Volkmann's ischemic contracture

Answer 1

Definition

Volkmann's contracture is a deformity of the hand, fingers, and wrist caused by injury to the muscles of the forearm.

See also: Compartment syndrome

Alternative Names

Ischemic contracture

Causes, incidence, and risk factors

Volkmann's contracture occurs when there is a lack of blood flow (ischemia) to the forearm. This usually occurs when there is increased pressure due to swelling, a condition called compartment syndrome.

Trauma to the arm, including a crush injury or fracture, can lead to swelling that compresses blood vessels and can decrease blood flow to the arm. A prolonged decrease in blood flow will injure the nerves and muscles, causing them to shorten and become stiff (scarred).

When the muscle shortens, it pulls on the joint at the end of the muscle just as it would if it were normally contracted, but because it is stiff the joint remains bent and cannot straighten. This condition is called a contracture.

In Volkmann's contracture, the muscles of the forearm are severely injured, resulting in contracture deformities of the fingers, hand, and wrist.

There are three levels of severity in Volkmann's contracture:

• Mild -- flexion contracture of two or three fingers only with no or limited loss of sensation
• Moderate -- all fingers are flexed and the thumb is stuck in the palm; the wrist may be stuck in flexion, and there is usually loss of some sensation in the hand
• Severe -- all muscles in the forearm that both flex and extend the wrist and fingers are involved; this is a severely disabling condition

The injury classically associated with this condition is an elbow fracture in children. Other conditions that can cause increased pressure in the forearm include any forearm fracture, burns, bleeding disorders, excessive exercise, injection of certain medications into the forearm, and animal bites.

Symptoms

The hallmark symptom is pain that does not improve with rest or nonsedating pain medications, and will continue to get worse with time. If the pressure is allowed to persist, there will be decreased sensation, weakness, and paleness of the skin.

Signs and tests

The doctor will perform a physical exam. If you have compartment syndrome in the forearm, you will have severe pain when the doctor moves the fingers up and down in. The forearm may be very swollen and shiny. There is also pain when the forearm is squeezed.

The diagnosis can be confirmed with a test that directly measures pressure in the area. This involves inserting a needle into the affected area. The needle is attached to a pressure meter. Compartment syndrome is diagnosed when the pressure is greater than 45 mmHg or within 30 mmHg of the diastolic blood pressure (the lower number of the blood pressure).

Treatment involves immobilizing the fingers and possibly the wrist so that they are in a bent (flexion) position.

Treatment

If there is a forearm or elbow fracture, you should use a sling or splint to keep the area still and raise the arm above heart level. This helps prevent further injury and excessive swelling.

The best treatment is early surgery to release the pressure in the forearm before any permanent injury to the muscles and nerves occurs. Reconstructive surgery to lengthen and sometimes transfer muscles is necessary to try to regain some hand function.

Expectations (prognosis)

How well a person does depends on the severity and stage of disease at the time treatment is started.

If surgery to relieve pressure is performed before permanent damage occurs, then the expected outcome is excellent. The wounds are usually left open (covered with a sterile dressing) and closed later (usually 48 - 72 hrs later) during a second surgery, once the swelling has resolved. Sometimes, several surgeries are needed to close the wound safely.

If there is high pressure in the forearm for an extended period of time, the muscles and nerves can be permanently damaged. If a nerve is compressed for longer than 12 to 24 hours, it will usually become permanently damaged.

Those with mild muscle contractures involving only a few fingers can expect a better return to normal function than those who lose normal function of all the muscles that move the fingers and wrist. People in this second group require major reconstructive surgery and do not do as well.

Complications

The more severe the contracture, the worse the function of the hand and wrist. In severe cases, the hand may not work at all, and you may have a loss of sensation (feeling) in the area.

Calling your health care provider

Contact your health care provider for an appointment if you have had an injury to your elbow or forearm and have developed swelling.

References

Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper extremity injuries. Pediatr Clin North Am. 2006;53(1):41-67.

Answer 2

Definition

Volkmann's contracture is a deformity of the hand, fingers, and wrist caused by injury to the muscles of the forearm.

See also: Compartment syndrome

Alternative Names

Ischemic contracture

Causes, incidence, and risk factors

Volkmann's contracture occurs when there is a lack of blood flow (ischemia) to the forearm. This usually occurs when there is increased pressure due to swelling, a condition called compartment syndrome.

