Erica Kholinne, 2014

VOLKMANN CONTRACTURE (pathology, clinical feature, treatment)

Definition :
Volkmann contracture is a paralytic contracture that develop only in
a few hours after injury caused by arterial insufficieny or ischaemia
of the muscles.
VIC is a sequel of untreated or inadequately treated compartment
syndrome in which necrotic muscle and nerve tissue has been
replaced with fibrous tissue.
Anatomy:
Forearm has 4 interconnected compartment :

Superficial volar ( PL, FCR, FDS, FCU, PT)

Deep volar ( FDP, FPL)

Dorsal (Supinator, EDC,ECU, EDQ)

Mobile wad ( BR, ECRL, ECRB)

Hand:

Dorsal interosseus

Volar interosseus

Adductor

Thenar

Hypothenar

Pathophysiology
Any condition that cause a decrease in compartment size or increase
in compartment pressure can initiate compartment syndrome.
Vicious cycle:

intracompartmental pressure increases,

capillary blood perfusion is reduced to a level that cannot

maintain tissue viability.

Erica Kholinne, 2014

The increase in interstitial pressure overcomes

intravascular pressure of the small vessels and capillaries,

causing the walls to collapse and impeding local blood flow.

The local tissue ischemia leads to local edema, which increases

intracompartmental pressure.

the

contracture results from ischemic degeneration of muscle

o irreversible muscle necrosis begins after 4-6 hrs
muscle degeneration is most affected at the middle third of muscle belly,
being most severe closer to bone
necrosis of the muscle with secondary fibrosis that may develop followed
by calcification in its final phase;

Clinical Features
Clinical features is based on the classification of the disease:
Classification:
Holden Classification is based on location
Level IInjury is proximal to the ischemia and later contracture
Level IIIschemia is directly under the injury (pressure)

Tsuge classification is based on the severity of the muscle

Mild Finger flexor

Erica Kholinne, 2014

Moderate wrist and finger flexor
Severeall muscles : wrist flexor, extensor, finger flexor

Clinical types of VIC :

Type I normal intrinsic muscle
Type II paralytic intrinsic muscle
Type III retracted intrinsic muscle
Type IV combined type
Type
Type
Type
Type

of digital deformity:
I simple digital claw
II opposition paralysis
III intrinsic claw hand

Treatment
Several clinical factor determine the choice of the most adequate surgical
procedure:
1. Type of digital deformity
2. Deformation of carpal bones after growing period
3. Functional condition and degree of retraction of long digital flexor
muscles
4. Sensory impairment
5. Clawhand complications
6. Thumb contracture

Type I
most favour, restoration of hand fracture due to normal intrinsic muscles
& cutaneous sensation

excision of retracted infarcted or fibrotic muscle (FDS, PL, FDP)

functional reconstruction by tendon transfer and tendinous lengthening

Erica Kholinne, 2014

o Z lengthening of flexor tendon (FCU, FCR, FPL)

ECRL transfer to FDP distal stump

Type II
First stage
o Retracted muscle of the forearm are corrected.
Second stage
o The problem is claw hand
o Active or passive surgical procedure
Lasso zancolli
MCP capsulotomy
Type III
Contracture of the muscle of the forearm and of the intrinsic muscles
must be corrected during the same surgical procedure
o Mild case
Distal intrinsic release classical technique of intrinsic
lateral bands and triangular interosseus lamina excisions
o Cases with flexion contracture of MCP
Proximal intrinsic release interosseus tendon are excised at
the level of the neck of the MCP bone