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'''Original Editors ''' - [[User:Alexander Ghyssels|Alexander Ghyssels]]  
'''Original Editors ''' - [[User:Alexander Ghyssels|Alexander Ghyssels]] as part of the [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]].


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;  
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== Definition/Description  ==
== Definition/Description  ==
 
[[File:Volkman's ischemic contracture.jpg|thumb|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.<ref name="p1">Von Schroeder HP, Botte MJ. Definitions and terminology of compartment syndrome and Volkmann's ischemic contracture of the upper extremity. Hand clinics. 1998 Aug;14(3):331.</ref><ref name="p2">Clover J. Sports Medicine Essentials: Core concepts in athletic training & fitness instruction. Cengage Learning; 2015 Feb 27.</ref>
A Volkmann's contracture is 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 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.<ref name="p1">Von Schroeder HP et al. Definitions and terminology of compartment syndrome and Volkmann's ischemic contracture of the upper extremity. Hand Clin. 1998 Aug;14(3):331-4.</ref><ref name="p2">Jim Clover. Sports medicine essentials, core concepts in athletic training. 2nd edition. 2010</ref>  
 
== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


The bones are an important factor in a Volkmann's contracture. We can see that the humerus of the upper arm is often involved in Volkmann's contracture. A fracture of the [[Supracondylar humeral fracture|supracondylary space]] causes a deficit in the circulation of the arteria brachialis.<br>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 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 [[Supracondylar Humeral Fracture|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:
**[[Pronator Teres|Musculus pronator teres]] (median nerve innervation)
**[[Flexor Carpi Radialis|Musculus flexor carpi radialis]] (median nerve innervation)
**[[Flexor Carpi Ulnaris Muscle|Musculus flexor carpi ulnaris]] (ulnar nerve innervation)
**[https://www.physio-pedia.com/Flexor_Digitorum_Superficialis Musculus flexor digitorum superfiscialis] (median nerve innervation)
**[[Palmaris Longus|Musculus palmaris longus]] (median nerve innervation)


<br>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.
* Deep flexors:
**[[Flexor Pollicis Longus|Flexor pollicis longus]] (median nerve innervation)
**[[Pronator Quadratus|Pronator quadratus]] (median nerve innervation)
**[[Flexor Digitorum Profundus|Flexor digitorum profundus]] (median nerve innervation)<ref name="p3">H.J. Seddon. Volkmann’s contracture: Treatment by excision of the infarct. London, England; from the institute of orthopaedics.</ref><ref name="p4">John AK. Volkmann Contracture. Available from: [https://emedicine.medscape.com/article/1270462-overview http://emedicine.medscape.com]</ref>


=== Muscles typically involved: ===
{{#ev:youtube|BjIab-huqgU|300}}<ref>AnatomyZone. Forearm Muscles Part 1 - Anterior (Flexor) Compartment - Anatomy Tutorial. Available from: https://www.youtube.com/watch?v=BjIab-huqgU [last accessed 31/10/2021]</ref>


==== '''Superficial flexors:''' ====
== Epidemiology/Etiology  ==
*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:''' ====
The incidence of Volkmann’s contracture is low. Its prevalence is 0,5%, which means it is a rare disease. The [[Compartment Syndrome|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.  
*Flexor pollicis longus (median nerve innervation)
*Pronator quadratus (median nerve innervation)
*Flexor digitorum profundus (median nerve innervation)<ref name="p3">H.J. Seddon. Volkmann’s contracture: Treatment by excision of the infarct. London, England; from the institute of orthopaedics.</ref><ref name="p4">emedicine.medscape.com Volkmann Contracture. Author: John A Kare, MD; Chief Editor: Mary Ann E Keenan, MD</ref>{{#ev:youtube|BjIab-huqgU}}


<br>
Possible causes can be animal bites, fractures of the forearm, bleeding disorders, burns, excessive exercise and injections of medications at the forearm.<ref name="p4" /><ref name="p5">nlm.nih.gov/medlineplus/Volkmann`s ischemic contracture  Author:  Linda J. Vorvick, MD, C. Benjamin Ma, MD, David Zieve, MD.</ref>  
 
