It is a genralized topic for master study to gain knowledge of the vic.

1. VOLKMANN ISCHAEMIC CONTRACTURE
Presenter. Dr. Sikandar kumar Mahto
PG 1ST Year Resident
NMCTH, Birgunj
Moderator: Dr. Prashant Thakur

2. Definition
Volkmann`s Ischemic contracture is a permanent shortening of the
forearm muscles resulting from injury that gives rise to a claw-like
deformity of the hand, wrist and fingers.

3. Historical Background
In 1881, Richard Von Volkmann described irreversible contracture of
the hand and forearm muscles.
In 1906, Hildebrand first used the term Volkmann`s ischaemic
contracture.
In 1909, Thomas reviewed 112 published cases of volkmann
contracture and found closed fractures to be the most common cause.
In 1914, Murphy was the first to suggest fasciotomy might prevent
volkmann contracture.

4. Epidemiology
• The incidence of Volkmann’s contracture is low.
• Its prevalence is 0.5%, which means it is a rare disease.
• Occurs most commonly in children and follows injuries particularly to
the elbow.

5. Etiology
• The intracompartmental pressure occurs when there is a bulging
caused by a trauma.
• Thus, there is not enough space for muscles, nerves and blood vessels
that lie within this fascia.
• This results in vascular defects and defects on nerves.

6. Possible causes can be
• fractures of the forearm
• Animal bite,
• bleeding disorders,
• burns,
• excessive exercise and
• injections of medications at the forearm

7. Relevant anatomy
The flexor group of
muscles in the anterior
forearm may be divided
into:
• superficial group
• deep group

8. Superficial group consists
• Pronator teres
• Flexor carpi radialis
• Flexor digitorum superficialis
• Palmaris longus
• Flexor carpi ulnaris

9. Deep group consists
• Flexor pollicis longus
• Pronator quadratus
• Flexor digitorum profundus

10. Pathophysiology
• Volkmann's Contracture is usually seen in children with displaced
supracondylar fractures of the humerus or forearm.
• It results from severe injury to the deep tissues and muscles of the
volar compartment secondary to increased compartmental pressures
• Volkmann's contracture is the end result of prolonged ischaemia of
muscles and nerves in the forearm.
• The muscles undergoes necrosis, fibrosis and contracture

11. Clssification
There are three main classification systems widely in use:
1. Holden classification
2. Tsuge classification
3. Zancolli classificationa

12. Holden classification (1979)
This system is based on the site of the vascular compression.
Type I
• The cause of compression is proximal to the site of ischemia
• Example supracondylar fracture resulting in distal ischemic damage
Type II
• There is direct localized compression in the distal segment, resulting
in a localized increase in compartmental pressure
• Example-tight bandage applied after forearm fracture

13. Tsuge classification (1975) [modification of
Seddon classification (1964)]
This system is based on the degree of the involvement of muscle
groups in the forearm.
Mild type:
• Localized
• Involves the deep flexor compartment, more commonly the FDP of
the middle and ring fingers and the FPL.
• Nerve involvement is absent or insignificant

14. Tsuge classification…
Moderate type'classic or typical type‘
• Involves all FDP and FPL tendons, with partial involvement of the FDS
• Nerve involvement is always present
• Sensory impairment is more common in the median nerve
distribution than the ulnar nerve
• Intrinsic minus deformity is common

15. Tsuge classification…
Severe type
• Involves all of the digital and wrist flexors and a varying amount of
extensor muscles.
• Nerve involvement is severe, with total loss of sensation and total
intrinsic palsy

16. Zancolli classification (1979)
This system is based on the degree of involvement of the intrinsic
muscles of the hand.
• Type I: Contracture involving forearm muscles with normal intrinsic
muscles
• Type II: Contracture involving forearm muscles with paralysis of
intrinsic muscles.
• Type III: Contracture involving forearm muscles with contracture of
intrinsic muscles
• Type IV: Combined type

17. Clinical Manifestations
The clinical presentation includes the five "Ps" which are:
• Pain
• Pulselessness
• Pallor
• Paresthesia
• Paralysis

18. Clinical Manifestations
Special findings include:
• Pain with passive stretching of the flexors
• Elbow flexion
• Forearm pronation
• Finger flexion
• MCPJ in extension
• The wrist is in palmar flexion

19. Clinical Manifestations
• Palpation of the affected region creates pain .
• Also, upon palpation, firmness of the tissues can be felt .
• Swelling
• Decreased sensation

20. Volkmann’s sign
• In classical claw hand deformity in
established VIC .
• This test consists of extending the
wrist, which exaggerates the
deformities and on flexion the
deformities appear less prominent

21. Treatment
Mild type:
• Dynamic splinting
• Physiotherapy- functional training and active use of muscle
• If multiple tendon involved- muscle sliding operation or wrist
resection
• If single i.e.pronater teres- excision

22. Treatment…
Moderate contracture:
• Muscle sliding operation
• Neuronolysis
• Excision of fibrotic tissue
• Volar transfer of dorsal wrist extensors-when no movement of finger
has been retained e.g. BR,ECRL

23. Treatment…
Severe contracture:
• Early excision of all necritic tissue with neurolysis
• Tendon transfer-to restore function e.g. BR to FPL,ECRL to FDP
• Free innervated muscle transfer using gracilis muscle- if motors to
restore finger flexion are unavailable

24. Oishi and Ezaki
• Recommended two stage procedure
Stage 1.
Initial muscle debridement and neurolysis
Stage 2
free functioning gracilis transfe – after return of sensation and intrinsic
function hand.

25. Established Intrinsic Muscle Contractures of
Hand
Mild contracture:
• MCP joint can be passively extended completely
• Positive intrinsic muscle tightness test- i.e. extended PIP joint while
MCP extended.

26. Established Intrinsic Muscle Contractures of
Hand…
More severe:
• Interosseus muscle- viable and contracted
• Intrinsic muscle tightness test- positive
• Active spreading of fingers- possible
• Contracted muscles released from MC shafts by muscle sliding
operation

27. Established Intrinsic Muscle Contractures of
Hand…
More severe:
• Interosseus muscle- viable and contracted
• Intrinsic muscle tightness test- positive
• Active spreading of fingers- possible
• Contracted muscles released from MC shafts by muscle sliding
operation

28. Established Intrinsic Muscle Contractures of
Hand…
• Most severe:
• Intrinsic muscles – contracted and also necrosed and fibrosed
• Each muscle must be divided to release of contracture with
• Capsulotomies and tendon transfer

29. References
• Campbell
• Apley & solomons
• Essential orthopaedics by Maheshwari
• Netter atalas