Volkmann’s Contracture

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Volkmann’s Contracture is a deformity of the hand, fingers, and wrist, which occurs as a result of a trauma such as fractures, crush injuries, burns, and arterial injuries. Following this trauma there is a deficit in the arteriovenous circulation in the forearm which causes a decreased blood flow – hypoxia, which can then lead to the damage of muscles, nerves, and vascular endothelium. This results in a contracture of the muscles in the forearm. Volkmann’s Contracture is a rare condition that occurs after injury to the elbow and upper arm, primarily from a crush injury. This condition can occur when an acute contracture is left untreated. Hand therapists are some of the providers who see patients in frequent and regular intervals after the onset of this type of injury. This makes them critical in the role of identifying and intervening if Volkmann’s Contracture begins to develop.

As already mentioned, Volkmann’s Contracture is a permanent flexion deformity at the hand and wrist that has a claw-like presentation. Volkmann’s contracture is caused by acute arterial insufficiency to the arm. Most commonly, this arterial insufficiency is caused by compartment syndrome that occurs after an individual has experienced trauma to the arm (between the shoulder and elbow) or at the elbow. Compartment syndrome is a condition where there is an increase of intra-fascial compression in a closed compartment. Volkmann’s Contracture develops from acute compartment syndrome if the compartment is not released, thus causing decreased blood flow and oxygen (arterial insufficiency) to the forearm as well as suppressed nerves within the compartment. When blood supply and oxygen are not able to supply muscles for an extended amount of time, it has severe effects on those muscles. These effects include the shortening of the muscles and loss of function.

Causes & Symptoms

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Volkmann’s Contracture occurs when there is a lack of blood flow (known as ischemia) to the forearm. This occurs when there is increased pressure due to swelling. Injury to the arm, including a crush injury or a fracture, can lead to swelling that presses on blood vessels and decreases blood flow to the arm. A prolonged decrease in blood flow injures the nerves and muscles, causing them to become stiff and shortened. 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 stuck; this condition is called contracture. In Volkmann’s Contracture, the muscles of the forearm are severely injured – this leads to contracture deformities of the fingers, hands, and wrist. There are three levels of severity in Volkmann’s Contracture, including the following:

 

  • Mild – Contracture of 2 or 3 fingers only, with no or limited loss of feeling.

 

  • Moderate – All fingers are bent, and the thumb is stuck in the palm; the wrist may be bent stuck, and there is normally a loss of some feeling 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. There is also a minimal movement of the fingers and wrist.

 

Here are some of the conditions that can cause increased pressure in the forearm:

 

  • Animal bites
  • Bleeding disorders
  • Burns
  • A forearm fracture
  • Injury of the blood vessels in the forearm
  • Injection of certain medicines into the forearm
  • Surgery on the forearm
  • Excessive exercise

 

Other symptoms of Volkmann’s Contracture include:

 

  • Decreased sensation.

 

  • Paleness of the skin.

 

  • Muscle weakness and loss.

 

  • Deformity of the wrist, hand, and fingers causes the hand to have a claw-like appearance.

Who gets Volkmann’s Contracture?

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Generally, Volkmann’s Contracture is a rare condition with an incidence percentage of 0.5%. There have been studies shown that Volkmann’s Contracture can affect children from the ages 13 and up quite severely, whilst older patients experience a mild or moderate level of this condition. Therefore, how well a person feels often depends on the severity and stage of the disease at the time and how quickly treatment has been commenced for those experiencing Volkmann’s Contracture. The outcome is typically good for people with mild contracture; they may even regain normal function of their arm and hand. However, patients with moderate or severe contracture who need surgery may not regain full function. Therefore, in most severe cases, patients who tend to deal with any signs and symptoms linked to this condition may result in partial or complete loss of function of the arm and hand if Volkmann’s Contracture is left untreated.

How Does It Affect You? How Serious Is It?

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Generally, pain is the first sign in Volkmann’s Contracture – a patient will begin to feel pain with palpations over the affected area of the forearm. If a patient is starting to have flexor stiffness in 2-3 digits and they have pain when palpating the arm, this may be a sign that the patient is beginning the early stages of Volkmann’s Contracture. As the condition progresses, the individual may show pallor where their skin looks bleached, as well as ‘pulselessness’, where you are unable to feel a pulse in the distal forearm. If the patient is in the moderate and severe stages, this is when they will show the signs of parenthesis, decreased sensation, and observable muscle paralysis. Volkmann’s Contracture not only is a condition that involves either mild, moderate, or severe levels depending on how much it has affected a patient; this condition can affect anyone permanently, therefore, immediate treatment is needed in case a patient experiences a severe contracture. Fortunately, despite the fact Volkmann’s Contracture is often permanent, there are ways to treat this condition with surgical procedures for patients who have dealt with a moderate contracture, or even severely. Additionally, patients who are living with mild contracture will only require muscle stretching exercises and splinting the affected fingers in order to recover the condition. However, surgery may be required to make the tendons longer. In most severe cases, surgery is needed to remove muscles, tendons, or nerves that are thickened, scarred, or dead. These are replaced by muscles, tendons, or nerves transferred from other body areas. Tendons that are still working may need to be made longer.

