Download the pathology and prevention of volkmann`s ischaemic contracture

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.,
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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