== Epidemiology/Etiology  ==
 
The incidence of Volkmann’s contracture is low. It counts 0,5%, which means it is a rare disease. The [[Compartment Syndrome|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.<ref name="p4" /><ref name="p5">nlm.nih.gov/medlineplus/Volkmann`s ischemic contracture  Author:  Linda J. Vorvick, MD, C. Benjamin Ma, MD, David Zieve, MD.</ref><br><br>  


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


The clinical presentation of Volkmann`s 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="p4" />  
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<ref name="p4" />  


Special findings:  
Special findings:  
*Bleach view at the level of the skin (pallor).  
*Bleach view at the level of the skin (pallor).  
*The wrist is in palmar flexion  
*The wrist is in palmar flexion  
*'''Clawed fingers'''
*Pain occurs with passive stretching of the flexor  
*Pain occurs with passive stretching of the flexor  
*Palpation of the affected region creates persistent pain (pain)  
*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).  
*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).<ref name="p6">Garner A, Handa A. Screening Tools in the Diagnosis of Acute Compartment Syndrome. Angiology. May 12 2010</ref><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="p6">Garner AJ, Handa A. [https://cognitiveclass.ai/learn/data-science-with-python Screening tools in the diagnosis of acute compartment syndrome]. Angiology. 2010 Jul;61(5):475-81.</ref><br>


{{#ev:youtube|8ZnbtrOOSmc}}
{{#ev:youtube|8ZnbtrOOSmc|300}}<ref>Nabil Ebreaheim. Volkmann's Ischemic Contracture Classic - Everything You Need To Know - Dr. Nabil Ebraheim. Available from: https://www.youtube.com/watch?v=8ZnbtrOOSmc [last accessed 31/10/2021]</ref>
 
<br>


== Differential Diagnosis  ==
== Differential Diagnosis  ==
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Pseudo-Volkmann's contracture <ref name="p7">A. LANDI, G. DE SANTIS, P. TORRICELLI, A. COLOMBO, P. BEDESCHI CT in Established Volkmann’s Contracture in Forearm MusclesJ Hand Surg [Br] February 1989 14: 49-52,</ref>  
Pseudo-Volkmann's contracture <ref name="p7">A. LANDI, G. DE SANTIS, P. TORRICELLI, A. COLOMBO, P. BEDESCHI CT in Established Volkmann’s Contracture in Forearm MusclesJ Hand Surg [Br] February 1989 14: 49-52,</ref>  


== Diagnostic Procedures ==
== 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.<br>
 
The deformity seen in this condition can be divided into different levels of severity:
#'''MILD:''' 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 flexed 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 intracompartimental pressure monitoring (ICP)<ref name="p9">Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper extremity injuries. Pediatr Clin North Am. 2006;53(1):41-67.</ref><ref name="p0">Prof Dr J.A.N. Verhaar, dr J.B.A. Van Mourik; Orthopedic manual Bohn Stafleu Von Loghum; Pag 100</ref>.
== Diagnostic Procedures ==
Pressure monitoring  
Pressure monitoring  


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== Outcome Measures  ==
== 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


[http://dokteranakku.com/downloads/Clin_Sports_Med_Vol_22.pdf#page=101 dokteranakku.com/downloads/Clin_Sports_Med_Vol_22.pdf#page=101]<br>
* Fine Motor Function
 
** McCarron Assessment of Neuromuscular Development (MAND)
[http://emedicine.medscape.com/article/1270462-treatment#a25 emedicine.medscape.com/article/1270462-treatment#a25]
 
== Examination  ==
 
For a Volkmann’s contraction, the findings are specific (as described above).<br>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 contraction and a loss of innervation.<br>


We can divide into different levels of severity:  
* Activities of Daily Living
** [https://www.physio-pedia.com/Jebsen-Taylor_Hand_Function_Test#editors Jebson Hand Function Test]


