Download volkmanns contracture

VOLKMANNS CONTRACTURE
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Original description of contracture and paralysis of the upper limb due to tight
bandaging
Pathogenesis
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End result is ischaemic degeneration of muscles caused by
 Enclosed compartment
 Venous stasis
 Increased intracompartmental pressure
 Arterial occlusion
Ellipsoid infarct concept (Seddon)
 Circulation in middle of mucle belly is most severely impaired
 Better collateral circulation at edges of muscle belly
 Ischaemia is worse at middle 1/3rd of muscle, especially close to bone
 Muscles most severe affected are
1. FDP
2. FPL
3. FDS
4. PT
 Ischaemia of wrist flexors and extensors and brachioradialis is usually mild.
 Median nerve (central) more affected than ulnar nerve
Regeneration
 Muscle recovery is most marked at the peripheries being pregressively poorer
towards the centre.
Types
1. Proximal ischaemia
 Due to major vessel injury proximal to the elbow
 Seen in children after supracondylar fractures
 Severe and complete contracture
2. Direct trauma
 Ischaemia develops at the site of the injury
3. Pseudo Volkmann’s contracture
 due to tethering of the flexor digitorum profundus secondary to fractures of the
ulna.
 occur 2 days to 16 years after the closed reduction
Classification
1. Mild (Localised)
 Degeneration limited to FDP – contractures of 2-3 fingers most often MF and
RF
 Cordlike induration palpable on the volar forearm
 Tenodesis effect present
 Sensation to fingers usually normal, occasionally mildly numb
 Intrinsic paralysis is absent or minimal
 Fixed joint contractures absent
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Usually from direct trauma
2. Moderate (Classic)
 Muscle degeneration affects FDP and FPL
 Also partial involvement of FDS and wrist flexors
 Flexion contractures of all fingers and thumb and wrist
 Intrinsic paralysis
 Sensory disturbance ulnar and median nerve
 Often follows supracondylar fractures in children aged 5-10
3. Severe
 Muscle degeneration of all forearm flexors and partial involvement of
extensors
 Most commonly caused by supracondylar fractures but also adults secondary
to overdoses, trauma
Management
Early management
 fasciotomy and splinting (serial splintage)
 Delayed fasciotomy after 24-48 hours risk further muscle ischaemia and
infection
Mild Type
 If contracture limited to FDP of 1-2 fingers, then either lengthen tendon or excise
affected muscle.
 If pronator teres is affected, may need excision
 If contracture involves FDP of 3 to 4 fingers, then perform flexor muscle slide
Method
 Volar incision
 Release ulnar and median nerve at elbow
 Neurolysis may be required in cases with severe nerve paralysis
 Ulnar nerve often transposed anteriorly
 Subperiosteally to release the origin of
1. PL, FCR, PT superficially
2. Humeral head of FCU and FDS origin
3. Ulnar head of FCU to middle 1/3rd of ulna
4. FDP released to interosseous crista (where interosseous membrane starts),
dissecting across membrane to the radial side
5. Muscle origins are then fixed to periosteum further distally
6. Careful to avoid injury to the common interosseous artery passing through
the space
Moderate type
 Curve incision radially (dangerous to release FPL from ulnar side)
 Insertion of PT released
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FPL detached subperiosteally from radius
Release common flexors
As muscle power is reduced in relation to the amount of slide, better to set the
lengthening to allow for some degree of contracture
If patient has weak finger flexion, consider tendon transfer – best done as
second stage after contractures are released and joints mobilised.
Method of tendon transfer
 Volar zigzag incision
 FDS is retained as usually less severely affected
 FDP and FPL are divided at the musculotendinous junction and the necrotic
muscles are excised.
 Neurolysis of median/ulnar nerve
 Transfers
1. ERCL to FDP
2. BR to FPL
 ERCL passed around radius passing underneath BR
Severe Type
 In severe cases, best to perform early excision of necrotic tissue and nerve
decompression to restore sensation and intrinsic function.
 Restoration of extrinsic function should be reserved as a secondary procedure,
often six months after 1st procedure:
1. Tendon transfer
2. Free muscle transplantation
 Muscles employed – pec major, gracilis, semitendinosus
 Muscle suture to medial epicondyle and distally to FPL and FDP.
 Slight muscle contraction at 3 months, increasing power flexion 6-12
months
 Restoration of thumb opposition and correction of claw deformity often done as a
third procedure
1. Opposition transfer – EDM
Intrinsic contracture
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Post traumatic intrinsic contracture due to oedema, hematoma, tight bandaging –
leading to muscle ischaemia
Acutely – release interosseous compartments as well as adductor pollicis and
carpal tunnel
In late interosseous contracture causing reduced PIPJ flexion (positive Bunnell
test) – perform distal intrinsic release (divide lateral and oblique bands)
If there is severe contracture affecting both MP and PIPJ, options are
1. dorsal capsule release
2. interosseous slide
o muscle origin of all interossei are stripped subperiostealy from the
proximal ½ of the metacarpus
o ADQ and FDM tendons are transected.
3. lateral band transection
o if the interossei are necrotic then the lateral bands are transected
proximal to the MCPJ.