Volkmann's Contracture: Difference between revisions
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== Characteristics/Clinical Presentation == | == Characteristics/Clinical Presentation == | ||
The clinical presentation of Volkmann contracture includes what is commonly referred to as the 5 P s. These are pain, pallor, pulselessness, paresthesias, and paralysis. Pain is the earliest sign<ref name="4" /> | The clinical presentation of Volkmann contracture includes what is commonly referred to as the 5 P s. These are pain, pallor, pulselessness, paresthesias, and paralysis. Pain is the earliest sign<ref name="4" /> | ||
Special findings:<br>- Bleach view at the level of the skin (pallor).<br>- The wrist is in palmar flexion<br>- Pain occurs with passive stretching of the flexor <br>- Palpation of the affected region creates persistent pain (pain)<br>- It is possible that the pulsations can not be felt in the swollen arm, mainly in the distal part (pulse less ness).<br>- 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).<ref name="6">Garner A, Handa A. Screening Tools in the Diagnosis of Acute Compartment Syndrome. Angiology. May 12 2010</ref><br><br> | Special findings:<br>- Bleach view at the level of the skin (pallor).<br>- The wrist is in palmar flexion<br>- Pain occurs with passive stretching of the flexor <br>- Palpation of the affected region creates persistent pain (pain)<br>- It is possible that the pulsations can not be felt in the swollen arm, mainly in the distal part (pulse less ness).<br>- 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).<ref name="6">Garner A, Handa A. Screening Tools in the Diagnosis of Acute Compartment Syndrome. Angiology. May 12 2010</ref><br><br> | ||
{{#ev:youtube|8ZnbtrOOSmc}} | {{#ev:youtube|8ZnbtrOOSmc}} | ||
== Differential Diagnosis<br> == | == Differential Diagnosis<br> == | ||
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Pressure monitoring | Pressure monitoring | ||
Intracompartmental pressure (ICP) can be measured by several means including: | Intracompartmental pressure (ICP) can be measured by several means including: | ||
*Wick catheter | *Wick catheter | ||
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*Side-ported needles | *Side-ported needles | ||
Critical pressure for diagnosing compartment syndrome unclear | Critical pressure for diagnosing compartment syndrome unclear | ||
Different authors consider surgical intervention if: | Different authors consider surgical intervention if: | ||
*Absolute ICP greater than 30 mmHg | *Absolute ICP greater than 30 mmHg | ||
*Difference between diastolic pressure and 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<br> | *Difference between mean arterial pressure and ICP greater than 40 mmHg <ref name="8">http://www.surgical-tutor.org.uk/default-home.htm?principles/emergency/compartment_syndrome.htm~right</ref><br> | ||
== Outcome Measures == | == Outcome Measures == | ||
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== Examination == | == Examination == | ||
For a Volkmann’s contraction, the findings are specific (as described above).<br>The main physical picture that we facing is a neurological deficit that occurs in the nerves that pass in the affected regions. The flection of the wrist is a result of contraction and a loss of innervation.<br>We can divide into different levels of severity:<br>- MILD: a flexion contracture of 2 or 3 fingers with no or limited loss of sensation<br>- MODERATE: All fingers are flexed and the thumb is oriented in the palmar orientation. The fist in this case can remain permanently in flexion and there is usually a loss of sensation in the hand.<br>- SERIOUS: all muscles in the forearm (flexors and extensors) are involved. This is a serious limiting condition.<br>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 the intracompartimental pressure monitoring (ICP).<ref name=" | For a Volkmann’s contraction, the findings are specific (as described above).<br>The main physical picture that we facing is a neurological deficit that occurs in the nerves that pass in the affected regions. The flection of the wrist is a result of contraction and a loss of innervation.<br>We can divide into different levels of severity:<br>- MILD: a flexion contracture of 2 or 3 fingers with no or limited loss of sensation<br>- MODERATE: All fingers are flexed and the thumb is oriented in the palmar orientation. The fist in this case can remain permanently in flexion and there is usually a loss of sensation in the hand.<br>- SERIOUS: all muscles in the forearm (flexors and extensors) are involved. This is a serious limiting condition.<br>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 the intracompartimental pressure monitoring (ICP). <ref name="9">Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper extremity injuries. Pediatr Clin North Am. 2006;53(1):41-67.</ref><ref name="10">Prof Dr J.A.N. Verhaar, dr J.B.A. Van Mourik; Orthopedic manual Bohn Stafleu Von Loghum; Pag 100</ref><br> | ||
== Medical Management<br> == | == Medical Management<br> == | ||
the most volkmann’s contractures are caused by a supracondylary fracture.We must ensure that this fracture disappears.<br>To avoid further complications there is often recommended to do a urgent fasciotomy. They do it when there is a intra-compartment pressure of 30 mmHg. They open the fascia around the muscles to make more place for the structures at the inside. <ref name=" | the most volkmann’s contractures are caused by a supracondylary fracture.We must ensure that this fracture disappears.<br>To avoid further complications there is often recommended to do a urgent fasciotomy. They do it when there is a intra-compartment pressure of 30 mmHg. They open the fascia around the muscles to make more place for the structures at the inside. <ref name="11">Collinge C, Kuper M. Comparison of three methods for measuring intracompartmental pressure in injured limbs of trauma patients. J Orthop Trauma. Jun 2010;24(6):364-8</ref><ref name="12">Ullah Barbar, Nowroz Shinwari, Mohammad Rahim Bangash, M Soaib Khan. Management of supracondylar fracture of humerus in children by close reduction and immobilization of the elbow in extension and supination. J ayub med coll abbottabad 2009;21(4)</ref><br><br> | ||
== Physical Therapy Management<br> == | == Physical Therapy Management<br> == | ||
