VOLKMANN'S ISCHAEMIA

Functioning Free Muscle Transplantation to Restore Finger Movement for Sequalae of Volkmann Ischemic Contracture

Volkmann ischemic contracture (VIC) is a devastating condition that results from neglected compartment syndrome, which leads to prolonged ischemia, irreversible tissue necrosis, and various degrees of muscle and nerve damage, causing serious motor and sensory functional implications for the limb and a spectrum of diseases associated with worsening deformities. A thorough understanding of the anatomy and VIC pathophysiology is needed to plan an appropriate strategy. Functioning free muscle transplantation (FFMT) can restore finger movement in a paralyzed limb but requires a three-staged approach to maximize the benefits of FFMT, leading to meaningful finger extrinsic function.

Refinements in the Treatment of Volkmann Ischemic Contracture of the Forearm: A Thematic Review

Volkmann contracture of the forearm is a devastating complication of muscle ischemia. It is most commonly associated with trauma and a sequela of compartment syndrome. In the last few decades, much has improved in our ability to treat these patients. Our preferred treatments are presented along with representative case studies that illustrate the functional gains that can be achieved with a focus on moderate and severe contractures. Refinements in care that have evolved over the past 40 years of experience in treating these patients are presented.

Acute anterior thigh compartment syndrome in Premiership rugby

A case study of acute compartment syndrome in the anterior lateral thigh of a professional Rugby Union Flanker with no history of trauma is presented. The report covers all details from initial occurrence; medical history; investigations and surgical treatment; manual stimulus and rehabilitation; return to play; challenges and considerations-resulting in a positive outcome. Resultant observations/recommendations are that investigations should be swift and carefully considered to facilitate surgical intervention via decompressive fasciotomy as required.

Management of Volkmann's Ischemic Contracture: Case Series of 32 patients

Introduction: Volkmann’s contracture condition is of high prevalence in our population and is linked to therapeutic faults. The treatment and its results are determined according to the severity of the lesions. Methods: This retrospective study was performed in three centers and was conducted over 30 years (1987–2018); it included 32 patients. The disabilities of the arm, shoulder and hand (DASH) score and the Weber test were used to evaluate the functional outcome looking at mid and long-term results. Results: Thirty-two patients were treated for Volkmann’s Ischemic Contracture (VIC). The age ranged from 4 to 58 years, with 19 patients aged under 15. Wrist fracture was the predominant cause in 16 cases. Fourteen patients obtained a completely functional hand, seven good functional results, four fair functional results, and seven poor results. Discussion: In comparison with other studies, we noticed significant differences: apart from the dominant male sex and right side, this is one large case series conducted over 30 years (1987–2018) looking at mid-and long-term results. All the patients presented with severe or moderate lesions on the first visit. In our study, the wrist fracture is predominant compared to elbow fractures and soft trauma. X-rays are especially helpful and are a first-line investigation for identifying displaced fractures and other associated lesions. Our study population is not large, and the treatment methods are varied, so it is impossible to provide statistically relevant correlations between the treatment method and outcome. But this work is based on the experience of more than 30 years, which makes it possible to help adequate decision making according to the state of the lesions. This study is a level IV case series.

Nerve Lesions in Volkmann Ischemic Contracture

Volkmann ischemic contracture (VIC) is a late sequela of acute compartment syndrome and consists of extensive muscle necrosis, fibrosis, contracture, and variable degrees of neural dysfunction. The outcome depends on successful restoration of muscle and neural function. The timing of surgery is often determined by the development of contractures and is delayed in the interest of observing some spontaneous recovery and infarct maturation. This period of observation may be detrimental to nerve function with gradual formation of scar tissue and worsening constrictive neuropathy. Early intervention appears to be more effective in preventing further nerve damage and restoring protective sensation. In this article, common features of compartment syndrome, frequently seen nerve lesions, and the effect of timing of surgical intervention on the outcome of VIC were reviewed in the light of the current basic and clinical science literature.

Clinical and Demographic Profile of Volkmann's Ischemic Contractures Presenting at National Institute of Rehabilitation Medicine, Islamabad, Pakistan

BACKGROUND

Established Volkmann’s ischemic contractures (VICs) represent the eventuality of neglected acute compartment syndrome (ACS) of the forearm. This study assessed the clinical and demographic presentation of VICs.

METHODS

This study was conducted at Department of Plastic Surgery, National Institute of Rehabilitation Medicine, Islamabad, Pakistan over a period of three years and included all patients of either gender who presented with VICs and analyzed various corrective procedures instituted as surgical remedies.

RESULTS

Among 37 included patients, 83.78% were male and 16.21% were female (mean age: 16.51±9.1 years). The underlying causes of the initial traumatic insults were tight bandages employed by traditional bone setters for treating forearm fractures (83.78%), high voltage electric burns involving hands/forearms (13.51%) and supracondylar fracture with vascular compromise (2.70%). Majority of patients belonged to Holden type 2 (97.29%) and Tsuge type 2 VICs (48.68%). The most common sufferers of VICs were young, illiterate males coming from rural regions. Treatment for forearm fractures by traditional bonesetters constituted the most common underlying cause. Most of the patients were managed with combination of procedures including tendon transfers, excision of the fibrosed muscles, tenolysis and neurolysis of median and ulnar nerves. Tendon transfers were the commonest corrective procedures instituted.

