Everything about volkmann ischemic contracture and it's details. This PPT can be used for conducting seminars.

1. VOLKMANN’S ISCHEMIC
CONTRACTURE
DR MANDEEP
PG-2
ORTHO UNIT-2

2. VIC
• DEFINITION:VOLKMANN
ISCHEMIC CONTRACTURE IS A
SEQUELA OF UNTREATED OR
INADEQUATELY TREATED
COMPARTMENT SYNDROME IN
WHICH NECROTIC MUSCLE AND
NERVE TISSUE HAVE BEEN
REPLACED WITH FIBROUS
TISSUE.

3. HISTORY
• 1881, VOLKMANN STATED IN HIS CLASSIC PAPER
THAT THE PARALYTIC CONTRACTURES THAT
COULD DEVELOP ONLY A FEW HOURS AFTER
INJURY WERE CAUSED BY ARTERIAL
INSUFFICIENCY OR ISCHEMIA OF THE MUSCLES.
• HE SUGGESTED THAT TIGHT BANDAGES WERE
THE CAUSE OF VASCULAR INSUFFICIENCY.

4. • 1909, THOMAS FOUND THAT PARALYTIC CONTRACTURE
DEVELOPED FOLLOWING SEVERE CONTUSIONS OF THE
FOREARM IN THE ABSENCE OF FRACTURES, SPLINTS, OR
BANDAGES.
• 1914, MURPHY REPORTED THAT HEMORRHAGE AND
EFFUSION INTO THE MUSCLES COULD CAUSE INTERNAL
PRESSURES TO INCREASE WITHIN THE UNYIELDING DEEP
FASCIAL COMPARTMENTS OF THE FOREARM, WITH
SUBSEQUENT OBSTRUCTION OF THE VENOUS RETURN.

5. • 1928, JONES CONCLUDED THAT VOLKMANN
CONTRACTURE COULD BE CAUSED BY
PRESSURE FROM WITHIN, FROM WITHOUT,
OR FROM BOTH

6. ANATOMY
•AT THE ENTRANCE TO
THE FLEXOR
COMPARTMENT OF
FOREARM, LACERTUS
FIBROSUS FANS
MEDIALLY FROM BICEPS
TENDON.
•BENEATH THE
LACERTUS FIBROSUS
THE BRACHIAL ARTERY
AND MEDIAN NERVE
PASS TO ENTER FLEXOR
COMPARTMENT.

7. • BRACHIAL ARTERY DIVIDES INTO
RADIAL AND ULNAR ARTERIES.
•RADIAL ARTERY COURSES
SUPERFICIALLY AND IS NOT
CROSSED BY ANY STRUCTURES IN
THE FOREARM.
•ULNAR ARTERY PASSES BENEATH
THE PRONATOR TERES WHERE IT
GIVES A BRANCH , COMMON
INTEROSSEOUS ARTERY.
•COMMON INTEROSSEOUS
ARTERY FURTHER DIVIDES INTO
POSTERIOR AND ANTERIOR
INTEROSSEOUS ARTERY.

8. • COMPARTMENTS OF FOREARM:
1. SUPERFICIAL VOLAR COMPARTMENT
2. DEEP VOLAR COMPARTMENT
3. DORSAL COMPARTMENT
4. THE COMPARTMENT CONTAINING THE MOBILE WAD
OF HENRY (BRACHIORADIALIS AND EXTENSOR CARPI
RADIALIS LONGUS AND BREVIS)

9. ETIOLOGY
• SUPRACONDYLAR
FRACTURE OF THE
HUMERUS IN
CHILDREN.
• BRACHAIL ARTERY MAY
GEY IMPINGED ON THE
SHARP PROXIMAL
FRAGMENT AGAINST
WHICH IT IS HELD BY
LACERTUS FIBROSUS.

11. • CRUSH INJURIES
• PROLONGED EXTERNAL COMPRESSION
• INTERNAL BLEEDING (ESPECIALLY AFTER INJURY IN
PATIENTS WITH HEMOPHILIA)
• EXCESSIVE EXERCISE
• BURNS
• SNAKE BITES
• INTRA ARTERIAL INJECTIONS OF DRUGS OR SCLEROSING
AGENTS
• INFECTIONS

12. TOLERANCE OF TISSUE
1. MUSCLE :
• FUNCTIONAL IMPAIRMENT AFTER 2-4 HOURS
OF ISCHAEMIA.
• IRREVERSIBLE FUNCTIONAL LOSS AFTER 6-8
HOURS.
2. NERVES:
• FUNCTIONAL IMPAIRMENT AFTER 30 MINS
OF ISCHAEMIA.
• IRREVERSIBLE FUNCTIONAL LOSS AFTER 6-8
HOURS.

