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Clinical Case: Volkmann’s Ischemic Contracture - want to learn more about it?

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Clinical Case: Volkmann’s Ischemic Contracture

Who's to say that the systems such as CNS and cardiovascular system are the only to offer excitement and dynamic in the daily clinical practice? Every system is equally important, and for someone who pursues carrier in the fields of clinic that involve musculoskeletal system, this case of Volkmann's Ischemic Contracture will be very interesting.

On the other hand, even though you're not such a fan of the muscles and bones, we bet that this clinical approach to the forearm muscles and bones will be interesting to you, since it is a very fun way to learn anatomy from a different perspective. Oh, not to mention that at the same time, it will give you a glance at something that students find very interesting - surgery.

Key Facts
Common flexor tendon

The tendon of origin for most of the flexor muscles of the wrist and digits that rises from the medial epicondyle of the humerus

Common extensor tendon The tendon of origin for many of the extensor muscles of the wrist and digits  that rises from the lateral epicondyle of the humerus
Golf elbow

Medial epicondyle pain, due to medial epicondylitis caused by the overuse (irritation, fibrosis or inflamation) of the common flexor tendon

Tennis elbow Lateral epicondyle pain, due to lateral epicondylitis caused by overuse of the common extensor tendon
Pronation & supination

Pronation - medial rotation of the radius at the distal and proximal radioulnar joints, resulting in the palm of the hand facing posteriorly

Supination - lateral rotation of the radius at the distal and proximal radioulnar joints, resulting in the palm of the hand facing anteriorly

Long bone growth

Ossification of the cartilaginous model via 3 processes: growth in length, growth in thickness, remodeling

Compartment sydrome

Sudden increase of pressure within a muscle compartment due to various insults; clinically there are 2 types: acute and chronic

After reviewing this case you should be able to describe the following:

  • The common elbow flexor and extensor tendons (flexor and extensor masses); golf and tennis elbow.
  • The joints that facilitate pronation and supination.
  • The mechanism of long bone growth in humans.
  • What is meant by compartment syndrome, the two types of compartment syndrome and their causes?

This article is based on a case report published in the Journal of Orthopaedic Case Reports in 2015 by Maheshwar L., Kiran K.K., Vamshi K.C., Siva Prasad R. and was modified by Joel A. Vilensky, Carlos A. Suárez-Quian and Aykut Üren.

Case Description

Figure 1. Bones of the forearm and distal humerus.

A seven-year-old boy, who was right-handed, fell from a tree and presented to the emergency room with an injury to his left forearm. He complained of pain, deformity and an inability to use his left hand since the fall. Examination revealed a tender swelling, a deformity and abnormal mobility in the left forearm. Radiography of that forearm revealed fracture of both the ulna and radius (Figure 2) between the upper and middle thirds.

Figure 2. Radiographs of the forearm at the first visit to the emergency room that show proximal diaphysis fractures of both radius and ulna (dashed square).

Manipulative reduction and above elbow plaster slab application were done under sedation. The patient then left the hospital against medical advice to stay for observation. Subsequently, the patient was treated by a traditional Indian bonesetter with multiple episodes of tight bandaging and massaging for a period of two months.

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.

Figure 3. Three and one-half months after injury, the patient shows Volkmann’s contracture of the left hand.

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).

Figure 4. Malunion of radius and non-union of ulna

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).

Figure 5. A. Intraoperative photograph showing radius (shortened) fixed by a metal plate. B. Intraoperative photograph of ulna after insertion of the radial graft.

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).

Figure 6. A. Postoperative radiograph showing radius fixed by plate and ulna by rush nail. B. Six weeks postoperative after implant removal from ulna.

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.

Figure 7. A. Ten weeks follow up postoperative radiograph showing union of radius and ulna. B. Post-operative follow up clinical photograph of the patient showing absence of Volkmann’s sign. C. Three years follow up radiograph of left forearm after the radial implant removal showing consolidation and incorporation of intercalary tubular radial graft in the ulna.

Surgical and Anatomical Considerations

Figure 8. Cadaver image of the superficial flexor muscles of the forearm.

This case classically represents neglected compartment syndrome caused by a combination of iatrogenic extrinsic pressure decreasing the forearm compartment. The tight external bandage applied by the native traditional bonesetter, and increased volume of the forearm compartments due to fracture of both bones of the forearm, ultimately ended in Volkmann's ischemic contracture (VIC).

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 articles, video tutorials and quizzes to fortify your knowlege about the flexors 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).

Can't remember all the details about the bones and joints of the forearm? Don't worry, we got you covered with great articles and video tutorials.

Explanation to Objectives

Objectives

  • The common elbow flexor and extensor tendons (flexor and extensor masses); golf and tennis elbow.
  • The joints that facilitate pronation and supination.
  • The mechanism of long bone growth in humans.
  • What is meant by compartment syndrome, the two types of compartment syndrome and their causes?

Golf Elbow & Tennis Elbow

The common flexor tendon (Figure 2) is the tendon of origin for most of the flexor muscles of the wrist and digits (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris). It arises from the medial epicondyle of the humerus. Irritation, fibrosis or inflammation of this tendon results in medial epicondylitis, which is commonly known as golf elbow and is considered an “overuse” injury. Golf elbow is associated with medial epicondyle pain. Many other repetitive activities besides golf can lead to golf elbow: e.g., throwing, chopping wood with an ax, running a chainsaw, and using many types of hand tools.

