- 25. MANAGEMENT - ACUTECOMPARTMENT SYNDROME (IMPENDING VIC) • Forearm fasciotomy • Incision :A volar curvilinear liberal incision medial to the biceps tendon, crossing the elbow flexion crease at an angle carring it distally to the palm to release the carpal tunnel.
- 26. MANAGEMENT - ACUTECOMPARTMENT SYNDROME (IMPENDING VIC) • Exploration must extend deeply to the FDPand FPL. • Necrotic muscle tissue is excised. • Median nerve freed beneath the lacertus fibrosus. • Ulnar nerve is freed and transplanted anteriorly . • Brachial artery must be inspected and decompressed . • Surgical wound is left open for secondary closure later when swelling subsibes. • Extremity supported with splint in funtional position.
- 27. CONSERVATIVE MANAGEMENT ESTABLISED DEFORMITIES •Robert Jones method(1930s).(1930s). • Wooden tongue depressors were used to correct established deformities gradually from distal to proximal over a prolonged period of time .
- 28. CONSERVATIVE MANAGEMENT ESTABLISED DEFORMITIES •Banjo splint : • Banjo splint used with rubber bands fastened to adhesive tape on the fingers permits the fingers to be exercised at all times and is most efficient.
- 29. ESTABLISHED VOLKMANN’S ISCHEMIC CONTRACTURE-MANAGEMENT • Muscle sliding operation of flexors of forearm. • Inglis & Cooper • Williams & Haddad
- 30. INGLIS & COOPER •Incision on the medial aspect of volar side of the arm 5 cm proximal to medial epicondyle and distally to midpoint of forearm over the ulna.
- 31. INGLIS & COOPER •Ulnar nerve is identified, released from the cubital tunnel and protected. • Tendinous origins of muscles on the medial epicondyle are cut. • Flexor carpi ulnaris and Flexor digitorum profundus are completely released from the medial epicondyle and ulna.
- 32. INGLIS & COOPER •Lacertus fibrosus is divided along with any remaining portions of the flexor muscle origin. • Ulnar nerve is trasposed anteriorly.
- 33. WILLIAMS & HADDAD •Medial aspect of arm and forearm anterior to the medial epicondyle of the humerus, beginning 5 cm proximal to the elbow extending distally to 5cm proximal to the elbow extending distally to 5cm proximal to the wrist.
- 34. WILLIAMS & HADDAD •Structures anterior and medial to the elbow are exposed.
- 35. WILLIAMS & HADDAD •Lacertus fibrosus is divided. • Origins of the superficial flexors are released from the medial epicondyle. • Origin of flexor digitorum superficialis is released from radius.
- 36. WILLIAMS & HADDAD •Origin of Flexor carpi ulnaris is released from olecronon. • Common origin of flexor carpi ulnaris and flexor digitorum profundus are released from ulna.
- 37. WILLIAMS & HADDAD •Origin of flexor digitorum profundus is released from volar aspect of ulna and interosseous membrane.
- 38. WILLIAMS & HADDAD •Origin of flexor digitorum profundus to the index finger is released from radius.
- 39. WILLIAMS & HADDAD •Ulnar nerve is transplanted anteriorly into brachialis muscle.
- 40. AFTER SURGERY • Suturesare removed after 3 weeks. • Extension hand splint should be worn for 3 months. • Occupation and physiotherapy should be continued until desirable function is attained.