Volkmann¶s ischemic contracture

VIC seminar for UG

1. VOLKMANN¶S ISCHEMICCONTRACTURECONTRACTUR

2. VOLKMANN’S ISCHEMIC CONTRACTURE Definition :A condition which is characterized by ischemic necrosis of the structures contained within the volar compartment of the forearm associated with crippling contractures and varying degrees of neurologic deficit.

3. HISTORY 1881, Volkmann stated that paralytic contractures that develop within a few hours after injury are caused by arterial insufficiency or  ischemia of muscles .

4. HISTORY 1906,Hildebrand first used the term "Volkmann   ischemic contracture“ to describe the final result of any untreated compartment syndrome. 1909, Thomas found that paralytic contractures followed severe contusions of the forearm without fractures. 1914, Murphy reported that increased internal pressures in the deep compartments of the forearm and effusion in the muscles resulted in ischemia.

5. 1928,Jones concluded that Volkmann’s contracture could be caused by pressure from within, from without or both.

6. Volkmann’s ischemic contracture is a late sequelae of untreated or  inadequately treated compartment syndrome in which necrotic muscle and nerve tissue are replaced with fibrous tissue .

7. ANATOMY At the entrance to the flexor compartment of the forearm , lacertus fibrosus fans medially from the biceps tendon. Beneath the lacertus fibrosus the brachial artery and median nerve pass to enter the flexor  compartment.

8. ANATOMY The brachial artery divides into radialand ulnar arteries . The radial artery courses superficially and is not crossed by any structure in the forearm. The ulnar artery passes beneath the pronator teres where it gives a  branch, the common interosseus artery. The common interosseus artery further divides into volar and dosal interosseus arteries.

9. ANATOMY The median nerve accompanies the brachial artery beneath the lacertus fibrosus and enters the substance of  the pronator teres passing between its humeral and ulnar heads.

10. ANATOMY Compartments of the forearm. 1. Superficial volar   compartment . 2. Deep volar compartment. 3. Dorsal compartment. 4. Mobile wad of Henry.

11. ETIOLOGY Supracondylar fractures of the humerus in children is the most common precipitating injury . The brachial artery may get impinged on the sharp proximal fragment against which it is held by lacertus fibrosus .

12. ETIOLOGY Hemorrhage and edema may further compress the brachial artery and the median nerve in this region.

13. ETIOLOGY Ischemia ±± Edema cycle as depicted by Eaton and Green

14. ETIOLOGY 1. Crush injuries. 2. Prolonged external compression. 3. Internal bleeding (Hemophilia ). 4. Burns . 5. Snake bites. 6. Intravenous regional anesthesia

15. TOLERANCE OF TISSUE 1. Muscle :- F unctional impairment after 2-4 hours of ischemia. Irreversible functional loss after   4-12 hours. 2. Nerves :- Functional impairment after 30 mins of ischemia. Irreversible function loss after   12-24 hrs.

16. CLINICAL PICTURE Acute compartment syndrome (Impending Volkmann’s ischemic contracture ) 1. If  local compression is the cause : Pulses intact ( in early stages) Paresis Stretch pain Parasthesia (median nerve sensory zone commonly ) Good capillary filling.

17. CLINICAL PICTURE Acute compartmentsyndrome ( Impending Volkmann’s   ischemic contracture) 2. If   arterial injury is the cause : Stretch pain Parasthesia Pulselessness Pallor ( or Cyanosis) Paresis

18. CLINICAL PICTURE Two point discrimination is more than 1 cm in in the sensory zone of the median nerve. Diminished perception of  vibratory sense of 256cycles/sec stimulus.

19. CLINICAL PICTURE Measurement of  intracompatmental pressure : 1. White sides handheld pressure monitoring system . 2. Wick catheter. 3. Slit catheter.

20. CLINICAL PICTURE Evaluating the  intracompartmental pressure . Range between 10 ± 20 mmHg below the diastolic pressure - cessation of blood flow is eminent. 40± 50 mmHg - muscle threatening compression and ischemia are present . Pressure of  30 mmHg or greater - criterion for  fasciotomy .

