Volkmann’s ischemic contracture

• Alternative Names

  Ischemic contracture

• Causes, incidence, and risk factors

  Volkmann's contracture occurs when there is a lack of blood flow (ischemia) to the forearm. This usually occurs when there is increased pressure due to swelling, a condition called 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 nonsedating 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.

• Signs and tests

  The doctor will perform a physical exam. If you have compartment syndrome in the forearm, you will have severe pain when the doctor moves the fingers up and down in. The forearm may be very swollen and shiny. There is also pain when the forearm is squeezed.

  The diagnosis can be confirmed with a test that directly measures pressure in the area. This involves inserting a needle into the affected area. The needle is attached to a pressure meter. Compartment syndrome is diagnosed when the pressure is greater than 45 mmHg or within 30 mmHg of the diastolic blood pressure (the lower number of the blood pressure).

  Treatment involves immobilizing the fingers and possibly the wrist so that they are in a bent (flexion) position.

• 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.

• Expectations (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.

• Complications

  The more severe the contracture, the worse the function of the hand and wrist. In severe cases, the hand may not work at all, and you may have a loss of sensation (feeling) in the area.

• Calling your health care provider

  Contact your health care provider for an appointment if you have had an injury to your elbow or forearm and have developed swelling.

• References

  Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper extremity injuries. Pediatr Clin North Am. 2006;53(1):41-67.

Review Date: 7/29/2008

Reviewed By: Thomas N. Joseph, MD, Private Practice specializing in Orthopaedics, subspecialty Foot and Ankle, Camden Bone & Joint, Camden, SC. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.