Volkmann’s contracture
Volkmann's contracture is a permanent flexion contraction of the wrist resulting in a claw like deformity with passive extension of fingers restricted and painful.
It is most commonly the result of a fracture in the elbow region, most commonly a supracondylar fracture of the humerus, which then affects the brachial artery. Other damage may also be seen such as anterior interosseous branch of the median nerve involvement.
The basic pathology is simple, decreased arterial perfusion and venous stasis causes ischemic degeneration of the muscles, necrosis begins after about 4 hours at which point damage is irreversible, the resulting edema leads to forearm compartment syndrome which then propagates progressive muscle necrosis. The most heavily impacted part of the muscle is the middle third of the muscle belly, as this is the closest to the bone.
Vasculature of the Arm
The brachial artery splits into the radial and ulnar artery in the cubital fossa. The radial artery is superficial while the ulnar is deeper, transversing pronator teres and giving rise to the common interosseous artery.
Flexor digitorum longus and pollicis longus derive their blood from the anterior interosseous.
Muscular anatomy
- Superficial Flexors
- Pronator teres - median N
- Flexor carpi radialis - median N
- Flexor carpi ulnaris - Ulnar N
- Flexor digitorum superficialis - Median N
- Palmaris longus - Median N
- Deep flexors
- Flexor pollicis longus - Median N
- Pronator quadratus - Median N
- Flexor digitorum profundus - Median N
There are three grades of Volkmann contracture:
- Mild - flexors of the wrist
- Moderate - injury to all flexors
- Severe - injury to flexors and extensors
As well as being a result of an epicondylar fracture of the humerus, Volkmanns can be caused by compartment syndrome, as well as being a cause of compartment syndrome. Presentation is the five Ps:
- Pain
- Pallor
- Pulselessness
- Paresthesias
- And paralysis
Pain accentuated by passive stretching seems to be the most reliable finding.
Treatment is decompression/restoration of the brachial artery, along with decompression of the compartment to prevent compartment syndrome. Complications include dry skin, pruritus, altered sensation around the wound, swollen limbs and pain in the arm.