Ischemic contracture

Definition

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

Alternative Names

Causes

Volkmann's contracture occurs when there is a lack of blood flow (ischemia) to the forearm, usually caused by increased pressure that results from swelling (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 non-sedating 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.

Exams and Tests

Typical physical exam findings include severe pain when a muscle is passively moved. For example, when the doctor moves the fingers up and down in a patient with compartment syndrome in the forearm, the patient will experience severe pain. The forearm may be tensely swollen and shiny. There is also pain when the forearm is squeezed.

The test that will absolutely diagnose this condition involves directly measuring the pressure in the compartment by inserting a needle attached to a pressure meter into the compartment. When the compartment pressure is greater than 45 mmHg or when the pressure is within 30 mmHg of the diastolic blood pressure (the lower number of the blood pressure), a diagnosis of compartment syndrome is made.

Once established, someone with Volkmann's ischemic contracture will have his or her fingers and possibly wrist stuck in flexion.

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.

Outlook (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.

Possible Complications

The condition of Volkmann's contracture is itself a complication of compartment syndrome. The more severe the contracture, worse the function of the hand and wrist. In severe cases, the hand may be nearly useless and without sensation.

When to Contact a Medical Professional

If you have suffered trauma to your elbow or forearm with a lot of swelling, contact your health care provider for proper treatment of your injury and evaluation for compartment syndrome.

If you have had an injury in the past to your arm and have muscle contractures as a result, contact your health care provider for proper referral and treatment of your condition.

Prevention

While there is probably no way to prevent compartment syndrome, being very aware of this condition and early diagnosis and treatment will help prevent many of the complications.