Volkmann's Contracture

Original Editors - Alexander Ghyssels as part of the Vrije Universiteit Brussel's Evidence-based Practice project.

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Definition/Description

volkman's ischemic contracture

A Volkmann's contracture is a deformity of the hand, fingers, and wrist which occurs as a result of a trauma such as fractures, crush injuries, burns and arterial injuries. Following this trauma, there is a deficit in the arterio-venous circulation in the forearm which causes a decreased blood flow and hypoxia can lead to the damage of muscles, nerves and vascular endothelium. This results in a shortening (contracture) of the muscles in the forearm.

Clinically Relevant Anatomy

The bones are an important factor in Volkmann's contracture. We can see that the humerus of the upper arm is often involved in Volkmann's contracture. A fracture of the supracondylary space causes a deficit in the circulation of the arteria brachialis. It is caused by the blocking of the circulation and a deficit in blood supply to the muscles and nerves malfunction. There is a contracture of the muscles, usually, the flexors of the wrist. Yet, there is also a contracture occurring with the extensors of the wrist, but this is less common. Muscles that are typically involved are the:

• Superficial flexors:
  • Musculus pronator teres (median nerve innervation)
  • Musculus flexor carpi radialis (median nerve innervation)
  • Musculus flexor carpi ulnaris (ulnar nerve innervation)
  • Musculus flexor digitorum superfiscialis (median nerve innervation)
  • Musculus palmaris longus (median nerve innervation)

• Deep flexors:
  • Flexor pollicis longus (median nerve innervation)
  • Pronator quadratus (median nerve innervation)
  • Flexor digitorum profundus (median nerve innervation)

Epidemiology/Etiology

The incidence of Volkmann’s contracture is low. Its prevalence is 0,5%, which means it is a rare disease. 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.

Possible causes can be animal bites, fractures of the forearm, bleeding disorders, burns, excessive exercise and injections of medications at the forearm.

Characteristics/Clinical Presentation

The clinical presentation of Volkmann`s contracture includes what is commonly referred to as the 5 Ps. These are pain, pallor, pulselessness, paresthesias, and paralysis. Pain is the earliest sign

Special findings:

• Bleach view at the level of the skin (pallor).
• The wrist is in palmar flexion
• Clawed fingers
• Pain occurs with passive stretching of the flexor
• Palpation of the affected region creates persistent pain (pain)
• It is possible that the pulsations can not be felt in the swollen arm, mainly in the distal part (pulselessness).
• There are also neurological limitations noticeable from the muscles that pinch the neural pathways, there is a decreased sensation (paresthesia) and there is an observable motor deficit (paresis).
  

Differential Diagnosis

Pseudo-Volkmann's contracture

Examination

For Volkmann’s contracture, the findings are specific as described in the clinical presentation subheading above. The main physical picture that we see is a neurological deficit that occurs in the nerves that pass in the affected regions. The flexion of the wrist is a result of contracture and a loss of innervation.

The deformity seen in this condition can be divided into different levels of severity:

1. MILD: Flexion contracture of 2 or 3 fingers with no or limited loss of sensation
2. MODERATE: All fingers are flexed and the thumb is oriented in the palmar orientation. The fist, in this case, can remain permanently flexed and there is usually a loss of sensation in the hand.
3. SERIOUS: All muscles in the forearm (flexors and extensors) are involved. This is a serious limiting condition.

An objective test to evaluate the ischemia and the pressure in a muscle compartment is an invasive test. It measures the absolute pressure in the compartment of the muscle. This is also called intracompartimental pressure monitoring (ICP).

Diagnostic Procedures

Pressure monitoring

Intracompartmental pressure (ICP) can be measured by several means including:

• Wick catheter
• Simple needle manometry
• Infusion techniques
• Pressure transducers
• Side-ported needles

Critical pressure for diagnosing compartment syndrome is unclear

Different authors consider surgical intervention if:

• Absolute ICP greater than 30 mmHg
• Difference between diastolic pressure and ICP greater than 30 mmHg
• Difference between mean arterial pressure and ICP greater than 40 mmHg

Outcome Measures

• Functional Outcome Measures
  • Active range of motion of the elbow and wrist
  • Active and passive range of motion of the digits
  • Shoulder and elbow strength using the sphygmomanometer
  • Hand strength measured using a dynamometer
  • Pad to pad pinch. key grip and tripod grip strength measured using a Preston pinch gauge
  • Sensation measured using:
    • Von Frey Test
    • Moving two point discrimination test
    • Functional hand sensation - Moberg pickup test

• Fine Motor Function
  • McCarron Assessment of Neuromuscular Development (MAND)

• Activities of Daily Living
  • Jebson Hand Function Test

Medical Management

Prevention is the best management in this condition. However, there are times, when surgical intervention will be indicated. The majority of Volkmann’s contractures are caused by a supracondylar fracture, and it is essential that all steps are taken to improve the healing of the fracture. When there is an intra-compartment pressure (ICP) of >30 mmHg,an urgent fasciotomy is recommended to avoid further complications, Raised ICP threatens the viability of the limb and compartment syndrome (CS) represents a true medical emergency. Thus, the a need for decompression by removal of all dressing down to the skin, followed by fasciotomy- Surgical opening of the fascia around the muscles to make more place for the structures inside. This is done to prevent the onset of Volkmann’s contractures.

In moderate Volkmann's contracture, tendon slide and Neurolysis surgery should be performed (median and ulnar) along with extensor transfer procedures.

Finally, in severe cases of Volkmann's contracture, debridement of injured muscle may be performed with releases of scar tissue and salvaging procedures. Range of motion and function after injury are improved by physical and occupational therapy.

Physiotherapy Management

After the surgery, it is important to ensure that the mobility is recovered by:

• Passive stretching techniques
• Range of motion exercises to enhance soft tissue elasticity.

Another part of the therapy programme involves activating and strengthening the weak agonist to ensure equilibrium in agonist and antagonist pull during joint movement.

Progressive Splinting, passive stretching and tendon gliding, as well as massage, can be used in mild to moderate cases of Volkmann's contracture.

By the use of an electromyographic device, the patient can train its affected muscles with cooperativity. The patient is more alert and there is more interaction between the patient and the therapist.

Clinical Bottom Line

Early diagnosis and treatment improve the chances of a successful outcome.