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THE PATHOLOGY AND PREVENTION OF VOLKMANN’S ISCHAEMIC CONTRACTURE C. the I’rotfl Ischaemia types occur: direct injury contracture an is a rare unyielding be made on clinical hundred compartment. diagnosis grounds years ago by the was caused This accepted, opinions changed. concept effusion” ( 1 91 venous circulation described pressure of an pressure a and in every fifty (Littlewood that 1 900) occurred in an that it was the pressure fascia that occluded 4) thought that and can only the indications that it was sympathetic case. Two be relieved to operate impossible stimulation, that it was interruption, unduly became the subsequent drawn and it was thought beneath the deep Murphy ischaemia limb and nerves of an was ischaemic ofexternal but during was “ London be excluded futile time-wasting doned. years the distinct by a timely on it can usually injured limb obstructed splitting of the the precipitate arterial spasm either directly or reflexly, to relieve practice still manoeuvre the Korean it by persists should War that by and sympathetic today; this finally crystallised be our aban- ideas on closed arterial injuries. We learned that a direct blow or a traction injury to an artery might cause an incomplete tear of the vessel wall. An intimal tear allowed stripping of this swelling the circulation. this pressure advocated to to impossible yet the it was Attention soft-tissue but must secondary in an injured Volkmann in origin bandage. Hospital. ( ollegt’ ‘S alone. the muscles the contracture tight to a limb This of ischaemia contracture which involved injured limb. He thought generally of injury HOLDEN King Deparitnetit. complication osteofascial The and A. Type I, where a proximal arterial injury gives rise to ischaemia distally; and Type II, where a gives rise to ischaemia at the site ofthe injury. Whatever the nature ofthe insult, an ischaemic only develops as a result of swelling of the soft tissues where these soft tissues are contained in fasciotomy. A Orllzopaedic E. the intima, branches; deep which fascia shearing the exposed a thrombus off would entrance provided form, and to collateral a raw surface as the on thrombosis to relieve it. During the First World War the problems of arterial injuries focused on the phenomenon of arterial spasm. Experience showed that the outcome was uncertain: the extended collateral limb might pletely. The now become an accepted part but the expertise of vascular unless orthopaedic surgeons, of acute vascular surgeons is to who see these surgery, no avail injuries because of the more obvious make the diagnosis of arterial bony injury, damage. learn spasm was develop gangrene or might mechanism of development ill-understood ( 1 928), Leriche but, it became a nervous reflex mediated nervous system occluding collateral branches. towards block practised In ischaemic with all ‘ ‘ in the spasm merely of and His it was after the Simeone vessels. C. E. A. Holden, on a Hunterian MS., F.R.C.S., Lecture or tight conclusions and, after This has can Royal Fig. spasm. was generally paper years. on There this that the work demonstrated Orthopaedic College Surgeon, of Surgeons The physiology mal arterial to of must artery ii To that does understand consider the 1). Normally King’s of England College April be a degree of the physiology of the traction Hospital, normal wall injury Denmark arterial is in a state Hill, London SE5 nor- T=P.R active tension coat and the the elastic coat blood pressure of radius R. not tear the vessel but simply the effect of such a stimulus an arterial 12, of 1 wall. where T is the of the muscle stretching of by the mean P in a vessel subfascial splintage were War (1949) Consultant to The segment continuity. T He dismissed occlusion that Second World and Perlow damaged to restore that Volkmann’s to an arterial injury and repeated in almost every over the subsequent twenty-five Kinmonth, 296 venous . of by directed of arterial collateral thought contributory” accepted subject Based he work caused therefore management of the to the it was the arc by sympathetic procedures became Griffiths asserted was due solely consideration haematoma was of this reflex stripping. These 1940 Lloyd contracture reflex due that cornarterial not only the main vessel but the as well. We were taught to explore such vessels, to excise extracting the thrombus, through the sympathetic both the main vessel and the Treatment interruption or arterial widely largely accepted recover of the it blocked branches the media to wall (Fig. of tension (T) 9RS, England. 