13. SEDDON’S ELLIPSOID INFARCT CONCEPT
• SEDDON DESCRIBED ISCHEMIC
ZONE OF INJURY USUALLY
FOLLOWING BRACHIAL ARTERY
INJURY THAT ACQUIRES
ELLIPSOID SHAPE
• HE DESCRIBED THE “AXIAL”
OXYGENATION AROUND
ANTERIOR INTEROSSEOUS
ARTERY WITH CENTER JUST
ABOVE MID-FOREARM

14. • SO THE MIDDLE THIRDS OF MUSCLES GET MOST INVOLVED EVOLVING IN AN
ELLIPSE WITH LONG AXIS ALONG THIS REGION.
• HE ALSO NOTED THAT THE CENTER OF MUSCLE WAS MOST ISCHEMIC AND
THE REGION WAS CLOSEST TO THE INTEROSSEOUS MEMBRANE (DEEPER
ASPECT OF FOREARM) WHILE THE PERIPHERAL PARTS ESCAPED MODERATE
REDUCTIONS IN MAINLINE BLOOD FLOW DUE TO COLLATERAL CIRCULATION.
• HENCE THE STRUCTURES CLOSEST TO THE INTEROSSEOUS MEMBRANE ARE
AFFECTED CENTRALLY.
• FDP AND FPL LYING ON EITHER SIDE OF VESSEL ARE THE MOST SEVERELY
AFFECTED MUSCLES.
• MEDIAN NERVE AT THE CENTER IS MOST AFFECTED IN VIC WHEREAS ULNAR
NERVE BEING IN PERIPHERY IS VARIABLY INVOLVED

15. CLASSIFICATION
• SEDDON IN 1956 AND 1964, AND MODIFIED BY TSUGE IN 1975
• MILD OR LOCALIZED TYPE (SEDDON DESCRIBED THIS AS HAVING DIFFUSE
BUT MODERATE ISCHEMIA WITHOUT INFARCT AND SPONTANEOUS
RECOVERY)
• THE DEEP FLEXOR MUSCLES ARE PARTLY DEGENERATED.
• THE RING FINGER AND THE LONG FINGER MOST OFTEN INVOLVED.
• JOINTS ARE SPARED.
• THERE IS USUALLY NO SENSORY DISTURBANCE BUT, IF PRESENT, IT IS
SLIGHT.
• VOLKMANN SIGN PRESENT.

16. • MODERATE OR CLASSIC TYPE (SEDDON DESCRIBED THIS AS INTENSE
BUT LOCALIZED MUSCLE DAMAGE WITH TYPICAL MUSCULAR
INFARCT WITH OR WITHOUT NERVE LESION):
• THE DEGENERATION INVOLVES NEARLY ALL OF THE DEEP FLEXOR
MUSCLES TO THE FINGERS AND THE POLLICIS LONGUS, WITH PARTIAL
INVOLVEMENT OF THE FDS AND WRIST FLEXORS LEADING TO
CONTRACTURE.
• FLEXION CONTRACTURES OF ALL FINGERS AND THUMB AND WRIST.
• NEUROLOGIC SIGNS ARE INVARIABLY PRESENT, MOST COMMONLY
MEDIAN NERVE

17. • THE SEVERE TYPE (SEDDON’S WIDESPREAD NECROSIS
AND FIBROSIS WITH SEVERE PARALYSIS AND
DEFORMITY):
• DEGENERATION OF ALL FLEXOR MUSCLES AND
PARTIAL INVOLVEMENT OF THE WRIST EXTENSOR
MUSCLES.
• EXTENSOR INVOLVEMENT IS SEEN IN 13% OF ALL THE
PATIENTS SEEN.
• THE NEUROLOGIC SIGNS ARE SEVERE

18. ZANCOLLI’S TYPE
• NORMAL INTRINSIC MUSCLE TYPE (TYPE I, SIMPLE DIGITAL
CLAW)—THE CONTRACTURE IS LIMITED TO THE FOREARM
MUSCLES.
• JOINTS SPARED—NO STIFFNESS.
• PARALYTIC INTRINSIC MUSCLE TYPE (TYPE II, INTRINSIC CLAW
HAND).
• SIMPLE CLAW TYPE—FLEXED POSITION OF WRIST, CONTRACTURE
OF THE LONG FLEXOR MUSCLES OF FINGERS.
• COMPLICATED CLAW TYPE—SEVERE INTRINSIC PARALYSIS ALONG
WITH DIGITAL JOINT STIFFNESS.

