Volkmann’s Ischaemic Contracture (VIC)

Volkmann’s contracture is shortening of forearm muscles, usually resulting from injury, that gives rise to a claw like deformity of the hand, fingers, and wrist.

• It is the most serious complication in supracondylar fracture.
  
• If the brachial artery is injured by the sharp edge of the proximal fragment or occlusion of arterial circulation occur ⇒ Inadequate blood supply to the flexor muscles of the forearm ⇒ resulting in volkmann’s ischaemia ⇒ which may progress to fibrosis⇒ resulting into typical volkmann’s sign and the deformity of flexion of the wrist and fingers.⇒
• If not stretched, the progressive fibrosis of the flexors result into fibrous ankylosis of the wrist and finger joint ⇒ giving rise to a typical VIC deformity with wrist in flexion, MCP in hyperextension and flexion at the PIP and DIP joint.
  

If the peripheral nerves[medial and ulnar nerve] are also damaged by ischaemia, there will be sensory and motor paralysis in the forearm and hand. Ultimately it may result into a totally nonfunctional hand.

History

It is named after Richard von Volkmann (1830 – 1889), the 19th century German doctor who first described it, in a paper on “non-Infective Ischemic conditions of various fascial compartments in the extremities”. Because the contracture occurred at the same time as the paralysis, he considered a nerve cause to be unlikely.

Pathophysiology

• local trauma and soft tissue destruction> bleeding and edema > increased interstitial pressure > vascular occlusion > myoneural ischemia

Causes

• Trauma
  • Fractures (most common)
    • distal radius fractures in adults
    • supracondylar humerus fracture in children
  • Crush injuries
  • Contusions
  • Gunshot wounds
• Tight casts, dressings, or external wrappings
• Extravasation of IV infusion
• Burns
• Post ischemic swelling
• Bleeding disorders
• Arterial injury

Pathology:

• Contracture results from insufficient arterial perfusion & venous stasis followed by ischemic degeneration of muscle;
• Irreversible muscle necrosis begins after 4-6 hrs;
• Resulting edema impairs circulation, leads to forearm compartment syndrome, which propagates progressive muscle necrosis;
• Muscle degeneration is most affected at the middle third of muscle belly, being most severe closer to bone;
• There is less involvement toward the proximal & distal surfaces;
• Necrosis of the muscle with secondary fibrosis that may develop followed by calcification in its final phase

Sign and symptoms

Within 3-4 hours following immobilization-

• Severe intractable continuous pain all along the area distal to the site of occulsion.
• Pain increase in intensity on passive finger extension.
• The finger and toes become swollen and dis-coloured first pale and then blue.
• Blisters may appear.
• Absence of radial pulse.
• Muscular spasm with hard and woody feel to touch.
• Loss of muscle extensibilty- giving a feeling of stiffness in the distal joints.
• Gradual loss of sensory status and motor status.
• Typical diagnostic sign develop- volkmann’s sign
  • Volkmann’s sign-
    • In this sign, the finger can not be fully extended passively, with the wrist extended,
    • But finger can be fully extended passively when the wrist is flexed.
• If not attended immediately, it may progress to an irreversible typical VIC deformity.

Examination

For a Volkmann’s contraction, the findings are specific as described in sign and syptoms subheading above.
The main physical picture that we see 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.

The deformity seen in this condition can be divided 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.

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

TREATMENT

(Suspected cases) in case any of these signs appear:

1. Immediate removal or discontinuation of pressure causing factors, eg. splint, POP cast, bandage.
2. Limb elevation and passive as well as active vigorous movements of segments distal and proximal to the affected area.
3. Heat to be applied to the other limbs and trunk to promote general vasodilation
4. Contrast bath, steam packs, massage and stimulation can be used to augment local circulation and nerve excitation provided the sensory status of the affected area is intact.

(Established cases) the prognosis depends upon the degree of permanent damage to the muscle and nerves.

The therapeutic approach, depends upon the type of VIC.

• Mild type:-
  • There is ischemia of the flexor digitorum profundus.
  • It could be managed by exercise and dynamic splinting to maintain finger extension
• Moderate type:-
  • It involves superficial as well as deep finger flexors, and flexors of the wrist and thumb
  • If these muscles are still functional, conservative approach of graded splinting and exercise are useful.
  • Muscle lengthening operation may be necessary in non responding cases.
• Severe type:-
  • Invariably needs surgery as the contracture are progressed beyond the scope of conservative management.
  • However, preoperative passive relaxed stretching and dynamic splinting facilitate surgery.

The ultimate aim is to achieve maximum extension at the wrist, which is a functional requirement.

• splinting
• for increasing the extensibilty of the contracted soft tissues on the flexors aspect, effective adjuncts like
  • Massage,
  • Ultrasonic and ,
  • axial traction can be used, besides relaxed passive movements.
• If the swelling persists, strong voluntary movements with the limb in elevation should be given.

SURGICAL TREATMENT: following surgical procedure may be done in selected cases:

• Shortening of forearm bones:
  • It is done to overcome contracture of the flexor group of muscles.
• Muscle sliding operation:
  • Also called as Max Page operation,
  • This allows correction of the flexion contractures at the wrist and finger joints.
• Excision of the dead muscles:
  • The necrotic muscle mass is excised and replaces by a healthy muscle obtained from the neighbourhood or from a distant site.
• Nerve grafting:
  • If the median nerve is damaged beyond repair, nerve grafting may sometimes be helpful.

PHYSIOTHERAPEUTIC MANAGEMENT FOLLOWING SURGERY: In all the four surgical procedure, the objective of physiotherapy is the re-education of the muscle action.

The muscle power, the joint range and the sensory status are assessed preoperatively.

Postoperative management following surgery;

• Provide a corrective splint, incorporated with immobilization.
• This is to maintain the corrected position of the contractures, and assists, in movements.
• The measures like
  • Diapulse
  • Hand elevation
  • Active resistive movements of the related joints are carried out to reduce inflammation and pain .

During mobilization: The basic therapeutic principles are

1. Care of the anaesthetic areas
2. Re-education of the muscle action
3. Sensory re-education
4. To improve the functional efficiency
5. Modification in the splint to further improve the function.