#MILD: a flexion contracture of 2 or 3 fingers with no or limited loss of sensation
==  Medical Management ==
#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.  
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 Humeral Fracture|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 &gt;30 mmHg,<ref name="p1" /><ref name="p2" />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.
#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)<ref name="p9">Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper extremity injuries. Pediatr Clin North Am. 2006;53(1):41-67.</ref><ref name="p0">Prof Dr J.A.N. Verhaar, dr J.B.A. Van Mourik; Orthopedic manual Bohn Stafleu Von Loghum; Pag 100</ref>.<br>
In moderate Volkmann's contracture, tendon slide<ref name=":0">Stevanovic M, Sharpe F.Management of established Volkmann's contracture of the forearm in children. Hand clinics,2006;22(1):99-111.</ref> and Neurolysis surgery should be performed (median and ulnar) along with extensor transfer procedures.


== Medical Management  ==
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.


The most Volkmann’s contractures are caused by a [[Supracondylar humeral fracture|supracondylary fracture]].We must ensure that this fracture disappears.<br>To avoid further complications there is often recommended to do a urgent fasciotomy, when there is a intra-compartment pressure of &gt;30 mmHg. Fasciotomy - open the fascia around the muscles to make more place for the structures at the inside<ref name="p1"/><ref name="p2"/>.&nbsp;Raised ICP threatens the viability of the limb and the treatment of CS (compartment syndrome) represents a true management emergency. Early diagnosis and beginning of the treatment so much bigger are the hopes of successful outcome.&nbsp;Removal of all dressing down to skin and on not sufficient correspondence, follow extensive fasciotomies (no fissions), is the treatment of choice.<br>
== 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.


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


*The circular cast can substantiate the adverse effects of raised ICP
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<ref name="p4" /><ref name="p5" />.
*Splitting of the cast on one side leads to an average fall in ICP 30%
*Splitting of the cast on both sides leads to an average fall in ICP 65%
*Complete removal of the cast reduced the pressure by another 15%
 
In these particular cases which the diagnosis is being considered and in those in whom resuscitation is proceeding, the following steps should be performed:
 
*Ensure the patient is normotensive, as hypotension reduces perfusion pressure and contributes in the anoxemia and the consequent tissue injury.
*Remove any circumferential or constricting bandages (even bloody bandages).
*Maintain the limb at heart level as elevation reduces the arterio-venous pressure gradient.
*Give supplemental oxygen to ensure optimal saturation.
 
Several surgical approaches have been tried. The surgical goal is one and only; the adequate decompressive for the viability of the limb or the prevention of permanent disability. The cosmetic or the location and lengths of incisions should not be considered. In treatment of CS there is no place for short cosmetic incisions. Surgical incisions less than 15cm may be lead in inadequate decompression.<br>Several surgical approaches have been suggested in the forearm. A single incision can be used to decompress the volar aspect of the forearm, approach that coincides with the Henry access.<br>
 
After decompression, delayed primary closure can be performed when swelling has subsided, however this may be difficult or unachievable due to skin retraction. Various methods and materials have been described using the elastic properties of the skin to aid wound closure. If the wound edges cannot be approximated, skin grafting may be required.<br>
 
Intamedullary nailing may increase ICP, fact that was taken into consideration seriously at the first years of nailing application and it was thought that nailing should be delayed for up to 7 days. However further research&nbsp;has shown that during reaming the pressure may rise to 180 mmHg, but it falls back to normal after removing the reamer. Similarly, the application of traction also increases the pressure but this immediately drops with release of the traction. Controversy still exists if monitoring should be performed during intamedullary nailing. Mcqueen et al suggested routine monitoring if facilities are available. Others have suggested that this may lead to over treatment and unnecessary fasciotomies<ref name="p3"/>.<br>
 
== Physical Therapy Management  ==
 
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 strengthening 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 electomyographic 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="p4"/><ref name="p5"/>.<br>


== Clinical Bottom Line  ==
== Clinical Bottom Line  ==


Early diagnosis and beginning of the treatment means much bigger hopes of successful outcome.<br>
Early diagnosis and treatment improve the chances of a successful outcome<ref name=":0" />.
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])<br>  ==
<div class="researchbox"><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1</rss></div>
== References  ==
== References  ==


