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Volkmann's Contracture

Volkmann Contractures

Trauma, including fractures, crush injuries, arterial injuries and burns, that affect the hand, fingers or wrist leading to deformities are known as Volkmann's contracture.


Presentation

Patients with Volkmann's contracture will often experience the five P’s which include pain, pallor, pulselessness, paresthesias and paralysis with pain usually being the first symptom detected. Other sings that may indicate Volkmann's contracture include palmar flexion of the wrist, pain when stretching the flexor, persistent pain upon palpation of affected area, no radial pulse, decreased sensation and the canonical presentation of the “claw hand” [12] [13] [14].
Cases of congenital Volkmann's contracture are very rare but 50 cases have been reported where neonates display skin, muscle and nerve lesions associated with ischemia. Congenital Volkmann's contracture is caused by increased intracompartmnet pressure that likely resulted from external compression of the fetus within the uterus although specific causes are unknown. Newborns who present with Volkmann's contracture may progress with subcutaneous and muscular necrosis and contracture. In cases of congenital Volkmann's contracture early diagnosis, emergency fasciotomy and physical therapy are the best methods to improve a patient’s prognosis.

Hunting
  • Arnoldo BD, Purdue GF, Kowalske K, Hem PA, Burris A, Hunt JL (2004) Electrical injuries: a 20-year review. J Burn Care Rehabil 25(6):479 CrossRef PubMed Google Scholar 2.[link.springer.com]
Fishing
  • Noble J, Gomez M, Fish J (2006) Quality of life and return to work following electrical burns. Burns 32:159 CrossRef PubMed Google Scholar 8. Kennedy PJ, Young WM, Deva AK, Haertsch PA (2006) Burns and amputations: a 24-year experience.[link.springer.com]

Workup

The level of supracondylar displacement, radial fractures and ulnar fractures can be determined with a radiograph of the upper and lower arm. Pressure monitoring should be performed to monitor compartment syndrome, although the diagnosis of this condition requires further tests. Tests to measure intracompartmental pressure (ICP) include wick catheters, simple needle manometry, side-ported needles, pressure transducers and infusion techniques.

Treatment

Treatment of Volkmann's contracture begins with removal of immobilization materials and administration of analgesics for pain management. Before Volkmann's contracture occurs physicians should perform an emergency fasciotomy to stop progression. Fasciotomy should be performed if the compartment pressure exceeds 30 mmHg although this level is contended and there are no absolute contraindications for this procedure [15].

In mild cases where Volkmann's contracture is already observed physical therapy should be performed along with dynamic splinting, tendon lengthening and slide procedures. Upon development of moderate Volkmann's contracture tendon slide and neurolysis 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 for Volkmann's contracture.
By far the best treatment for Volkmann's contracture, especially if done early, is surgical fasciotomy using either the volar or dorsal approach to relieve pressure on the nerves and muscles of the forearm. Permanent nerve damage may occur if a nerve is compressed for more than 12 to 24 hours. Surgery to relieve pressure is especially important if patients have injuries deep to the lacertus fibrosus, in the carpal tunnel and between the humeral and ulnar heads [16] [17] [18] [19] [20] [21] [22]. Additional surgeries to lengthen or transfer muscle may be performed in an effort to restore function.

Prognosis

The most common complication in Volkmann's contracture, observed in 25-60%of patients, is cubitus varus (gunstock deformity) which is characterized by the arm deviating toward the midline of the body. Patients who develop cubitus varus loose the carrying angle of their arm. Injury to the radial, median and ulnar nerve may also be observed in around 7% of patients. Directly after injury is when patients experience the most deficits and motor function typically returns after 7-12 weeks. Conservative management often leads to the resolution of neropraxias and sensation usually returns after six months [11]. In some children who fracture their supranodylar bone there may be no measurable radial pulse (10%) which is most often due to swelling and not brachial artery injury. In this case radial pulse usually returns once fracture is reduced or resolved.

Etiology

Volkmann's contracture is a hand, wrist or finger deformity caused by trauma, such as fractures, crush injuries, arterial injuries or burns, which cause irreversible muscle death. Injuries to the elbow or forearm and casts that are too tight may decrease blood flow to muscles of the wrist, hand and fingers which can also cause irreversible muscle death and Volkmann's ischemic contractures. In children fractures of the distal humerus, caused by trying to brace for a fall by extending arms, is common especially between the ages of three and eleven years old. Trauma such as this may damage the median or radial nerve and subsequent Volkmann's contractures. In cases where the forearm fracture, such as a supracondylar fracture, causes neurovascular injury patients may develop compartment syndrome which then leads to Volkmann's ischemic contracture which is characterized by a flexion contracture characterized by a clawlike hand deformity [1] [2]. Intra-articular fractures may cause hemarthrosis (bleeding into the joint space).