If an individual chooses to prevent any further symptoms linked to Volkmann’s Contracture, a recommended prevention of the condition requires restoration of blood flow after injury and reduction of compartmental pressure on the muscles. Any splints, bandages, or other devices that might be obstructing circulation must be removed. In addition, a fasciotomy may be required to help reduce pressure in the muscle compartment.

Recommended Treatment & Rehabilitation

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Within the findings for diagnosing Volkmann’s Contracture, signs suggestive of increased compartmental pressure may be found on physical examination. One of the reliable findings is pain accentuated by passive movement. Firmness or induration of the tissues often is noted on palpation. Pulselessness and paralysis are also late findings during diagnosis. Below are a few different types of diagnosis to seek signs of Volkmann’s Contracture:

 

Pseudo-Volkmann’s contracture – Tethering of the flexor digitorum profundus; secondary to fractures of the ulna occurs 2 days to a few years after a closed reduction of fractures of the shafts of the radius and ulna. This can be prevented by a routine check of the passive range of motion after fracture reduction and repeat manipulation of the fracture is detected. Surgery release may be needed in some cases.

 

X-ray imaging – X-rays are done to evaluate bony injury in detail and assess the amount of displacement of supracondylar fractures and combined radial and ulnar fractures.

 

The goal of treatment is to restore adequate circulation before irreparable damage is done, thus averting contracture deformities. In treatment, time is a major factor. The condition is a progressive one in which more damage is done as time progresses. All measures favoring circulation generally are of the greatest value – these include elevation of the part, removal of any splint or circulation bandage, and the application of mild external warmth. When the diagnosis has been determined with certainty, emergency fasciotomy is required to prevent progression to Volkmann’s Contracture. Patients with compartment pressures exceeding 30mm Hg should be taken for emergency fasciotomy. When required, arterial repair and fixation of the fracture should be carried as well.

Once contracture has occurred, treatment depends on the degree of Volkmann’s Contracture presented. Some of these treatments include:

 

  • Splinting
  • Physiotherapy
  • Tendon lengthening
  • Slide procedures

 

For more moderate and severe contracture, treatments include the following:

 

  • Tendon slide
  • Neurolysis of median nerve and extensor transfer procedures
  • Extensive debris event of a damaged muscle
  • Multiple scar tissue release
  • Salvaging procedures
  • Release of contracted tendons and tendon transfers at a later date

 

The very first in treatment is to prevent contractures and maintain a supple joint with a full range of movements, and so a splint is applied which makes use of elastic traction to prevent the muscles contracting, whilst at the same time permitting the joints of the fingers and wrist to be moved, if necessary passively, to prevent them from becoming stiff.

Alternative & Homeopathic Treatment

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When this condition strikes a patient, the most commonly affected areas of the body are the forearms, the lower legs, and the upper thighs. Stretching and light exercise may help alleviate some forms of Volkmann’s Contracture – these include:

 

Activity modification

 

For chronic contracture, stop the activity that is triggering the increased symptoms. Treatment of mild contracture begins with rest from the aggravating activity until the symptoms have lessened or dissipated completely. For many athletes, this means a significant break from their spot. Once the symptoms have left, a modified return to the activity may begin. If you want to continue with your sports activity, surgical treatment is the best option.

 

Stretching and ice exercise

 

For mild contracture patients, relax the muscles of the affected limb by lightly stretching. Continue with an ice massage to reduce swelling and pain. As an example, if compartment syndrome has affected the lower leg, raise your toes toward your nose for a count of 30 seconds. Then point the toes for another 30 seconds. Repeat this procedure three to five times a day. Finally, rest the limb comfortably and rub an ice cube along with the tender muscles for 5 to 15 minutes.

 

Swelling reduction exercise

 

For patients living with mild contracture, release the pressure of residual swelling by using a massage stick or foam roller to roll along the muscles. You can begin by rolling slowly from the affected limb towards the body. Reducing the swelling and pressure of the muscles will alleviate pain.