CONCLUSION

This study highlighted the gravity of this largely preventable but neglected catastrophe and there is a need to institute robust preventive measures to address the issue. Emphasis should be on creation of public awareness and robust education of health care providers to ensure correct primary management of upper limb trauma.

Reconstruction of a Chronic Volkmann Contracture following Forearm Revascularization with Burkhalter's Procedure and Fractional Flexor Tendon Lengthening after a Failed Stiles-Bunnell Transfer

Volkmann ischemic contracture is a cause of limb dysfunction that can lead to varying amounts of limb deformity, stiffness, and paralysis. Several procedures have been used to improve limb function in these patients. An 11-year-old male patient sustained a domestic accident with a glass door, resulting in a severe soft tissue trauma to his proximal third of the right forearm with damage to flexor muscles and tendons, complete section of median and ulnar nerves, and radial and ulnar arteries. He was submitted to immediate repair of the radial artery and median and ulnar nerves. Ulnar artery was not repairable due to extensive soft tissue loss. Despite surgical treatment and successful revascularization, postoperatively he developed a postreperfusion syndrome, and in consequence an ischemic contracture. To improve his condition, simultaneous Burkhalter's procedure and fractional flexor tendon lengthening were used after a previous failed Stiles-Bunnell transfer. After 6 months, a good result was obtained, with restoration of a more anatomical hand rest position, improved arc of motion, and significant improvement of hand function with DASH (Disabilities of the Arm, Shoulder and Hand) score improving from 59 to 43 despite a slight reduction in grip strength. Opposition to the ring or little finger tip with the interphalangeal joint (IPJ) of the thumb extended was observed. The combination of fractional flexor tendon lengthening and Burkhalter's procedure is a reliable and simple procedure in cases of Volkmann's ischemic contracture and combined median and ulnar nerve palsy, without significant complications.

Functional and socioprofessional outcome of surgery for Volkmann's contracture

OBJECTIVES

Volkmann's ischemic contracture is rare and surgical treatment remains a challenge. The goal of treatment is to obtain permanent recovery of joint range of motion and strength. The goal of this study was to evaluate the functional and socioprofessional outcome of surgical treatment of Volkmann's ischemic contracture.

METHODS

This retrospective study was performed in two centers with one surgeon. Seven patients were included; mean age 23.6 years old. The Quick-Dash score, Patient Rated Wrist Questionnaire (PRWE) scores were obtained. Grip strength was compared to the contralateral side. Satisfaction was evaluated by the question: would you have surgery again? The surgical technique included 7 muscle slide procedures.

RESULTS

Wrist and finger range of motion was good at least 6.1years in all cases according to the system by Buck-Gramcko. Grip strength on the operated side was 72.3% of the contralateral side. The mean PRWE was 14.64/100, mean QUICK-DASH score was 7.9/100. Patients returned to their professional activities in all cases. Patients who were questioned were all satisfied with surgery.

CONCLUSIONS

Once the contracture is established in Volkmann's contracture Page-Scaglieti-Gosset muscle slide procedure can be used with good results allowing a return to socioprofessional activities.

LEVEL OF EVIDENCE

IV, retrospective study.

Results of neurolysis in established upper limb Volkmann's ischemic contracture

BACKGROUND

Treatment of established cases of Volkmann's ischemic contracture (VIC) of upper limb is very tedious. Since the period of Volkmann, various experimental works are being performed for its treatment, but none are effective. Disabilities from nerve palsy and hand muscle paralysis are more problematic than any other deformity in VIC. To solve these problems, we conducted a study to see the result of neurolysis of median and ulnar nerve and their subcutaneous placement in established cases of VIC.

MATERIALS AND METHODS

Twelve cases of established VIC operated between July 2007 and August 2010 with complete records and followup were included in the study. VIC of lower limb and contracture of nonischemic etiology were excluded from the study. Their evaluation was done by the British Medical Research Council grading system for sensory and motor recovery. Followup was done for an average period of 24.3 months (range 15-30 months) (the average age was 8.3 years).

RESULTS

To study the results, we divided the cases into two series. One group consisted of cases which were operated within 6 months from onset of VIC. The second group consisted of cases which were operated after 6 months from onset of VIC. Our results revealed that there was no statistically significant difference between the two groups operated, though both had significant improvement in motor and sensory recovery in both median and ulnar nerve distribution.

CONCLUSIONS

Neurolysis of the nerves definitely improved the outcome for motor and sensory components of median and ulnar nerves but the timing of the surgery did not play a role in the outcome contrary to the clinical assumption. This study can serve as a template and further such studies could help us find the answer to a long standing issue.

