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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)