The common extensor tendon (Figure 9) is the tendon of origin for many of the extensor muscles of the wrist and digits (extensor carpi radialis brevis and longus (partially), extensor digitorum, extensor digiti minimi, extensor carpi ulnaris). The tendon arises from the lateral epicondyle of the humerus.

Figure 9. Cadaver image showing common extensor tendon and extensor muscles of forearm

Lateral epicondylitis, commonly known as tennis elbow, is a painful condition involving the extensor tendon due to similar irritation of the tendon as in medial epicondylitis. In lateral epicondylitis there is typically pain associated with activities in which these muscles (especially the short radial extensor) are active, such as lifting, gripping, and/or grasping. Sports such as tennis (backhand, specially when trying to put topspin on the ball) are commonly associated with these movements, but the pain can occur with many different types of activities (e.g., repetitive hammering by carpenters).

Pronation and Supination

Pronation and supination of the forearm occur at the radioulnar joints (Figure 1, 10, 11). The proximal radioulnar joint is located immediately distal to the humeroulnar and humeroradial joints, but is enclosed within the same articular capsule at these joints (Figure 10A).

Figure 10. A. Cadaver photograph showing proximal radioulnar joint (covered by annular ligament). B. Cadaver photograph showing distal radioulnar joint and wrist joint; TFCC (The triangular fibrocartilage complex).

The proximal radioulnar joint is formed by a pivot type of articulation between the head of the radius, the annular ligament and the radial notch of the ulna. Movement occurs when the head of the radius rotates within the annular ligament causing the radial shaft to cross over the shaft of the ulna in pronation. The distal radioulnar joint (Figure 10B, 11) is located just proximal to the wrist joint. It is an articulation between the ulnar notch of the radius, and the head of the ulna. In addition to anterior and posterior ligaments supporting this joint, there is also a fibrocartilaginous articular disk (Figure 10B,11). This disk is more correctly termed the Triangular Fibrocartilaginous Complex (TFCC). The TFCC acts to connect the distal radius and ulna and to separate the distal radioulnar joint from the wrist joint. The distal joint is also a pivot type of synovial joint.

The interosseous membrane of the forearm (sometimes referred to as the middle or intermediate radioulnar joint) is a fibrous sheet that connects the interosseous margins of the shafts of the radius and the ulna (Figure 10B). It is the main part of the radioulnar syndesmosis, a fibrous joint between the two bones. The fibers of the interosseous membrane are oriented obliquely so that when force is applied the fibers are stretched, shifting more of the load to the stronger of the two forearm bones, the ulna.

Figure 11. Coronal T2 contrast-enhanced wrist MRI arthrogram showing distal radioulnar joint with intact TFCC (courtesy of Dr. Ed Weber).

Long bone growth

All human long bones (except the clavicle) are formed from a cartilaginous model by the process of ossification. Once an immature bone is formed, growth continues in three processes: 1) Growth in length - cartilage cells are laid down at the epiphyseal plate of cartilage (physis) between the diaphysis and the epiphysis (Figure 12). These chondrocytes are eventually replaced by osteocytes (bone cells), thus lengthening the bone. Bone growth ends when the diaphysis, epiphysis (ends of the bones) and metaphysis (area of bone surrounding the physis) unite; the age at which this occurs varies for each joint. 2) Growth in thickness - the diaphysis grows in thickness by multiplication of cells in the deep layer of the periosteum. Osteoblastic cells in this layer produce osteocytes which thicken the bone. Thus, growth in bone girth occurs by deposition of new bony tissue on the surface of the diaphysis. 3) Remodeling - the appositional growth of long bones can result in shape alterations; in order to maintain proper bone shape, osteoclastic cells remove unwanted bone and thus act to maintain the shape of the bone.

Figure 12. Diagrammatic image of long bone growth.

Compartment Syndrome

Raised intra-compartmental pressure (compartment syndrome) is a complication of a wide variety of insults to the structures within a fascial-osseous limb compartment ranging from severe soft tissue injuries, fractures of bones contained in the compartments, vascular injuries, burns and iatrogenic injuries due to tight bandaging. Acute compartment syndrome is an orthopedic emergency and needs to be appropriately treated within four to six hours from its onset to prevent damage such as VIC in the forearm.

Chronic exertional compartment syndrome is an exercise-induced condition in which the pressure in the muscles within a compartment increases to extreme levels during exercise. The pressure decreases blood flow to the affected area, which leads to ischemia. The symptoms are a sensation of extreme tightness in the compartment muscles followed by a burning sensation if exercise is continued. Chronic exertional compartment syndrome typically is found in athletes who participate in repetitive impact sports such as running.

Clinical Case: Volkmann’s Ischemic Contracture - want to learn more about it?

Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster.

Sign up for your free Kenhub account today and join over 1,128,267 successful anatomy students.

“I would honestly say that Kenhub cut my study time in half.” – Read more. Kim Bengochea Kim Bengochea, Regis University, Denver

Show references

References:

  • Maheshwar L, Kiran KK, Vamshi KC, Siva Prasad R. Volkmann's Ischemic Contracture with Atrophic Non-union of Ulna Managed by Bone Shortening and Transposition of Radial Autograft. Journal of Orthopaedic Case Reports 2015 Jan-March: 5(1):Page 65-68.
  • Modified by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD.

Authors:

  • Joel A. Vilensky 
  • Carlos A. Suárez-Quian
  • Aykut Üren

Layout:

  • Dimitrios Mytilinaios
  • Abdulmalek Albakkar
  • Jana Vaskovic
© Unless stated otherwise, all content, including illustrations are exclusive property of Kenhub GmbH, and are protected by German and international copyright laws. All rights reserved.

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