VIC seminar for UG

1. VOLKMANN¶S
ISCHEMICCONTRACTURECONTRACT
UR

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,Hildebrand first 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
contracture could
be caused by
pressure from
within, from
without or both.

6. • Volkmann’s ischemic
contracture is 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 the entrance 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 brachial artery 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 median nerve
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 of the
forearm.
• 1. Superficial
volar compartment.
• 2. Deep volar
compartment.
• 3. Dorsal compartment.
• 4. Mobile wad of Henry.

11. ETIOLOGY
• Supracondylar
fractures of the
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
edema may 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. Crush injuries.
• 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
• Acute compartment 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’s ischemic
contracture)
• 2. If arterial injury is the
cause :
• Stretch pain
• Parasthesia
• Pulselessness
• Pallor ( or Cyanosis)
• Paresis

18. CLINICAL PICTURE
• Two point
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
of intracompatmental
pressure :
• 1. White sides
handheld pressure
monitoring system.
• 2. Wick catheter.
• 3. Slit catheter.

20. CLINICAL PICTURE
• Evaluating the 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’s ischemic
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’s ischemic
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’s ischemic
contracture
• Severe type :
• All the flexor muscles are
involved.
• Neurological deficit is
severe.
• Joint contractures are
marked.
• Wasting of forearm
muscles .

24. MANAGEMENT - ACUTE COMPARTMENT
SYNDROME (IMPENDING VIC)

25. MANAGEMENT - ACUTE COMPARTMENT
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 - ACUTE COMPARTMENT
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
• Sutures are removed after 3 weeks.
• Extension hand splint should be worn for 3
months.
• Occupation and physiotherapy should be
continued until desirable function is attained.