VOLKMANN¶S

ISCHEMICCONTRACTURECONTRACT
UR
 VOLKMANN’S ISCHEMIC CONTRACTURE

• Definition :A condition which is characterized

by ischemic necrosis of the structures contained
within the volar compartment of the forearm
associated with crippling contractures and varying
degrees of neurologic deficit.
• HISTORY
• 1881, Volkmann stated
that paralytic
contractures that
develop within a few
hours after injury are
caused by arterial
insufficiency or ischemia
of muscles.
• HISTORY
• 1906,Hildebrand first used the term
"Volkmann ischemic contracture“ to describe the final
result of any untreated compartment syndrome.
• 1909, Thomas found that paralytic contractures
followed severe contusions of the forearm without
fractures.
• 1914, Murphy reported that increased internal
pressures in the deep compartments of the forearm
and effusion in the muscles resulted in ischemia.
• 1928,Jones
concluded that
Volkmann’s
contracture could
be caused by
pressure from
within, from
without or both.
• Volkmann’s ischemic
contracture is a late
sequelae of untreated
or inadequately
treated compartment
syndrome in which
necrotic muscle and
nerve tissue are
replaced with fibrous
tissue .
 ANATOMY
• At the entrance to the
flexor compartment of
the forearm , lacertus
fibrosus fans medially
from the biceps tendon.
• Beneath the lacertus
fibrosus the brachial
artery and median
nerve pass to enter the
flexor compartment.
 ANATOMY
• The brachial artery divides into
radialand ulnar arteries.
• The radial artery courses
superficially and is not crossed by
any structure in the forearm.
• The ulnar artery passes beneath
the pronator teres where it gives
a branch, the common
interosseus artery.
• The common interosseus artery
further divides into volar and
dosal interosseus arteries.
 ANATOMY
• The median nerve
accompanies the brachial
artery beneath the
lacertus fibrosus and
enters the substance
of the pronator teres
passing between its
humeral and ulnar heads.
 ANATOMY
• Compartments of the
forearm.
• 1. Superficial
volar compartment.
• 2. Deep volar
compartment.
• 3. Dorsal compartment.
• 4. Mobile wad of Henry.
 ETIOLOGY
• Supracondylar
fractures of the
humerus in children is
the most common
precipitating injury.
• The brachial artery may
get impinged on the
sharp proximal
fragment against which
it is held by lacertus
fibrosus.
 ETIOLOGY
• Hemorrhage and
edema may further
compress the brachial
artery and the median
nerve in this region.
 ETIOLOGY

• Ischemia ±± Edema cycle as depicted by Eaton

and Green
 ETIOLOGY
• 1. Crush injuries.
• 2. Prolonged external
compression.
• 3. Internal bleeding
(Hemophilia).
• 4. Burns.
• 5. Snake bites.
• 6. Intravenous regional
anesthesia
 TOLERANCE OF TISSUE
• 1. Muscle :-
• Functional impairment after
2-4 hours of ischemia.
• Irreversible functional loss
after 4-12 hours.
• 2. Nerves :-
• Functional impairment after
30 mins of ischemia.
• Irreversible function loss
after 12-24 hrs.
 CLINICAL PICTURE
• Acute compartment syndrome
(Impending Volkmann’s
ischemic contracture)
• 1. If local compression is the
cause :
• Pulses intact ( in early stages)
• Paresis
• Stretch pain
• Parasthesia (median nerve
sensory zone commonly)
• Good capillary filling.
 CLINICAL PICTURE
• Acute
compartmentsyndrome
(Impending
Volkmann’s ischemic
contracture)
• 2. If arterial injury is the
cause :
• Stretch pain
• Parasthesia
• Pulselessness
• Pallor ( or Cyanosis)
• Paresis
 CLINICAL PICTURE
• Two point
discrimination is more
than 1 cm in in the
sensory zone of the
median nerve.
• Diminished perception
of vibratory sense of
256cycles/sec
stimulus.
 CLINICAL PICTURE
• Measurement
of intracompatmental
pressure :
• 1. White sides
handheld pressure
monitoring system.
• 2. Wick catheter.
• 3. Slit catheter.
 CLINICAL PICTURE
• Evaluating the intracompartmental pressure.