After the surgery, it is important to ensure that the mobility is recovered. we can increase the mobility by passive stretching techniques. We force the normal range of motion and by that, we can enhance the range of motion. This range is limited by loss of soft tissue elasticity.<br>An other part in the therapy is activating and strengthering the weak agonist. By that, we can ensure that the agonist pulls the antagonist in balance.<br>Inhibition control of the contracted muscles can prove that they can decrease spasticity of the affected muscles.<br>By the use of an electomyografic 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.<ref name=" | After the surgery, it is important to ensure that the mobility is recovered. we can increase the mobility by passive stretching techniques. We force the normal range of motion and by that, we can enhance the range of motion. This range is limited by loss of soft tissue elasticity.<br>An other part in the therapy is activating and strengthering the weak agonist. By that, we can ensure that the agonist pulls the antagonist in balance.<br>Inhibition control of the contracted muscles can prove that they can decrease spasticity of the affected muscles.<br>By the use of an electomyografic 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. <ref name="13">Duschau-Wicke A et al. Patient-cooperative control increases active participation of individuals with SCI during robot-aided gait training. J Neuroeng Rehabil. 2010 Sep 10;7:43.</ref><ref name="14">Review of Physical Therapy Alternatives for Reducing Muscle Contracture. DIANNE B. CHERRY, MS</ref><br><br> | ||
== Key Research == | == Key Research == | ||
Revision as of 10:28, 6 August 2012
Original Editors - Alexander Ghyssels
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Definition/Description[edit | edit source]
A Volkmann contracture is a deformity of the hand, fingers, and wrist 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 the hypoxia can lead to the damage of muscles, nerves and vascular endothelium.
This results in a shortening (contracture) of the muscles in the forearm.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Clinically Relevant Anatomy[edit | edit source]
The bones are an important factor in a Volkmann contracture. We can see that the humerus of the upperarm 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 deficit in supply of blood that the muscles and nerves malfunction. There is a contraction of the muscles.
The muscles who are usually involved are the flexors of the wrist. Yet there is also a contracture occur in the extensors of the wrist, but this is less common.
Musles who are involved:
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:
- Musculus flexor pollicis longus (median nerve innervation)
- Musculus pronator quadratus (median nerve innervation)
- Musculus flexor digitorum profundus (median nerve innervation)Cite error: Invalid
<ref>tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid<ref>tag; name cannot be a simple integer. Use a descriptive title
Epidemiology /Etiology[edit | edit source]
The incidence of Volkmann’s contracture is low. It counts 0,5%, which means it is a rare disease.
The intracompartimental pressure occurs when there is a bulging causes by a trauma. 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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Characteristics/Clinical Presentation[edit | edit source]
The clinical presentation of Volkmann contracture includes what is commonly referred to as the 5 P s. These are pain, pallor, pulselessness, paresthesias, and paralysis. Pain is the earliest signCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Special findings:
- Bleach view at the level of the skin (pallor).
- The wrist is in palmar flexion
- 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 (pulse less ness).
- 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).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Differential Diagnosis
[edit | edit source]
Pseudo - Volkmann`s contracture Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Diagnostic Procedures[edit | edit source]
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 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 Cite error: Invalid
<ref>tag; name cannot be a simple integer. Use a descriptive title
Outcome Measures[edit | edit source]
add links to outcome measures here (also see Outcome Measures Database)
Examination[edit | edit source]
For a Volkmann’s contraction, the findings are specific (as described above).
The main physical picture that we facing is a neurological deficit that occurs in the nerves that pass in the affected regions. The flection of the wrist is a result of contraction and a loss of innervation.
We can divide into different levels of severity:
- MILD: a flexion contracture of 2 or 3 fingers with no or limited loss of sensation
- MODERATE: All fingers are flexed and the thumb is oriented in the palmar orientation. The fist in this case can remain permanently in flexion and there is usually a loss of sensation in the hand.
- 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 the intracompartimental pressure monitoring (ICP). Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Medical Management
[edit | edit source]
the most volkmann’s contractures are caused by a supracondylary fracture.We must ensure that this fracture disappears.
To avoid further complications there is often recommended to do a urgent fasciotomy. They do it when there is a intra-compartment pressure of 30 mmHg. They open the fascia around the muscles to make more place for the structures at the inside. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Physical Therapy Management
[edit | edit source]
After the surgery, it is important to ensure that the mobility is recovered. we can increase the mobility by passive stretching techniques. We force the normal range of motion and by that, we can enhance the range of motion. This range is limited by loss of soft tissue elasticity.
An other part in the therapy is activating and strengthering the weak agonist. By that, we can ensure that the agonist pulls the antagonist in balance.
Inhibition control of the contracted muscles can prove that they can decrease spasticity of the affected muscles.
By the use of an electomyografic 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. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Key Research[edit | edit source]
add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)
Resources
[edit | edit source]
add appropriate resources here
Clinical Bottom Line[edit | edit source]
add text here
Search Strategy[edit | edit source]
First I’ve used the databases PubMed, Pedro, Google Scholar and Web of Knowledge. I’ve searched in the library of the Brussels Free University for related articles.
Keywords I have used in my literature search were: Volkmann's contracture, ischemic muscle, Acute compartment syndrome and physiotherapy.
By combining the keywords I found very usable literature.
I’ve searched in the medical library of the VUB, and found a number of books where the disease is described in (see references below)
Recent Related Research (from Pubmed)
[edit | edit source]
References[edit | edit source]
see adding references tutorial.
