- See:
Compartment Syndrome
- Discussion:
- type of forearm ischemic contracture resulting from
brachial artery injury usually associated w/
supracondylar frx of humerus;
- may see loss of motor & sensory function, however, classic involvment is w/
anterior interosseous branch of
median nerve;
-
pathology:
- contracture results from insufficient arterial perfusion & venous stasis followed by ischemic degeneration of muscle;
- irreversible muscle necrosis begins after 4-6 hrs;
- resulting edema impairs circulation, leads to
forearm comapartment syndrome, which propagates progressive muscle necrosis;
- muscle degeneration is most affected at the middle third of muscle belly, being most severe closer to bone;
- there is less involvement toward the proximal & distal surfaces;
- necrosis of the muscle with secondary fibrosis that may develop followed by calcification in its final phase;
-
anatomy:
- distal to lacertus fibrosus
brachial artery branches into
radial &
ulnar artery;
- radial artery is superficially located, whereas ulnar artery is deeply situated, traversing deep to
pronator teres muscles;
- ulnar artery gives rise to the common interosseous artery, which divides immediately into anterior & PIN branches;
-
flexor digitorum longus and the
flexor pollicis longus muscles derive their blood supply thru anterior interosseous artery;
-
pathoanatomy:
- infarct has ellipsoid shape w/ its axis along anterior interosseous artery & its central point slightly above middle of the forearm;
- therefore, the muscles most dependent on the anterior interosseous artery (
FDP,
FPL, FDS, and the pronator teres;
- FDP and FDS muscles become contracted and are replaced by scar, which leads to wrist flexion contracture and clawing of the fingers;
- inaddition to muscle necrosis, there will also be injury to the
median and ulnar nerves leading to high
ulnar nerve and
median nerve palsy;
-
fingers:
- may lie in
intrinsic minus position (due to high nerve palsy)
- alternatively, the fingers may lie in an
intrinsic plus position (MP's flexed, PIP extended), if there has been a concomitant
compartment syndrome of the hand
resulting in intrinsic contracture;
- Case Example:
- 2 yr old male who sustained a simple distal radial torus frx;
- he was treated w/ a sugar tong splint, was sent home, and cried all night;
- several days later, it was apparent that he sustained a 3rd degree burn to the forearm, as well as a Volkman's ischemic contracture;
- Prevention:
- requires restoration of blood flow;
- reduction of compartmental pressure
- Management:
- proper initial splinting of hand in the function position;
- release of forearm flexors;
- muscle slide
- tendon lengthening;
- test for intrinsic tightness
Pattern of contracture and recovery following ischaemia of the upper limb.
Volkmann's contracture in children: aetiology and prevention.
Volkmann's ischemic contracture. A case report.
The evolution of the compartment syndrome since 1948 as recorded in the JBJS (B)
