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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Volkmann's contracture



- 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;
           - in addition 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-year-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)




Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, January 4, 2013 11:27 am