Trauma to the arm, including a crush injury or fracture, can lead to swelling that presses on blood vessels and can decrease blood flow to the arm. A prolonged decrease in blood flow will injure the nerves and muscles, causing them to become stiff (scarred) and shortened.

When the muscle shortens, it pulls on the joint at the end of the muscle just as it would if it were normally contracted. But because it is stiff, the joint remains bent and cannot straighten. This condition is called a contracture.

In Volkmann's contracture, the muscles of the forearm are severely injured. This leads to contracture deformities of the fingers, hand, and wrist.

There are three levels of severity in Volkmann's contracture:

• Mild -- contracture of two or three fingers only, with no or limited loss of feeling
• Moderate -- all fingers are flexed and the thumb is stuck in the palm; the wrist may be stuck in flexion, and there is usually loss of some feeling in the hand
• Severe -- all muscles in the forearm that both flex and extend the wrist and fingers are involved; this is a severely disabling condition

The injury that usually causes this condition is an elbow fracture in children. Other conditions that can cause increased pressure in the forearm include:

• Animal bites
• Any forearm fracture
• Bleeding disorders
• Burns
• Excessive exercise
• Injection of certain medications into the forearm

Symptoms

The main symptom is pain that does not improve with rest or pain medications, and continues to get worse with time. If the pressure is allowed to continue, there will be:

• Decreased sensation
• Paleness of the skin
• Weakness

Signs and tests

The doctor will perform a physical exam. If you have compartment syndrome in the forearm, you will have severe pain when the doctor moves the fingers up and down. Your forearm may be very swollen and shiny. You will feel pain when your forearm is squeezed.

The diagnosis can be confirmed with a test that directly measures pressure in the area. This involves inserting a needle into the affected area. The needle is attached to a pressure meter. There is a specific pressure level that confirms the diagnosis of compartment syndrome.

Treatment involves releasing the pressure in the forearm. The fingers and wrist can also be stretched so that they are in a bent (flexion) position to avoid contracture. The fingers and hand are moved to avoid stiffness.

Treatment

If there is a forearm or elbow fracture, you should use a sling or splint to keep the area still and raise the arm above heart level. This helps prevent further injury and excessive swelling.

The best treatment is early surgery to release the pressure in the forearm before any permanent injury to the muscles and nerves occurs. Reconstructive surgery to lengthen and sometimes transfer muscles is necessary to try to regain some hand function.

Expectations (prognosis)

How well a person does depends on the severity and stage of disease at the time treatment is started.

If surgery to relieve pressure is performed before permanent damage occurs, then the outcome is usually excellent. The wounds are usually left open (covered with a sterile dressing) and closed later (usually 48 - 72 hrs later) during a second surgery, once the swelling has resolved. Sometimes, several surgeries are needed to close the wound safely.

If there is high pressure in the forearm for an extended period of time, the muscles and nerves can be permanently damaged. If a nerve is compressed for longer than 12 to 24 hours, it will usually become permanently damaged.

People with mild muscle contractures involving only a few fingers have a better chance of returning to normal function. People who lose normal function of all the muscles that move the fingers and wrist need major reconstructive surgery and do not have a complete recovery.

Complications

The more severe the contracture, the worse the function of the hand and wrist. In severe cases, the hand may not work at all, and you may have a loss of sensation (feeling) in the area.

Calling your health care provider

Contact your health care provider for an appointment if you have had an injury to your elbow or forearm and have developed swelling.

References

Jobe MT. Compartment syndromes and Volkmann contracture. In: Canale ST, Beaty JH, eds. Campbell's Operative Orthopaedics. 11th ed. Philadelphia, Pa: Mosby Elsevier;2007:chap 71.

Hensinger RN. Complications of fractures in children. In: Green NE, Swiontkowski MF, eds. Skeletal Trauma in Children. 4th ed. Philadelphia, Pa: Saunders Elsevier;2008:chap 6.

Reviewed By

Review Date: 07/28/2010

Linda J. Vorvick, MD, Medical Director, MEDEX Northwest Division of Physician Assistant Studies, University of Washington, School of Medicine; and C. Benjamin Ma, MD, Assistant Professor, Chief, Sports Medicine and Shoulder Service, UCSF Department of Orthopaedic Surgery. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.