19. • TOTALLY RIGID CLAW HAND—FLEXED INTERPHALANGEAL JOINTS
WHILE METACARPOPHALANGEAL (MCP) JOINTS STIFF IN
EXTENSION.
• RETRACTED INTRINSIC MUSCLE TYPE (TYPE III, INTRINSIC
CONTRACTURE OF THE INTEROSSEOUS AND/OR THUMB MUSCLES):
MCP JOINTS ARE FLEXED WHILE THE INTERPHALANGEAL JOINTS
ARE IN EXTENSION.
• DISTAL INTERPHALANGEAL JOINT FLEXED DUE TO FDP
CONTRACTURE.
• WRIST IS ALSO FLEXED.

21. ASSESSMENT OF PATIENT
• DETAILED HISTORY:THIS MAY ENLIGHTEN AS TO THE
CAUSE AND EXTENT OF DAMAGE.
• SUPRACONDYLAR FRACTURES RESULT IN MODERATE
TYPE OF VIC MOST OFTEN.
• TREATMENT RECEIVED IS IMPORTANT MODIFIERS TO
MANAGEMENT, TIGHT BANDAGE, MASSAGE, QUACK
TREATMENT ALL INCREASE THE SEVERITY OF ISCHEMIA.

22. • FUNCTIONAL EVALUATION/EXAMINATION:
• THE ACTIVE AND PASSIVE RANGE-OF-MOTION OF
ALL JOINTS: –
• VOLKMANN’S SIGN: INABILITY TO ACTIVELY
EXTEND FINGERS (AT INTERPHALANGEAL AND/OR
MCP JOINTS) WITHOUT FLEXING WRIST AND
PASSIVE EXTENSION OF FINGERS POSSIBLE ONLY
WITH WRIST FLEXION. THIS IS A CLASSICAL SIGN
FOR TYPE I VIC

23. Figs 4A to C: (A and B) Volkmann sign—
with wrist flexed the fingers can be
extended; however, (C) it is virtually
impossible to extend the finger
completely with wrist extended

24. • Wrist flexion
• Pronated forearm
• wasting
• Flexed elbow
• Cord-like induration on the flexor side,
extensors affected/spared
• Paresthesia or anesthesia in the hand and
fingers
• Flexed and adducted thumb
• Deformity and trophic changes due to ulnar
and median nerve involvement.

25. INVESTIGATION
• RADIOGRAPHS OF FOREARM AND ELBOW:TO EVALUATE
AND UNDERSTAND THE PRIMARY PATHOLOGY
(FRACTURE TYPE, LOCATION, STATUS OF UNION AND
NONUNION, MALUNION AND DEGREE OF MALUNION).
• RADIOGRAPHS OF THE HAND TO DETERMINE JOINT
SUBLUXATIONS AND SEVERITY OF FLEXION
CONTRACTURE/ SECONDARY CHANGES IN JOINTS IN
LONG NEGLECTED CASES.

26. • ELECTROMYOGRAPHY CAN PRODUCE INFORMATION
CONCERNING NERVE FUNCTION AND NERVE
REGENERATION
• ANGIOGRAPHY IS REQUIRED FOR INFORMATION
REGARDING THE VASCULAR STATUS.
• MRI DEMONSTRATES FIBROSIS AND THE EXTENT OF
LOSS OF MUSCULAR TISSUE.

27. DIFFERENTIAL DIAGNOSIS
• POST-TRAUMATIC HEMATOMA AND RESULTING
CONTRACTURE.
• OSTEOMYELITIS AND MUSCLE INVOLVEMENT
EITHER BY INTERVENTION OR DISEASE PROCESS.
• PSEUDO-VIC
• BURNS.

28. TREATMENT
• CONSERVATIVE:
• CONSISTING OF A
COMBINATION OF EXERCISES
AND ORTHOSES FOR WRIST,
HAND AND FINGERS.
• STIFFNESS OF JOINTS SHOULD
AT ALL TIMES BE PREVENTED.
• TURNBUCKLE SPLINT TO
MOBILIZE THE FINGERS.