21. Deformities in Volkmann’s ischemic contracture Mild type : Deep flexors are partially involved particularly, Flexor   digitorum profundus . Flexion contractures of one or  more fingers which can be extended on hyperflexing the wrist. Resistant pronation contracture involving either the pronator teres or pronator quadratus .

22. Deformities in Volkmann’s ischemic contracture Moderate type : Involves most of the flexor   digitorum profundus , flexor   pollicis longus and part of flexor digitorum superficialis . Neurological deficit  involving median nerve more than ulnar  nerve is present. Deformity is intrinsic minus hand. Diminished sensations in median and ulnar nerve zones.

23. Deformities in Volkmann’s ischemic contracture Severe type : All the flexor muscles are involved. Neurological deficit is severe. Joint contractures are marked. Wasting of forearm muscles .

24. MANAGEMENT - ACUTE  COMPARTMENT SYNDROME (IMPENDING VIC)

25. MANAGEMENT - ACUTE COMPARTMENT SYNDROME (IMPENDING VIC) Forearm fasciotomy Incision :A volar curvilinear liberal incision medial to the biceps tendon , crossing the elbow flexion crease at an angle carring it distally to the palm to release the carpal tunnel.

26. MANAGEMENT - ACUTE COMPARTMENT SYNDROME (IMPENDING VIC) Exploration must extend deeply to the FDPand FPL. Necrotic muscle tissue is excised. Median nerve freed beneath the lacertus fibrosus . Ulnar nerve is freed and transplanted anteriorly . Brachial artery must be inspected and decompressed . Surgical wound is left open for  secondary closure later when swelling subsibes . Extremity supported with splint in funtional position .

27. CONSERVATIVE MANAGEMENT ESTABLISED   DEFORMITIES Robert Jones method(1930s).(1930s ). Wooden tongue depressors were used to correct established deformities gradually from distal to proximal over a prolonged period of time .

28. CONSERVATIVE MANAGEMENT ESTABLISED DEFORMITIES Banjo splint : Banjo splint used with rubber bands fastened to adhesive tape on the fingers permits the fingers to be exercised at all times and is most efficient.

29. ESTABLISHED VOLKMANN’S ISCHEMIC CONTRACTURE- MANAGEMENT Muscle sliding operation of flexors of  forearm . Inglis & Cooper   Williams & Haddad

30. INGLIS & COOPER Incision on the medial aspect of volar side of the arm 5 cm proximal to medial epicondyle   and distally to midpoint of forearm over the ulna .

31. INGLIS & COOPER Ulnar nerve is identified, released from the  cubital tunnel and protected . Tendinous origins of muscles on the medial  epicondyle are cut . Flexor carpi ulnaris and Flexor digitorum profundus are completely released from the medial epicondyle and ulna.

32. INGLIS & COOPER Lacertus fibrosus is divided along with any remaining portions of the flexor muscle origin . Ulnar nerve is  trasposed anteriorly .

33. WILLIAMS & HADDAD Medial aspect of arm and forearm anterior to the medial epicondyle of the humerus , beginning 5 cm proximal to the elbow extending distally to 5cm proximal to the elbow extending distally to 5cm proximal to the wrist .

34. WILLIAMS & HADDAD Structures anterior and medial to the elbow are exposed.

35. WILLIAMS & HADDAD Lacertus fibrosus is divided . Origins of the superficial flexors are released from the medial epicondyle . Origin of flexor digitorum superficialis is released from radius.

36. WILLIAMS & HADDAD Origin of Flexor carpi ulnaris is released from olecronon . Common origin of flexor carpi ulnaris and flexor   digitorum profundus are released from ulna.

37. WILLIAMS & HADDAD Origin of flexor digitorum profundus is released from volar aspect of ulna and interosseous membrane.

38. WILLIAMS & HADDAD Origin of flexor digitorum profundus to the index finger is released from radius.

39. WILLIAMS & HADDAD Ulnar nerve is transplanted anteriorly into brachialis muscle.

40. AFTER SURGERY Sutures are removed after 3 weeks . Extension hand splint should be worn for  3 months. Occupation and physiotherapy should be continued until desirable function is attained .