volkmaan ischaemic contracture

1. Dr (Major) Parthasarathy S
PG Resident,MS Orthopaedics
Stanley Medical College,Chennai
Ref : Campbell’s operative orthopaedics 13th
edn

2.  Circulation within a closed compartment is
compromised
 by an increase in pressure within compartment
 causing necrosis of muscles,nerves
 eventually the skin because of excessive swelling
 In upper limb common in forearm
 Hand intrinsic muscles may be involved
 Arm rare

3.  Volkmann ishaemic contracture
 sequele of untreated/inadequetly treated
compartment syndrome
 necrotic muscle and nerve have been replaced
with fibrous tissue

4.  1881 –Volkmann
 paralytic contractures post trauma due to arterial
insufficiency/ishaemia of muscle
 He stated that tight bandage is the cause
 1909-Thomas
 Extrinsic force is not the sole cause
 1914-Murphy
 Hge and effusion increases internal pressure within
unyielding deep fascial compartments with subsequent
obstruction of venous return
 1928-Jones
 May due to pressure from within/outside/both
 Eichler/Lipscomb
 fasciotomy techniques

5.  Forearm-4 compartments
 Superficial volar
 Deep volar
 Dorsal
 Dorsal mobile wad of Henry
 Volar commonly involved

6.  Superficial volar
 FCU
 Palmaris longus
 FCR
 FDS
 Pronator teres
 Deep volar
 FDP
 FPL
 Pronator quadratus

8.  Mobile wad of Henry
 BR
 ECRL
 ECRB
 Dorsal extensor
 Anconeus
 ECU
 EDC
 EDQ
 Extensor digitorum
 Extensor digiti minimi
 APL
 EPL
 Extensor indicis
 Supinator

9.  Hand
 8 interosseous compartments
 Adductor pollicis
 Thenar
 hypothenar

10.  Crush injury
 Prolonged external compression
 Internal bleeding(haemophilia)
 Fracture
 Excessive exercise
 Burn
 Snake bite
 Intraarterial injection(drug/sclerosing agent)

11.  18% -fracture
 23%-soft tissue injury
 In 15% Elbow injury
supracondylar fracture

12.  EATON & GREEN CYCLE

13. o In ischaemia
 Muscle
Functional impairement 2-4 hrs
Irreversible loss 4-12 hrs
 Nerve
Functional impairement 30mins
Irreversible loss 12-24 hrs

14.  High index of suspicion
 Increasing pain that is out of proportion to
injury
 Passive stretching of involved muscle
 Tender tense swelling
 Finger tip sensation dimished
 2 point discrimination,vibration sense
reduced
 Distal pulse absence late sign
 Bulla/ulcerative skin lesion

16.  Compartment pressure
 >30mmHg/within 20mmHg of diastolic pressure
 All compartents measured
 Methods
 Hand held pressure monitoring system
 Arterial line monitoring system
Connected to straight needle/side port needle/slit
catheter
Arterial line manometer with a slit catheter most
accurate(Boody et al)

19.  Impending tissue necrosis – 20-30mm Hg
below the diastolic pressure(in hypotensive
patient acceptable level less)
 Higher pressure & symptoms,signs –
fasciotomy recommended

20.  Normotensive with positive clinical findings
with >30mmHg and duration of increased
pressure is unknown/thought to be longer
than 8 hrs
 Uncoperative/unconscious patient with
>30mmHg
 Hypotensive with >20mmHg
As a rule when in doubt fasciotomy should be
done

21.  Delay in diagnosis –most imp factor in
predicting outcome
 68% of patients had normal function when
fasciotomy done within 12hrs

28.  More common in lower limb
 Commonly in forearm involves 1st
dorsal
interosseous & volar forearm
 Motorcyclists,kayakes,rowers,adolescent
after puberty
 Mini open fasciotomy
 Quicker recovery
 cosmesis

32.  Untreated/inadequately treated –pressure
increases
 FDP mid 1/3RD
forearm earliest changes seen
 Second comon FPL>Pronator teres

34.  Elbow flexion
 Forearm pronation
 Wrist flexion
 Thumb adduction
 Mcp jt extension
 Finger flexion

36. Mild/Localised Volkmann contracture
 Partial ischemia of FDP
 Flexion contracture only 2/3 fingers
 Sensory mild/absent
 No intrinsic muscle/joint contracture
 Moderate
 Long finger flexors,FPL,wrist flexors
 Median & ulnar nerve sensory change
 Intrinsic minus deformity
 Severe
 Flexors & extensors
 Sensory impairement

37.  Mild
 Dynamic splinting
 Functional training
 Active exercise
 After 3 months tendon release/lengthening
 When multiple tendon units involved –muscle sliding
operation/wrist resection/pronator teres excision

38.  Moderate
 Muscle sliding operation
 Neurolysis of median/ulnar nerve
 Excision of any fibrotic muscle mass
 When no useful movement of finger flexors retained –
volar transfer of dorsal wrist extensor
 BR to FPL
 ECRL to FDP
 Complete release of flexors

39.  Severe
 2 stage procedure
 First-excision of necrotic muscles,neurolysis
 Second-tendon transfer(BR to FPL,ECRL to FDP)
free gracilis/medial gastrocnemius
myocutaneous flap
Appropriate time-after 3 months and before 1 year
f ischaemic event

40.  Positive intrinsic tightness test-when MCP jt
is held extended flexion at PIP jt is not
possible
 Severe-muscle viable but
contracted
 More severe-necrosed/fibrosed

41.  LITTLER release –positive intrinsic tightness
test

42.  Severe- viable contracted muscle
 Muscle released from MC shafts by muscle sliding
operation
 Most severe-necrosed/fibrosed muscle
 Tendon release
 Capsulotomy
 Tendon transfer