29. • OPERATIVE:
1. EXCISION OF FIBROUS TISSUE:
• CAPSULOTOMY—NEEDED IF THE FINGERS CANNOT BE STRETCHED
AFTER MUSCLE SEQUESTRUM EXCISION.
• NEUROLYSIS.
• TENOLYSIS.
2. TENDON LENGTHENING
3. TENDON TRANSFERS
4. NERVE GRAFTING.
5. FREE, VASCULARIZED, INNERVATED MUSCULOCUTANEOUS FLAPS

30. • MILD TYPE:
• STRETCHING AND PHYSIOTHERAPY IF ADEQUATE
MUSCLE MASS IS PRESERVED.
• CORRECT WRIST FLEXOR CONTRACTURE BY
RELEASING FLEXOR CARPI RADIALIS (FCR) (MORE
COMMONLY AFFECTED) AND FLEXOR CARPI
ULNARIS (FCU) (LESS COMMON).
• IF THE CONTRACTURE RECURS THEN WRIST
ARTHRODESIS IS APPROPRIATE.

31. • TENDON TRANSFER/LENGTHENING WHEN
THERE IS LOSS OF MUSCLE MASS DUE
CONTRACTURE OF FDP AND FPL:
- Z-PLASTY: IT IS COMMONLY DONE BY FDS TO
FDP TRANSFER, WHERE THE DISTAL CUT
TENDONS OF FDP ARE ATTACHED PROXIMALLY
TO FDS.

32. • PAGE’S OPERATION: FOR INVOLVEMENT OF MULTIPLE
TENDON UNITS.
• STEPS:
• USE ULNAR DISTAL ARM INCISION EXTENDING TO THE
ULNAR BORDER OF FOREARM UP TO WRIST.
• MOBILIZE ULNAR NERVE BUT DO NOT DEVASCULARIZE IT.
• FLEXOR PRONATOR MASS IS ELEVATED OFF THE MEDIAL
EPICONDYLE OF HUMERUS AND PRESERVE MEDIAL
COLLATERAL LIGAMENT.

33. • FCU, FDS AND FDP ARE ELEVATED OFF THE ULNA, AND
INTEROSSEOUS MEMBRANE PROTECTING THE
INTEROSSEOUS NERVE AND ARTERY.
• KEEP CHECKING THE CORRECTION AT WRIST AND FINGER
MOVEMENTS, OFTEN THE DISSECTION IS CONTINUED TILL
WRIST TO ACHIEVE ACCEPTABLE CORRECTION.
• PRONATOR RELEASE IS NEEDED IF THE CORRECTION OF
FIXED PRONATOR DEFORMITY IS NOT ACHIEVED.

34. • MODERATE TYPE (CLASSIC TYPE)
• INITIAL STRETCHING AND CORRECTION OF WRIST FLEXOR
CONTRACTURE FOLLOWED BY :
• FOR PRESERVED MUSCLE MASS—MUSCLE SLIDING OPERATION (OF
MAX PAGE) WITH NEUROLYSIS OF MEDIAN AND ULNAR NERVE AS
NEUROLOGICAL DAMAGE IS CHARACTERISTIC OF MODERATE TYPE.
• WHEN THERE IS NO USEFUL FINGER FLEXION LEFT, OR THERE IS
PROXIMAL SKIN PROBLEM THEN BRACHIORADIALIS AND EXTENSOR
CARPI RADIALIS LONGUS (ECRL) TRANSFER TO FLEXORS (FPL AND
FDP RESPECTIVELY) AND COMPLETE RELEASE OF CONTRACTURE
AND NEUROLYSIS IS THE USUAL OPTION.

35. • EXTENSOR INDICIS IS USED FOR THUMB
OPPOSITION.
• SENSATION MAY BE RESTORED BY NERVE
GRAFTING.
• OTHER OPTIONS ARE PROXIMAL ROW
CARPECTOMY OR FOREARM SHORTENING BY
2–3 CM (GARRE’S OPERATION).

36. • SEVERE TYPE
• TWO STAGE APPROACH
• STAGE 1: EARLY EXCISION OF ALL NECROTIC
TISSUE WITH COMPLETE NEUROLYSIS OF ULNAR
AND MEDIAN NERVES TO GIVE THEM FAIR
CHANCE TO RECOVER (AT LEAST 3 MONTHS).
THIS IS FOLLOWED BY AGGRESSIVE
MOBILIZATION OF JOINTS OF WRIST AND HAND
TO PREVENT DEFORMITY AND RETAIN MOBILITY.

37. • STAGE 2:Reconstruction is DONE by tendon
transfer.
• If no tendons are available (due to extensor
involvement) then Gracilis or latissimus
dorsi/medial gastrocnemius (myocutaneous)
free innervated muscle graft transfer is
needed.