Epidemiology

The incidence of Volkmann's contracture is approximately 0.5% making it a rare condition. In a longitudinal study over 13 years of nearly 1,000 patients with upper extremity long-bone fractures only 33 patients had a supracondylar fracture. Of the 33 patients with supracondylar fracture only 3 patients developed compartment syndrome. A total of nine children in this study had displaced forearm fractures and of those only three developed Volkmann's contractures. The total percentage of Volkmann's contractures in all orthopedic cases is estimated to be 0.105% with most of these occurring in males (77.5%) from 20 to 40 years of age. Socioeconomic status may impact risk of Volkmann's contractures since most patients who develop this condition reside in rural areas.

Sex distribution
Age distribution

Pathophysiology

Volkmann's contracture is a consequence of serious injury to the deep tissue of the forearm and muscles within the volar compartment, with the most common example observed in children with forearm fractures or displaced supracondylar fractures of the humerus [3] [4] [5] [6]. Tissue and muscle injury typically arise secondary to increased compartmental pressure [7] [8]. Injuries leading to Volkmann's contracture most often affect wrist flexor muscles but wrist extensors may also be involved, although this is rarely observed. The specific superficial flexors associated with Volkmann's contracture include the musculus pronator teres, musculus flexor carpi radialis, musculus flexor carpi ulnaris, musculus flexor digitorum and musculus palmaris longus which all have median nerve innervation except for the flexor carpi ulnaris which is innervated by the ulnar nerve. The specific deep flexor muscles include the flexor musculus pollicis longus, musculus pronator quadratus and musculus flexor digitorum profundus which are innervated by both the medial and ulnar nerves except the flexor pollicis longus which is only innervated by the ulnar nerve.

Traumatic injury to the arm can result in vascular injury and swelling which may progress to compartment syndrome after 12 to 24 hours [10]. Ultimately, compartment syndrome along with ischemia and infarction will cause Volkmann's contracture if it is not treated quickly [9]. Manifestations of Volkmann's contractures include joint extension of the metacarpal-phalangeal joint, fixed flexion of the elbow and wrist and pronation of the forearm [10]. Injuries with extensive ischemia may either resolve, form contractures or the most severe cases develop gangrene although distinguishing between contracture and gangrene is important. Contracture is characterized by partial ischemia in certain regions, whereas, gangrene involves all tissue, especially distal appendages like the fingers. With contractures the hand and fingers may not be ischemic, although they are numb and paralyzed. This is caused by ischemia of proximal muscles and nerves. One study demonstrated that upper arm injuries associated with muscle or nerve damage and subsequent forearm contraction almost always affect the same region of the forearm.

Prevention

Serious disability may be prevented through early detection and prevention. After injury and before the onset of Volkmann's contracture patients that receive proper therapy, including surgery to relieve pressure and repair vasculature, often have a full recovery and restoration of function. The best practice is to monitor injuries that have a high risk of developing Volkmann's contracture and treat accordingly. Conservative therapy for established contractures is usually optimal although operations may be necessary depending on a number of factors.

Summary

Trauma that damages the superficial or deep flexor muscles supporting the hand, wrist or fingers may result in deformities known as Volkmann's contractures. The most common cause of Volkmann's contractures is trauma that may include fractures, crush injuries, arterial injuries or burns. The superficial flexor muscles that if injured may cause Volkmann's contractures include the pronator teres, flexor carpi radialis, flexor carpi ulnaris, flexor digitorum and palmaris longus which are all innervated by the median nerve except for the flexor carpi ulnaris which is innervated by the ulnar nerve. The deep flexor muscles that are involved in Volkmann's contractures include the flexor pollicis longus, pronator quadratus and flexor digitorum profundus which all have both medial and ulnar innervations except the flexor pollicis longus which is only innervated by the ulnar nerve.

Patient Information

Volkmann's contracture is a “clawlike” deformity of the wrist, hand and fingers caused by certain injuries to the forearm and upper arm. Flexion of the elbow and wrist, pronation of the forearm and extension of the wrist and finger joints lead to the “clawlike” appearance. This condition has a high likelihood of developing in children with forearm fractures or displaced supracondylar fractures of the humerus which cause increased pressure in compartments of the arm along with deep muscle and nerve damage. If untreated, compartment syndrome may develop and this condition, which is characterized by inadequate blood flow (ischemia) and obstruction of blood flow (infarction), will lead to underlying tissue damage. Patients that have Volkmann's contracture usually exhibit the 5 P’s which include pain, pallor (pale skin), pulselessness, paresthesias (tingling), and paralysis. Early detection of injuries that will cause Volkmann's contracture is the best way to prevent disease progression. Initial treatment involves splint removal and analgesic administration. To prevent patients from progressing to Volkmann's contracture surgeries may be performed to relieve pressure which will otherwise cause muscle and nerve damage. To restore range of motion and function patients should undergo physical and occupational therapy.

References

Article

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Last updated: 2018-06-22 01:19