VOLKMANN ISCHEMIC CONTRACTURE SEMINAR.pptx

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.

10. 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

11. TOLERANCE OF TISSUE 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.

12. 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

13. 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

14. 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.

15. 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

16. 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

17. 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.

18. 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.

19. 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.

20. 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

21. 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

22. 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.

23. 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.

24. 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.

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

26. 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.

27. 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

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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).

34. 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.

35. 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.