Volkmann's Ischemic Contracture
Description
Volkmann’s Ischemic Contracture is the end result of
untreated compartment syndrome. Acute compartment syndrome in the forearm is a serious condition that involves increased pressure in
a muscle compartment. The compartment syndrome is associated with
supracondylar fractures, from constrictive casts or dressings, or may occur
with severe bleeding from trauma to the forearm. Functional
changes occur in the muscle after 2 to 4 hours of total ischemia. Capillary endothelium swells by 30% to 60%
after 3 hours of ischemia and nerves cause paresthesia and hypesthesia within 30
minutes of ischemia. After 12 to 24 hours of total ischemia, the severity of
muscle damage undergoes necrosis, fibrosis and contracture. Muscle contracture is the irreversible scarring and shortening caused by muscle necrosis of the untreated compartment syndrome. Concomitant nerve
injury causes further muscle dysfunction, sensibility deficits, or chronic
pain. The result is a dysfunctional, deformed limb known as Volkmann’s Ischemic
Contracture.
Volkmann’s Ischemic Contracture is classified into 3 types: mild, moderate and severe.
Volkmann’s Ischemic Contracture is classified into 3 types: mild, moderate and severe.
- Mild type, or localized ischemia results in minimal or no neurologic changes. In the forearm, typically involves a portion of the flexor digitorum profundus (FDP), resulting in contractures of two or three fingers.
- Moderate type has more muscle involvement and some neurologic changes. In the forearm, typically involves all of the FDP, the flexor pollicis longus, and part of the superficial muscles (pronator teres, flexor carpi radialis and ulnaris, flexor digitorum superficialis, palmaris longus).
- Severe type involves the muscles of an entire muscle compartment, and some muscles of the adjacent or opposite compartment. In the forearm, severe contractures of all flexors and some of the extensors. As well as, bone deformity, joint contractures, and skin changes.
Signs & Symptoms
- Arm appearance is characterized by a fixed position of elbow flexion, forearm pronation, wrist flexion, MP extension, IP flexion, thumb adduction
- Swollen and tense tender compartment
- Severe pain, exacerbated with passive stretch of the forearm muscles
- Sensory deficits
- Motor weakness and/or paralysis
- No absence of radial and ulnar pulses at the wrist
- Severe palsy in the distribution of the median nerve and ulnar nerve
Diagnostic Tests
- Measuring the intra-compartmental tissue fluid pressure
- Removal of the constricting splint, dressing, or cast
-
Surgical intervention for those whose symptoms
do not resolve quickly
PT Implications
- Pressure monitoring, early diagnosis and fasciotomy is necessary to avoid the development of Volkmann’s Ischemic Contracture
- Patient education especially after surgery to increase the mobility by passive stretching techniques to reduce functional loss
- Activate and strengthening the weak agonist, to ensure that the agonist pulls the antagonist in balance