Introduction:
The hand is the extension of the forearm in the human body. The joint between the forearm and the hand constitutes the wrist. The hand includes a flat, broad, and central area followed by five separate digits (four fingers and a thumb). It plays an essential role in sensing, holding, and manipulating objects. There are two main groups of muscles (flexors and extensors) in the forearm responsible for bending and stretching movements of the wrist, hand, and fingers. These muscles are supplied by the branches of the brachial artery and are innervated by the median nerve.
What Is Volkmann Contracture?
Volkmann contracture, also known as Volkmann ischemic contracture, is the deformity of the wrist, hands, and fingers caused by injury and pain to the forearm muscles. The contracture (arm contracture) causes permanent forearm muscle shortening, resulting in a claw-like deformity (a stiff bend) of the hands, fingers, and wrist. Forceful extension of the same is limited and painful.
Volkmann contracture happens due to sudden restriction of blood and oxygen supply, resulting in the death of the muscle tissue. Secondarily, the neighboring nerves are also affected. The muscle fibers involved in the contraction are a group of flexor muscles of the forearm, especially the flexor digitorum profundus and flexor pollicis longus. The muscles become stiff, short, and lag in action. The condition was first described by Richard Von Volkmann in 1881, but the term Volkmann contracture was given by Hildebrand in 1889. It is also known as the Volkmann ischemic contracture.
What Are the Levels of Volkmann Contracture?
Volkmann contracture is classified into three levels according to the Tsuge system. They are,
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Mild: In the mild form of Volkmann contracture, only the deep flexor muscles of the forearm are partially affected. Two or three fingers are involved with no loss of sensation. The wrist joint remains unaffected.
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Moderate: In this type, more flexor muscles are affected. All the fingers and the thumb are bent and struck. The condition may involve the wrist joint with some loss of sensation.
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Severe: Both the flexor and extensor muscles of the forearm are affected. This results in a severely disabling condition limiting the complete movement of the wrist, hand, and fingers. There is a severe loss of sensation and the typical claw-like deformity.
What Are the Causes of the Volkmann Contracture?
The most common causes of Volkmann contracture include:
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Trauma leads to soft tissue injury or the fracture of bones in the forearm.
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Internal bleeding or clotting in the case of patients with blood disorders.
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Burns, snake bites, and injuries cause rupture of blood vessels.
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Supracondylar fracture of the humerus (long bone of the upper arm).
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Prolonged external compression-like tight cast or brace.
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Damage to the arteries.
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Regional intravenous (IV) anesthesia.
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Tumors involving the arm.
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Crush injuries.
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Chronic infection.
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Heavy intensive exercises.
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Sometimes, Volkmann contracture may be congenital (birth defect) and idiopathic (unknown cause).
What Are the Signs and Symptoms of Volkmann Contracture?
The manifestations of Volkmann contracture are often associated with compartment syndrome (excessive pressure building up in the enclosed muscle space). The clinical presentation of Volkmann contracture involves five ‘P’s. They are,
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Pain.
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Pulselessness.
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Palor (pale coloring of the skin).
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Paresthesia (abnormal sensations like tingling or pricking).
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Paralysis (inability to move the hand).
Other visible findings are,
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Bent position of fingers, wrist, and elbow.
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The extended position of the palm.
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Rotation of the forearm and hands.
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Patients may complain of the following symptoms,
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Severe pain while moving the hand.
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Tenderness.
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Stiffness of the joints.
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Swelling.
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Decreased sensation.
What Are the Diagnostic Exams and Tests for Volkmann Contracture?
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Medical History and Physical Examination: A previous history of arm bone fracture and soft tissue injuries can direct the physician toward diagnosing Volkmann contracture.
Physical examination involves passive stretching of the hand and fingers, palpating the forearm, and checking for a pulse. These evaluations yield important clues and are the key to timely diagnosing and preventing Volkmann contracture.
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X-rays: X-ray imaging visualizes a fracture and assesses the severity and displacement of the fractured bones.
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Manometry: The manometer is a device used to measure fluid pressure. Thus, manometry measures intracompartmental (muscle space) pressure in Volkmann contracture.
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Angiogram: It is a type of X-ray used to check blood vessels. The veins are infused with a special dye, so the blood vessels are visible clearly in the X-rays. An angiogram is a resultant image obtained from the angiography. Therefore, an angiogram detects the rupture of blood vessels in Volkmann contracture.
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MRI (Magnetic Resonance Imaging): MRI gives detailed images of both the soft and hard tissues and is used to disclose and locate muscle fibrosis (abnormal thickening and scarring of the muscle tissues).
How Is Volkmann Contracture Managed?
The treatment of the Volkmann contracture depends on the level of the condition. It involves,
1. Medical Management:
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Removal of cast or brace to relieve compression.
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Treating underlying medical conditions like bleeding disorders.
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Pain-killing drugs for symptomatic relief.
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Antibiotics to treat infections.
2. Surgical Management:
For Mild Level Condition
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Fasciotomy: Fascia is made of layers of connective tissue below the skin. These layers enclose organs and separate the muscles. Fasciotomy is a surgical procedure where the fascia is cut to relieve tension or pressure from the muscle compartment. This procedure is mainly done to halt the progression of the Volkmann contracture.
For Moderate Level Condition
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Tenolysis: Tendons are the band of connective tissue that attaches the muscle to the bone. Tenolysis is a procedure that releases the surface of tendons from adhesions surgically.
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Neurolysis: Surgical dissection of damaged nerves to relieve or free the nerve from local tissue restrictions or adhesions.
For Severe Level:
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Debridement of Damaged Muscle: The damaged, dead, and contaminated muscle tissues are removed to promote healthy healing of the neighboring tissues.
What Is the Recommended Postoperative and Rehabilitation Care for This Condition?
The incisions given for acute compartment syndrome are usually left open. If the major veins and arteries are not exposed, a negative pressure wound dressing is applied and aseptically changed every 24 to 48 hours to prevent any wound infection. Also, after seven to ten days, delayed primary wound closure is used to subside the inflammation to a great extent. The rehabilitation care for Volkmann contracture depends upon the type of surgery. Complete immobilization is recommended for two to four weeks in the case of a splint or cast. A patient is advised to use the limb slowly after gradually increasing the activity level with time afterward.
Conclusion:
Volkmann contracture is a relatively rare condition. The condition frequently occurs in children and follows the injury of the elbow and forearm. Early detection of compartment syndrome and timely treatment can prevent the development of Volkmann contracture. The treatments formulated for Volkmann contracture can restore good hand function in patients with sufficient healthy remaining muscles.