Free myocutaneous flap transfer to treat congenital Volkmann's contracture of the forearm

The purpose of this study is to report our experience with free functional muscle transfer procedures for the late sequelae of the rare condition of congenital Volkmann's ischaemic contracture of the forearm. Four children, with an average age of 9.5 years (range 1.5-17), were treated and were followed for a mean of 6 years (range 1-14). Two patients had dorsal forearm contractures, and two had both flexor and extensor forearm contractures. We carried out free functional muscle transfers to replace the flexor or extensor muscles. The functional result was assessed according to the classification system of Hovius and Ultee. All patients had wrist contractures and skeletal involvement with limb length discrepancy that influenced the outcome. All five transferred muscles survived and improved the function of the hand in three of the four patients. LEVEL OF EVIDENCE 4.

Volkmann's Ischemic Contracture with Atrophic Non-union of Ulna Managed by Bone Shortening and Transposition of Radial Autograft

INTRODUCTION

Volkmann's ischemic contracture (VIC) is a complex and variable flexion deformity of wrist and fingers resulting from fibrosis and contracture of flexor muscles of forearm. It is caused by ischemic injury to the deep tissues enclosed in the tight unyielding osteo-facial compartments secondary to neglected acute compartment syndrome. VIC may be associated with malunion or non-union of forearm fractures. To the best of our knowledge, this article is the first case report of VIC associated with atrophic non-union of ulna managed by shortening of forearm bones combined with transposition of intercalary auto graft from the fellow bone.

CASE REPORT

A seven year old boy presented with flexion deformity of wrist and hand with inability to use his left hand since three and half months subsequent to an injury to his left forearm due to fall from a tree of six feet height. The patient was diagnosed and treated by a native traditional bone setter for his Radius and Ulna fracture of left forearm with massaging and tight bandaging. On examination there was wasting of left forearm with positive Volkmann's sign, flexion contracture of wrist with loss of grip strength and tenderness over the upper and middle third junction of left ulna with a palpable gap. The radiograph of forearm revealed atrophic non-union of left ulna. In order to tackle both the issues, shortening osteotomy of radius with transposition of tubular radius intercalary graft onto ulna was done. Radius was fixed with a dynamic compression plate and Ulna was fixed with a rush nail effecting overall two and half centimetres shortening of both bones of forearm. This approach has addressed both atrophic non-union of ulna and VIC in a single stage and gave excellent functional outcome till the last follow-up of three years from the date of surgery.

CONCLUSION

Bone shortening and transposition of auto-graft from the fellow bone may prove to be an excellent treatment modality for VIC with associated non-union of involved compartmental bones in properly selected and executed cases.

Management of established Volkmann's contracture of the forearm in children

As with many diagnoses in medicine, the best treatment for Volkmann's ischemic contracture is prevention. Early recognition and prompt treatment of impending Volkmann's ischemia should decrease the presentation and severity of late contracture and hand dysfunction. The authors have found the flexor muscle slide the best treatment option for mild and moderate deformity. This procedure can be combined with additional reconstructive procedures to maximize functional outcome. The authors believe this procedure results in the best preservation of the muscle resting length and limits the scarring around the adjacent muscles. For severe cases,early wide excision with functional free-muscle transfer may limit the injury to the nerves, decreasing the distal problems associated with mo-tor and sensory impairment in the hand.

A new strategy to prevent the sequelae of severe Volkmann's ischemia

This paper compares two treatment strategies in severe Volkmann's ischemia that differ in the time of exploration and excision of the muscle infarct. Six patients underwent late exploration, more than 1.5 months after injury, and 5 patients underwent early exploration, within 3 weeks of injury. Functioning free-muscle transplantation was later performed on all 11 patients for functional restoration. Hand function was evaluated in each group to determine the degree of intrinsic muscle function and sensibility. In the late group, all patients had restricted hand function due to clawing, poor opposition, and sensory disturbance. In the early group, all patients had preserved metacarpophalangeal joint flexion and interphalangeal joint extension without clawing, and two had preserved opposition. Sensory disturbance was mild, and good hand function was achieved. In severe Volkmann's ischemia, we advocate early reexploration with excision of the infarcted muscle within 3 weeks of injury or fasciotomy. Early exploration is technically simple, and neurolysis is not necessary. It preserves hand intrinsic function and sensation by removing the ischemic environment and preventing fibrosis that adds to nerve compression and nerve damage.

CT in established Volkmann's contracture in forearm muscles

Differential diagnosis between true and pseudo-Volkmann's contracture should not be based on clinical grounds alone, because clinical data are often insufficient in determining the severity and the extent of muscle damage. CT has been utilised in 11 cases where a flexion contracture of the forearm muscles was present and corresponded closely with the surgical findings. True and pseudo-Volkmann's contracture can thus be distinguished and the severity and extent of the muscle damage determined.

The use of the latissimus dorsi muscle as an active motor unit for digital flexion

A technique is described to restore flexion of the fingers and thumb using a latissimus dorsi muscle island as an active motor unit. It has been performed in a ten-year-old child with a satisfactory result.

Ischaemic contracture of muscle associated with carbon monoxide and barbiturate poisoning

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