Vic

volkmaan ischaemic contracture

1. Dr (Major) Parthasarathy S
PG Resident,MS Orthopaedics
Stanley Medical College,Chennai
Ref : Campbell’s operative orthopaedics 13
th
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. oIn 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 1
st
dorsal
interosseous & volar forearm
Motorcyclists,kayakes,rowers,adolescent
after puberty
Mini open fasciotomy
Quicker recovery
cosmesis

32. Untreated/inadequately treated –pressure
increases
FDP mid 1/3
RD
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