Clinical case: Volkmann’s ischemic contracture

Complications

The patient returned after three and half months with complaints of pain, wasting of left forearm, deformity of wrist and hand and an inability to use his left hand. On examination, there was reduced muscle mass in the left forearm, tenderness over the upper and middle thirds junction of the left ulna with a palpable gap, and positive Volkmann's sign (flexion attitude of fingers with the wrist in extension, with correction in the wrist in flexion). Additionally, there was a flexion contracture of wrist flexors (Figure 3&8) and the grip strength was reduced.

The intrinsic muscles of the hand functioned normally. Sensory testing of the left forearm and hand was normal and there was no vascular deficit. Painful pronation and supination of the forearm were noted. A radiograph of the forearm, wrist and hand showed atrophic non-union of the upper and middle third junction of left ulna and malunion of left radius (Figure 4).

Surgical treatment

All three pathologies (non-union of the ulna, malunion of the radius and the Volkmann's contracture) were surgically repaired under general anesthesia in one session. Atrophic non-union location of the ulna was exposed sub-periosteally and all the intervening fibrous tissue with necrotic bone ends was excised; bone edges were freshened till punctate bleeding points were noted in the bone, and the medullary cavity was exposed on both ends. This surgical exposure revealed a five-centimeter gap in the ulna.

Radius was similarly exposed sub-periosteally in the middle third portion through a dorsal approach, and a two and half centimeters tubular piece of the bone was harvested. The ends of the radial fragments were approximated and fixed with a small (3.5mm) dynamic compression plate and screws leading to a two and a half centimeter radial shortening (Figure 5A).

The two and half centimeter, harvested piece of radius was used as graft for the ulnar gap site and was fixed with a rush nail (Figure 6A). The limb was supported with an above elbow slab initially, which was replaced by a cast after suture removal. Patient, however, did not maintain the cast properly. The cast was found to be broken at the elbow at six weeks follow up, requiring removal of the rush nail (Figure 6B).

Recovery

The forearm was then supported with an above elbow plaster cast for ten weeks. Finger stretching exercises/physical therapy was begun early in the post-operative period. The patient was monitored for three years by examination and radiography. The radial osteotomy had fused in six weeks and the ulnar intercalary graft site fused in ten weeks (Figure 7A). Volkmann's sign was no longer positive after the surgery and the surgical forearm shortening (Figure 7B).

Functional evaluation of the limb found full flexion/extension at elbow, pronation/supination of forearm and normal grip strength of hand when compared with the contralateral upper limb. Three years follow up radiograph after radial plate removal (at request of patient) showed consolidation and incorporation of tubular radial graft into the ulna (Figure 7C). This case shows that bone shortening and use of autologous graft facilitated effective treatment of Volkmann’s contracture by reinstating appropriate bone/tendon length ratios.

Volkmann's ischemic contracture (VIC)

Repeated episodes of manipulation resulted in inadequate immobilization of the fracture of ulna resulting in atrophic non-union. Richard Von Volkmann of Halle, Germany (1881) was the first one to describe ischemic contracture of the flexor muscles of the forearm (Figure 3) and attributed the cause to acute ischemic necrosis.

VIC is a complex and variable flexion deformity of the fingers and wrist resulting from fibrosis and contracture of the forearm flexor muscles caused by ischemic injury secondary to untreated acute compartment syndrome. About 20% of ischemic contractures occur as a complication of diaphyseal forearm fracture. The clinical situation may be compounded by malunion, or non-union of diaphyseal fragments. Failure to form unions causes additional difficulties in treatment because abnormal healing alters the normal relationship between the radius and ulna.

We recommend these learning materials to fortify your knowlege about the flexors and extensors of the forearm.

Surgical approach to non-unions

Non-union of the forearm bones occurs when the fracture is inadequately immobilized, which leads to abrasions at the fracture site and eventual bone loss. The aim of surgical treatment in these cases is to restore the reciprocal three-dimensional relationship between the radius and ulna for appropriate recovery of function.

Autologous bone grafts are the best and are most commonly used technique to bridge the gaps in the treatment of atrophic and gap non-unions. It is proposed that the muscles of the involved extremity adapt to the alterations in skeletal length in cases where bones are shortened. Given the context of atrophic non-union of the ulna in this VIC case, graduated shortening of the radius provided two and half centimeters of autogenous tubular intercalary bone to be grafted onto the ulna and bridged the five-centimeter gap, thereby effectively shortening the forearm length by two and half centimeters. This technique (forearm shortening) effectively alleviated the VIC (matching bone to shortened flexor tendons).

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