Volksman ischemic Contracture orthopaedics .pptx

It is a genralized topic for master study to gain knowledge of the vic.

1. VOLKMANN ISCHAEMIC CONTRACTURE Presenter . Dr. Sikandar kumar Mahto PG 1 ST Year Resident NMCTH, Birgunj Moderator: Dr. Prashant Thakur

2. Definition Volkmann`s Ischemic contracture is a permanent shortening of the forearm muscles resulting from injury that gives rise to a claw-like deformity of the hand, wrist and fingers.

3. Historical Background In 1881, Richard Von Volkmann described irreversible contracture of the hand and forearm muscles . In 1906, Hildebrand first used the term Volkmann`s ischaemic contracture . In 1909, Thomas reviewed 112 published cases of volkmann contracture and found closed fractures to be the most common cause . In 1914, Murphy was the first to suggest fasciotomy might prevent volkmann contracture.

4. Epidemiology The incidence of Volkmann’s contracture is low. Its prevalence is 0.5 %, which means it is a rare disease . Occurs most commonly in children and follows injuries particularly to the elbow.

5. Etiology The intracompartmental pressure occurs when there is a bulging caused by a trauma. Thus , there is not enough space for muscles, nerves and blood vessels that lie within this fascia. This results in vascular defects and defects on nerves.

6. Possible causes can be fractures of the forearm Animal bite, bleeding disorders, burns , excessive exercise and injections of medications at the forearm

7. Relevant anatomy The flexor group of muscles in the anterior forearm may be divided into: superficial group deep group

8. Superficial group consists Pronator teres Flexor carpi radialis Flexor digitorum superficialis Palmaris longus Flexor carpi ulnaris

9. Deep group consists Flexor pollicis longus Pronator quadratus Flexor digitorum profundus

10. Pathophysiology Volkmann's Contracture is usually seen in children with displaced supracondylar fractures of the humerus or forearm . It results from severe injury to the deep tissues and muscles of the volar compartment secondary to increased compartmental pressures Volkmann's contracture is the end result of prolonged ischaemia of muscles and nerves in the forearm . The muscles undergoes necrosis, fibrosis and contracture

11. Clssification There are three main classification systems widely in use : Holden classification Tsuge classification Zancolli classificationa

12. Holden classification (1979) This system is based on the site of the vascular compression . Type I The cause of compression is proximal to the site of ischemia Example supracondylar fracture resulting in distal ischemic damage Type II There is direct localized compression in the distal segment, resulting in a localized increase in compartmental pressure Example-tight bandage applied after forearm fracture

13. Tsuge classification (1975) [modification of Seddon classification (1964)] This system is based on the degree of the involvement of muscle groups in the forearm . Mild type: • Localized • Involves the deep flexor compartment, more commonly the FDP of the middle and ring fingers and the FPL. • Nerve involvement is absent or insignificant

14. Tsuge classification… Moderate type'classic or typical type‘ Involves all FDP and FPL tendons, with partial involvement of the FDS Nerve involvement is always present Sensory impairment is more common in the median nerve distribution than the ulnar nerve Intrinsic minus deformity is common

15. Tsuge classification… Severe type Involves all of the digital and wrist flexors and a varying amount of extensor muscles . Nerve involvement is severe, with total loss of sensation and total intrinsic palsy

16. Zancolli classification (1979) This system is based on the degree of involvement of the intrinsic muscles of the hand. Type I: Contracture involving forearm muscles with normal intrinsic muscles Type II: Contracture involving forearm muscles with paralysis of intrinsic muscles. Type III: Contracture involving forearm muscles with contracture of intrinsic muscles Type IV: Combined type

17. Clinical Manifestations The clinical presentation includes the five "Ps" which are: Pain Pulselessness Pallor Paresthesia Paralysis

18. Clinical Manifestations Special findings include: Pain with passive stretching of the flexors Elbow flexion Forearm pronation Finger flexion MCPJ in extension The wrist is in palmar flexion

19. Clinical Manifestations Palpation of the affected region creates pain . Also , upon palpation, firmness of the tissues can be felt . Swelling Decreased sensation

20. Volkmann’s sign In classical claw hand deformity in established VIC . This test consists of extending the wrist, which exaggerates the deformities and on flexion the deformities appear less prominent

21. Treatment Mild type: Dynamic splinting Physiotherapy- functional training and active use of muscle If multiple tendon involved- muscle sliding operation or wrist resection If single i.e.pronater teres - excision

22. Treatment… Moderate contracture: Muscle sliding operation Neuronolysis Excision of fibrotic tissue Volar transfer of dorsal wrist extensors-when no movement of finger has been retained e.g. BR,ECRL

23. Treatment… Severe contracture: Early excision of all necritic tissue with neurolysis Tendon transfer-to restore function e.g. BR to FPL,ECRL to FDP Free innervated muscle transfer using gracilis muscle- if motors to restore finger flexion are unavailable

24. Oishi and Ezaki Recommended two stage procedure Stage 1. Initial muscle debridement and neurolysis Stage 2 free functioning gracilis transfe – after return of sensation and intrinsic function hand.

25. Established Intrinsic Muscle Contractures of Hand Mild contracture: MCP joint can be passively extended completely Positive intrinsic muscle tightness test- i.e. extended PIP joint while MCP extended.

26. Established Intrinsic Muscle Contractures of Hand… More severe: Interosseus muscle- viable and contracted Intrinsic muscle tightness test- positive Active spreading of fingers- possible Contracted muscles released from MC shafts by muscle sliding operation

27. Established Intrinsic Muscle Contractures of Hand… More severe: Interosseus muscle- viable and contracted Intrinsic muscle tightness test- positive Active spreading of fingers- possible Contracted muscles released from MC shafts by muscle sliding operation

28. Established Intrinsic Muscle Contractures of Hand… Most severe: Intrinsic muscles – contracted and also necrosed and fibrosed Each muscle must be divided to release of contracture with Capsulotomies and tendon transfer

29. References Campbell Apley & solomons Essential orthopaedics by Maheshwari Netter atalas