• Range between 10 ± 20 mmHg below the

diastolic pressure - cessation of blood flow is
eminent.
• 40± 50 mmHg - muscle threatening compression
and ischemia are present.
• Pressure of 30 mmHg or greater - criterion
for fasciotomy.
 Deformities in Volkmann’s ischemic
contracture
• Mild type :
• Deep flexors are partially
involved particularly,
Flexor digitorum profundus.
• Flexion contractures of one
or more fingers which can be
extended on hyperflexing
the wrist.
• Resistant pronation
contracture involving either
the pronator teres or
pronator quadratus.
 Deformities in Volkmann’s ischemic
contracture
• Moderate type :
• Involves most of the
flexor digitorum profundus,
flexor pollicis longus and part
of flexor digitorum superficialis.
• Neurological deficit involving
median nerve more than
ulnar nerve is present.
• Deformity is intrinsic minus
hand.
• Diminished sensations in
median and ulnar nerve zones.
 Deformities in Volkmann’s ischemic
contracture
• Severe type :
• All the flexor muscles are
involved.
• Neurological deficit is
severe.
• Joint contractures are
marked.
• Wasting of forearm
muscles .
MANAGEMENT - ACUTE COMPARTMENT
SYNDROME (IMPENDING VIC)
MANAGEMENT - ACUTE COMPARTMENT
SYNDROME (IMPENDING VIC)
• Forearm fasciotomy
• Incision :A volar
curvilinear liberal
incision medial to the
biceps tendon, crossing
the elbow flexion
crease at an angle
carring it distally to the
palm to release the
carpal tunnel.
 MANAGEMENT - ACUTE COMPARTMENT
SYNDROME (IMPENDING VIC)
• Exploration must extend deeply
to the FDPand FPL.
• Necrotic muscle tissue is excised.
• Median nerve freed beneath the
lacertus fibrosus.
• Ulnar nerve is freed and
transplanted anteriorly .
• Brachial artery must be inspected
and decompressed .
• Surgical wound is left open
for secondary closure later when
swelling subsibes.
• Extremity supported with splint in
funtional position.
 CONSERVATIVE MANAGEMENT
ESTABLISED DEFORMITIES
• Robert Jones
method(1930s).(1930s).
• Wooden tongue
depressors were used to
correct established
deformities gradually
from distal to proximal
over a prolonged period
of time .
 CONSERVATIVE MANAGEMENT
ESTABLISED DEFORMITIES
• Banjo splint :
• Banjo splint used
with rubber bands
fastened to adhesive
tape on the fingers
permits the fingers to
be exercised at all
times and is most
efficient.
ESTABLISHED VOLKMANN’S ISCHEMIC
CONTRACTURE- MANAGEMENT
• Muscle sliding operation of flexors of forearm.

• Inglis & Cooper

• Williams & Haddad

 INGLIS & COOPER

• Incision on the medial aspect of volar side of

the arm 5 cm proximal to medial
epicondyle and distally to midpoint of forearm
over the ulna.
 INGLIS & COOPER

• Ulnar nerve is identified, released from the cubital tunnel and

protected.
• Tendinous origins of muscles on the medial epicondyle are cut.
• Flexor carpi ulnaris and Flexor digitorum profundus are completely
released from the medial epicondyle and ulna.
 INGLIS & COOPER

• Lacertus fibrosus is divided along with any

remaining portions of the flexor muscle origin.
• Ulnar nerve is trasposed anteriorly.
 WILLIAMS & HADDAD

• Medial aspect of arm and forearm anterior to the medial

epicondyle of the humerus, beginning 5 cm proximal to the
elbow extending distally to 5cm proximal to the elbow
extending distally to 5cm proximal to the wrist.
 WILLIAMS & HADDAD

• Structures anterior and medial to the elbow

are exposed.
 WILLIAMS & HADDAD

• Lacertus fibrosus is divided.

• Origins of the superficial flexors are released from the
medial epicondyle.
• Origin of flexor digitorum superficialis is released from
radius.
 WILLIAMS & HADDAD

• Origin of Flexor carpi ulnaris is released from

olecronon.
• Common origin of flexor carpi ulnaris and
flexor digitorum profundus are released from ulna.
 WILLIAMS & HADDAD

• Origin of flexor digitorum profundus is

released from volar aspect of ulna and
interosseous membrane.
 WILLIAMS & HADDAD

• Origin of flexor digitorum profundus to the

index finger is released from radius.
 WILLIAMS & HADDAD

• Ulnar nerve is transplanted anteriorly into

brachialis muscle.
 AFTER SURGERY
• Sutures are removed after 3 weeks.
• Extension hand splint should be worn for 3
months.
• Occupation and physiotherapy should be
continued until desirable function is attained.