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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 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).

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

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.

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

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