Volkmann's ischaemic contracture

This presentation is made to act as a guide and a short reminder to clinicians and medical students on Volkmann's Ischaemic Contracture, which is a medical condition that can lead to activities limitation and public participation restriction. This presentation explore aspects of the condition such as what it is, causes, how it can be diagnosed, how it can be managed and others.

1. Volkmann's Ischaemic Contracture NIHINLOLA OLUWAMAYOWA Part 5 physiotherapy student, Bowen University, Iwo, Osun State. 1

2. OUTLINE: INTRODUCTION ETIOLOGY/EPIDEMIOLOGY CLINICAL RELEVANT ANATOMY CLINICAL PRESENTATION EXAMINATION DIAGNOSTIC PROCEDURE MANAGEMENT CONCLUSION REFERENCES 2

3. Volkmann's contracture is a deformity of the hand, fingers, and wrist which occurs as a result of a trauma such as: fractures, crush injuries, burns and arterial injuries. Following this trauma, there is a deficit in the arterio -venous circulation in the forearm which causes a decreased blood flow and the hypoxia can lead to the damage of muscles, nerves and vascular endothelium. INTRODUCTION 3

4. A fracture of the supracondylary space blocks blood circulation ad a result of lesion to the brachial artery. deficit of blood supply causes muscles and nerves malfunction. ETIOLOGY/EPIDEMIOLOGY The incidence of Volkmann’s contracture is low. It counts 0.5 %, which means it is a rare disease . 4

5. ETIOLOGY/EPIDEMIOLOGY CONT’D 5

6. T h e muscles who are usually contracted due to ischaemia are the wrist flexors and the wrist extensor less commonly affected. WRIST FLEXORS CLINICAL RELEVANT ANATOMY MEDIAN NERVE ULNAR NERVE PRONATOR TERES PALMAR CARPAL ULNARIS PALMAR CARPAL RADIALIS FLEXOR DIGITORIUM PROFUNDUS(MEDIAL part) PALMARIS LONGUS MEDIAN NERVE CONT’D FLEXOR DIGITORIUM SUPERFICIALIS FLEXOR POLLICIS LONGUS FLEXOR DIGITORIUM PROFUNDUS(lateral part) PRONATOR QUADRATUS 6

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8. 8 The wrist is in palmar flexion
Clawed fingers
Pain occurs with palpation of the affected region and passive stretching of the flexors CLINICAL PRESENTATION It is possible that the pulsations can not be felt in the swollen arm, mainly in the distal part ( pulselessness ). there is a decreased sensation ( paresthesia ) and there is an observable motor deficit (paresis) .

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10. EXAMINATION The deformity seen in this condition can be divided into different levels of severity MILD: a flexion contracture of 2 or 3 fingers with no or limited loss of sensation
MODERATE: All fingers are flexed and the thumb is oriented in the palmar orientation. SEVERE: all muscles in the forearm (flexors and extensors) are involved . O bjective test to evaluate the ischemia and the pressure in a muscle compartment is an invasive test that measures the intracompartimental pressure. 10

11. Pressure monitoring: Intracompartmental pressure (ICP) can be measured by several means including : Wick catheter Simple needle manometry Infusion techniques
Pressure transducers
Side-ported needles DIAGNOSTIC PROCEDURES 11

12. 12 Simple needle manometry Wick catheter

13. Different authors consider surgical intervention if:

Absolute ICP greater than 30 mmHg
Difference between diastolic pressure and ICP greater than 30 mmHg
Difference between mean arterial pressure and ICP greater than 40 mmHg DIAGNOSTIC PROCEDURES CONT’d “Differential Diagnosis: Pseudo-Volkmann's contracture ” 13

14. Prevention is the best management in this condition. Often times, the management require the surgical and physical therapy intervention for a better outcome. SURGICAL INTERVENTION Fasciotomy : (surgical opening of the fascia around the muscles to make more place for the structures inside ) is recommended when the ICP is >30 mmHg. Debridement: removal of dead tissues. Neurolysis . Tendon release. And other salvaging procedures MANAGEMENT 14

15. MANAGEMENT CONT’D Passive range of motion Using heating modalities (infrared, short wave diathermy etc. Soft tissues massage. Sustained passive stretching. Strengthening weak muscles. Progressive splinting. Functional activities. 15

16. MANAGEMENT CONT’D After the surgery: it is important to ensure that the mobility is recovered by passive stretching techniques, range of motion exercises to enhance soft tissue elasticity. Another part of the therapy is activating and strengthening the weak agonist to ensure equilibrium in agonist and antagonist pull during joint movement . Using electomyographic device to train affected muscles with co- operativity . The patient is more alert and there is more interaction between the patient and the therapist 16

17. 17 PROGNOSIS Outcome is usually good for people with mild contracture. They regain function of their arms and hands People with moderate or severe contracture who need major surgery may not regain full function. Early diagnosis and treatment means better outcome . Patient and caregivers corporation also determines the prognosis. The patient financial status (If he/she can afford surgery or physiotherapy cost.)

18. 18 OUTCOME MEASURES Verbal rating scale (VRS) Visual analogue rating scale (VARS) Numerical pain scale (NPS)

19. 19 CONCLUSION Volkmann’s Ischaemic Contracture is a localized condition that can be diagnosed at an early stage in an environment with proper medical care. Diagnosis can be done without the use of sophisticated modalities but they are needed to confirm the subjective diagnosis. With proper management, its effects can be reduce and or removed and the functional ability of the hand return to normal thereby improving the individual’s quality of life.

20. REFERENCES http://www.physiopedia.com LANDI , G. DE SANTIS, P. TORRICELLI, A. COLOMBO, P. BEDESCHI CT in Established Volkmann’s Contracture in Forearm MusclesJ Hand Surg [Br] February 1989 14: 49-52 Von Schroeder HP et al. Definitions and terminology of compartment syndrome and Volkmann's ischemic contracture of the upper extremity. Hand Clin . 1998 Aug;14(3):331-4. 20