Volkmann's Contracture

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Definition/Description

A Volkmann's 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.

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 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.

Muscles typically 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:

• Flexor pollicis longus (median nerve innervation)
• Pronator quadratus (median nerve innervation)
• Flexor digitorum profundus (median nerve innervation)

Epidemiology/Etiology

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.

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

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 (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).
  

Differential Diagnosis

Pseudo-Volkmann's contracture

Diagnostic Procedures

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
  

Outcome Measures

dokteranakku.com/downloads/Clin_Sports_Med_Vol_22.pdf#page=101

emedicine.medscape.com/article/1270462-treatment#a25

Examination

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 flexion of the wrist is a result of contraction and a loss of innervation.

We can divide into different levels of severity:

1. MILD: a 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 in flexion 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 the intracompartimental pressure monitoring (ICP).

Medical Management

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, when there is a intra-compartment pressure of >30 mmHg. Fasciotomy - open the fascia around the muscles to make more place for the structures at the inside. 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. Removal of all dressing down to skin and on not sufficient correspondence, follow extensive fasciotomies (no fissions), is the treatment of choice.

Experimental evidence has shown:

• The circular cast can substantiate the adverse effects of raised ICP
• 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.
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.

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.

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 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.

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.
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.

Clinical Bottom Line

Early diagnosis and beginning of the treatment means much bigger hopes of successful outcome.

Recent Related Research (from Pubmed)

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