1978. THE JOURNAL OF BONE AND an stretches we must JOINT SURGERY THE which arises muscle coat in two PATHOLOGY main ways: the normal exerting AND the PREVENTION active tension vasomotor tone elastic tension due to the elastic coat being the mean arterial blood pressure (P) . Such ment allows physiological variations ofblood be accommodated vessel wall and These by variation functions are simply T= P. R. If any level the collapses, (Burton variation in the of these system becomes time the bone manipulated, it to contract. shortening may is broken or stretch the The muscle to one sixth formula the vessel to an artery, when the muscle fibres of their either and logical size, my experience, successful to the vessel, this than the technique is traditional more application vessel wall. If the technique one is not dealing simply with a to be as well repair. DEVELOPMENT OF AN ISCHAEMIC severe ischaemic outcomes. There may may have be complete three recovery, peroneal, leg, and vary Singh develops in the of whether the elbow that although anatomically forearm. importance. It can 1. in the in severity this from but applied with or (Holden 1974). be in the are In four warm of front of the of the upper a manometer The thigh. by results the arm, and the (Figs. is of cadavers millilitres flexor the fundamental the saline anterior aspect that in the elbow l00 above elbow 50 knee 05 volume Fig. Comparison VOL. 6 61-B, No. . AUGUST 1979 injected volume (litres) Fig. 2 of rise in pressure after injection of saline into cadaveric 0’S injected 3 muscle. l0 (litres) was described (mmHg) above forearm achieved previously 3) showed was tibial of the bdow I00 the of the of the pressure technique 2 and within normal into leg tibial, compartments compartments this human 25 confined anterior pressur#{128} 50 prelevel remarkably that ‘Sc (mm Hg) the the was the shown increments the front measured pressure the or the to contractures in the arm. in these sites below knee 150 but (Aggarwal, regardless or below and the deep posterior the flexor and the extensor possible gan- the paralysed, always compartments: compartment. insult and splints showed might and osteofascial and A limb above (1956) shape introduced CONTRACTURE tight ischaemia of the applied in its site; Experiment THE the as to those The muscles of papavarine with the collapse of a vessel distal to an intimal tear. This will therefore direct attention to the lesion which needs or the leg below hand or the foot-are are numb of unduly insult in constant the but most to a level insult. A of the neck of the humerus to that of a Colles’s fracture the ischaemia was always confined to the forearm. He described the pathological abnormality as an infarct of the muscles and nerves of the forearm, which varied in in fails to dilate critical closure the rises arterial ischaemia (Eastcott 1 973) of of the distal segment of a They I 969) cipitating and, likely use Seddon equation. to reverse the Gureja segment has been deficit a quantitative different; particularly toes-and of the and between to ischaemia of the muscles and nerves more II is significant that when a contracture distal splint purely means tissues, below the elbow distal tissues-the ischaemic. follows R to Laplace’s physical usually is knee. It seems all is a “selective” and nerves arm most course difference is not a purely are significantly contracture the muscles degree, R will fall to will collapse and closure can only be and increasing its of fluid through the 1 962). This restores by purely involves a middle The fingers or the by the level calibre of the vessel narrows to this an unphysiological level, the vessel blood flow will cease. Such critical diagnosed by exploring the vessel diameter again by injecting a bolus narrow segment (Mustard and Bull physical pursue develop. distal-the determined at If the or it may and contracture two conditions gangrene 297 CONTRACTURE may this is due proximally. fracture length. result, gangrene one. The not coat and stimulate are capable of original may limb-the knee. The known as critical closure will cease before the blood pressure has fallen to zero. A traction stimulus applied the and ISCHAEMIC contracture to an unphysiological unstable VOLKMANN’S grene the stretched by an arrangepressure to by Laplace’s falls a phenomenon I 95 1 ). Blood flow of the and in the tension of the radius of the vessel (R). related factors OF distal 298 C. segment of a limb pressure with proximal segment it was alarming possible ease of the to achieve but same that a rise this did in the not E. A. is hydrostatic occur in the more limb. insults that cause an ischaemic contracture to be of two main types. Type I is the classical major arterial injury occurring above the knee appear case of a or above site shows or of the insults a constant nature have the pathology of the ability regardless precipitating to make soft insult. reactive hyperaemia There wall so that differential capillaries volume plasma decreases. than the of that so is also anoxic the to the colloids leak out Much more returns tissue filtration damage and fluid force capillary the osmotic leaves the and there is an increase in the fluids. Where the tissues are of the these reached All tissues a increases. confined in compartments this increase in volume will cause a rise in pressure in the tissues. As the pressure rises the venous end of the capillary will become occluded and eventually the whole capillary, and even the arterioles, may become occluded. A stage will be the elbow with the ischaemia centred in the distal segment. Type II is a direct insult to the distal segment, but the ischaemia still develops in that distal segment. Examination of the infarct produced in both types of contracture HOLDEN where Harman swell. almost (1948) no fluid described returns this to the state of capillary. affairs: “It 4C Pressure mm Hg 20 -. - rise in arterial muscles quantified 4 ischaemic After two (1948) showed tourniquet-induced swell after the this swelling muscles hours experimentally ischaemia release of the by comparing with those from of tourniquet-induced