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[[Category:Conditions]] [[Category:Hand]] [[Category:Haemodynamics]] [[Category:Paediatrics]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Conditions]]  
[[Category:Hand]]  
[[Category:Paediatrics]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Vrije_Universiteit_Brussel_Project]]  
[[Category:Primary Contact]]
[[Category:Paediatrics - Conditions]]
[[Category:Hand - Conditions]]

Latest revision as of 07:48, 6 December 2023

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

Top Contributors - Didzis Rozenbergs, Alexander Ghyssels, Kim Jackson, Wendy Walker, Admin, Uchechukwu Chukwuemeka, WikiSysop, Evan Thomas, Redisha Jakibanjar, Nikhil Benhur Abburi, Agoro Bukola Zainab, Scott Buxton, Claire Knott, Anas Mohamed and 127.0.0.1  

Definition/Description[edit | edit source]

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.[1][2]

Clinically Relevant Anatomy[edit | edit source]

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:

[5]

Epidemiology/Etiology[edit | edit source]

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.[4][6]

Characteristics/Clinical Presentation[edit | edit source]

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[4]

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).[7]

[8]

Differential Diagnosis[edit | edit source]

Pseudo-Volkmann's contracture [9]

Examination[edit | edit source]

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)[10][11].

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 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[12]

Outcome Measures[edit | edit source]

  • 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)

Medical Management[edit | edit source]

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,[1][2]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[13] 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[edit | edit source]

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[4][6].

Clinical Bottom Line[edit | edit source]

Early diagnosis and treatment improve the chances of a successful outcome[13].

References[edit | edit source]

  1. ↑ 1.0 1.1 Von Schroeder HP, Botte MJ. Definitions and terminology of compartment syndrome and Volkmann's ischemic contracture of the upper extremity. Hand clinics. 1998 Aug;14(3):331.
  2. ↑ 2.0 2.1 Clover J. Sports Medicine Essentials: Core concepts in athletic training & fitness instruction. Cengage Learning; 2015 Feb 27.
  3. ↑ H.J. Seddon. Volkmann’s contracture: Treatment by excision of the infarct. London, England; from the institute of orthopaedics.
  4. ↑ 4.0 4.1 4.2 4.3 John AK. Volkmann Contracture. Available from: http://emedicine.medscape.com
  5. ↑ AnatomyZone. Forearm Muscles Part 1 - Anterior (Flexor) Compartment - Anatomy Tutorial. Available from: https://www.youtube.com/watch?v=BjIab-huqgU [last accessed 31/10/2021]
  6. ↑ 6.0 6.1 nlm.nih.gov/medlineplus/Volkmann`s ischemic contracture Author: Linda J. Vorvick, MD, C. Benjamin Ma, MD, David Zieve, MD.
  7. ↑ Garner AJ, Handa A. Screening tools in the diagnosis of acute compartment syndrome. Angiology. 2010 Jul;61(5):475-81.
  8. ↑ Nabil Ebreaheim. Volkmann's Ischemic Contracture Classic - Everything You Need To Know - Dr. Nabil Ebraheim. Available from: https://www.youtube.com/watch?v=8ZnbtrOOSmc [last accessed 31/10/2021]
  9. ↑ A. LANDI, G. DE SANTIS, P. TORRICELLI, A. COLOMBO, P. BEDESCHI CT in Established Volkmann’s Contracture in Forearm MusclesJ Hand Surg [Br] February 1989 14: 49-52,
  10. ↑ Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper extremity injuries. Pediatr Clin North Am. 2006;53(1):41-67.
  11. ↑ Prof Dr J.A.N. Verhaar, dr J.B.A. Van Mourik; Orthopedic manual Bohn Stafleu Von Loghum; Pag 100
  12. ↑ http://www.surgical-tutor.org.uk/default-home.htm?principles/emergency/compartment_syndrome.htm~right
  13. ↑ 13.0 13.1 Stevanovic M, Sharpe F.Management of established Volkmann's contracture of the forearm in children. Hand clinics,2006;22(1):99-111.


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