After four hours perpetuated, after such the contracture. Harman could of this perpetuation. Normally, fluid is effected by the pressure forcing fluid. Counteracting plasma proteins (Fig. 4). At the exchange filtration fluid not normal ischaemia limb. the the was no greater the ischaemia was fourteen days a permanent the through mechanism the capillary of the and crystalloids this is the osmotic He of although explain force in the cent, and after was completely and if animals were killed insult they had developed an that made of ischaemia, amount of swelling that was produced than after three hours, he found that appeared filtered tourniquet. the weights muscles increased in weight by 35 per three hours by 50 per cent: such swelling reversible. pressure wall capillary blood out into the differential tissue of the drawing fluid back into arterial end of the capillary rn’ipaired Tourniquet-induced alterations in the fluid exchange in the capillary brought about by a reactive hyperaemia, anoxia increasing the permeability of the capillary wall, and accumulation of fluid in the tissues causing capillary occlusion. Fluid exchange in the capillary, showing the relation between the hydrostatic pressure of the blood (solid line) and the colloid osmotic pressure exerted by the plasma proteins (interrupted line). Harman a pressure venous drcnage Fig. 5 NORMAL rabbits faR in osmotic venous end end Fig. capillary the the capillary filtration force exceeds the osmotic force and so fluid leaves the capillary. At the venous end the position is reversed and fluid returns. After tourniquet-induced ischaemia (Fig. 5) there as if the liquid component of the blood off almost completely” As the microcirculation had . in the soft tissues becomes occluded the ischaemia becomes increasingly severe and a vicious circle occurs (Fig. 6). Once this is established it cannot be broken by relieving the original insult; only a prompt and generous fasciotomy dangerous will allow the rise of pressure. TYPE I Arterial tissues to swell aischaemia injury without Reduced capillary blood flow I I I TYPEU pirect injury IFasciotoiiM Hoemorrhage Increcised tension Fig. The vicious circle that develops 6 in the ischaemic limb. It can be shown that the anterior tibial compartment of the rabbit is covered with a dense deep fascia, and by instilling fluid into it a rise in pressure can be built up in exactly the same way as in the human cadaver. THE JOURNAL OF BONE AND JOINT SURGERY a THE Experiment series 2. Harman’s of the applied ischaemic period hours. tissues Blomfield Nembutal In all cases considerable oedema muscles was the a patchy staining stained darkly being rabbits the more central ischaemic left in the other thigh for performed this and time Examination failed to demonstrate in any at the time quite hours, rabbits a tourniquet then allowed for any of releasing tibial ischaemic the fibres In seventeen though The applied wound to occur in any that the to the At the of the ischaemic of the anterior the then end blue performing prevented was was of 1 think that by the the perpetuation swelling of limb of muscles of ischaemia explain the compartments. constancy pathological damage seen Such of site findings in in ischaemic and the the muscle contractures. a concept would constancy of the at a time before is a relatively injury to a limb. but it should be sought necessary its effects in every if ischaemia stages. observe ischaemia it is essential to the distal segments may be occurring. Pain is the overriding progressive aggravated and by Aggarwal, 51-B, N. D., Singh, 779-780. think of symptom. through the on the from examination end of a plaster. digits? Can Is they be is much be severe in the pulse is yet the the but there by in muscle peripheral limb vessel proximally a distal (Patman. pulse may is a considerable body distal the tender? compartments about their will, of personally Soft Are tissues they decompressed tension. of suggests that provided this is the sign and that there is no pain on and normal sensation and then there is no indication to Such a patient by the surgeon they nor not obliterated circulation Similarly, a good when the major possible. Are rarely transected more 1 964). Conversely, vessel. observed deterioration. Whenever for operation ischaemia will course, be to detect should swollen? in the Type be Are tense? Where the diagnosis of an arterial injury the artery itself must be explored and repaired, of missed in the that is early It ischaemic unnecessary measure que of intracompartmental Whitesides et a!. It should contractures they is made and the if there is any II cases prompt doubt and arteriography cases. are pressure using (1975), but the should usually all be but to the technidecision to be a clinical possible to the severely most avoid one. ischaemic mutilating inj uries. REFERENCES Blount, VOL. W. P. ( 1 950i 61-B. No B., and Gureja, Volkmann’s 3. AUGUST 1979 ischemic Y. P. ( 1Q69i Compression contracture Surgery. ischaemia Gynecology of limbs and from tight obstetrics. splintagc 90, 244-24o. Journal ofBone and an time- it is possible must be based on a high degree vigilance and a clear understanding abnormalities that may be present. now in as in most a fasciotomy Clinical judgement suspicion. eternal the pathological is such and It is perslstent. lmmobilisation. of the investigations wasting perform anatomically. and to the limb in which the unrelieved by passive stretching pass an opinion generous fasciotomy alone should relieve the ischaemia. The diagnosis of both types of ischaemia in injured limb can usually be made on clinical examination complication to be been Shires absent. palpated. when the can be so devastating case. Eternal suspicion is not these is at a standstill. easily be detected totally alone. uncommon distal swelling and nerve pulse may any DiAGNOSIS Ischaemia that often is not an indication guarantee that The explore repeatedly and the nerve and demands that diagnosis of such ischaemia be made fasciotomy could relieve the tension ischaemia has become perpetuated. in informed opinion which only abnormal physical full passive dorsiflexion muscle power distally, contractures. An ischaemic contracture can develop from a multitude of different insults provided that the insult causes swelling of the soft tissues which are such nerves too may be difficult enough to elicit but even to interpret. Blount ( I 950) sum marises ‘The pulse is unreliable as a danger signal. Its absence its presence a be after ‘. ln normal has actually Poulos and injury is due to these tissues being contained in an unyielding compartment. and that this accounts for the selective” ischaemia that is the basis of all ischaemic contalned All is skin. compartmental tibial nerves in those sensation develop.” a fasciotomy the and the side infarct caused deficit but this extensive to ischaemia. and 15 an increasing circulation in muscle has to be formed of five digits that protrude from the was development most sensitive physical sign compartment. The pulse more difficult this difficulty: oval fasciotomy of bromphenol area tourniquet of some it may be absent altogether, cases where there has been damage. Nerve is the tissue most Important neurological 299 CONTRACTURE actively moved? Their colour and temperature less helpful. as compartmental ischaemia may but yet may in no way diminish the circulation model. was muscles It appeared anterior a central generous swelling of there in Seddon’s injection anterior of the rabbits. a normal the Rarely. in those affected of rabbits at all many compartment. intravenous of the to stain In to that and all at all. failed to and evidence parts well. similar tibial hours identical made muscles muscles anterior three an of the weight of the nerve the injected ISCHAEMIC muscle. usually of overdose In four stained of compartment rabbits some being stained twenty-four the fibres, not an showed three or end (Clark by normally muscle some produced four on sutured of the body muscles muscles In was tibial tibial hours a period circulation anterior anterior swelling. and was the the for solution killed rubber at the kilogram then to be stained parts area of and mass peripheral per were of four VOLKMANN’S in a a released to swell capillary ischaemic appeared periods blue OF repeated rabbits. was allowed a fuctioning with were for bromphenol muscles compared thigh tourniquet animals the and PREVENTION white of 3 millilitres with and left tissues cent 1#{176}45).The examined tibial 4 per Zealand the the in a dosage those side and Then intravenously stain rabbits AND experiments New to the In twenty-four three an adult being longer tourniquet forty-eight tourniquet PATHOLOGY Joint Surgery of of 300 C. A. C. ( I 95 1) On Burton, Clark, the W. E. Le Gros, and devascularized muscle. Eastcott, Griffiths, Harman, of H. H. G. D. LI. ( I 973) (1940) Arterial R. Littlewood, 24, I, Murphy, Mustard, (1928) Surgery ( I 900) H. Surgery, of small blood edition. vascular system. Indications sympathetic on some 1 9. London: Journal the and 164, 3 1 9-3 29. observations on skeletal muscle. the regeneration of of ischemic necrosis in American Journal 5, 223-227. affecting complications with 28, 239-260. production Injury, Physiology, Medical. ofSurgery. in the of anastomoses. Pitman Journal in muscles. Factors A,nerican of intramuscular British V. ( 1 949) HOLDEN vessels. phenomena ischaemia and Perlow, lecture p. contracture. of local tension , of the A clinical Second ischaemic The significance 625-641. Holden, C. E. A. (1974) Traumatic Kinmonth, J. B., Simeone, F. A. spasm. Surgery, 26, 452-471. Leriche, equilibrium A. Blomfield, L. B. ( 1 945) The efficiency Journal ofAnatomy, 79, 15-32. Volkmann’s J. W. ( 1 948) Pathology. physical E. diameter results. following on of large arteries Annals ofSurgerv, injuries about with particular reference to traumatic 88, 449-469. the elbow-joint and their treatment. 155, 339-344. Laneet. 290-292. J. B. ( I 9 1 4) Myositis. W. T., and Bull. C. Patman, R. D., Poulos, E., 118, 725-738. Seddon, H. J. ( 1 956) Volkmann’s Whitesides, T. E., Jun., Haney, faseiotoniv. ( 11111(01 of Journal tizt’ Ainerkan ( I 962) A reliable method and Shires, G. T. ( 1 964) Orthopuedu contracture: T. C., Morimoto, .s (111(1 Related treatment tIedieal for The 63, Association, relief of traumatic management by excision of 1249- vascular civilian 1 255. spasm. of Annal.s arterial injuries. of the infarct. Journal of K., and Harada, H. ( I 975) Re.o’ar/i. 1 13, 43- 5 1 Tissue pressure measurements THE Bone Surgery. Surgery. 011(1 JOURNAL (kieeology Joint 38-B, Surgery. as a determinant OF BONE a,i/ AND for JOINT Obstetrics. I 52- I 74. the need SURGERY of