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Volkmann's Ischemia - NEET PG Orthopedics

Apr 5, 2023

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Definition 

Common Sites of Volkmann's Ischemia  

Etiology of Volkmann's Ischemia

Clinical Features of Volkmann's Ischemia 

Classification of Volkmann's Ischemia 

Volkmann's Sign

Treatment of Volkmann's Ischemia 

If Clinical Signs are +ve

Fasciotomy:

Process

In a Doubtful Situation

Conservative management

In an Established IVC

Volkmann's Ischemia - NEET PG Orthopedics

Get ready to boost your Orthopedics preparation by learning everything about Volkmann's Ischemia in this blog post. 

Volkmann's Ischemia, also known as Volkmann contracture, is a condition that occurs when blood stops flowing to the forearm. This results in swelling and increased pressure around the area, leading to a condition called compartment syndrome.

Let’s learn more about this condition in detail. 

  • Other name: Compartment syndrome.
  • Compartment syndrome: Raises intracompartmental pressure and leads to consequences.
  • If not treated on time, all the muscles can undergo necrosis fibrosis contracture.
  • So the established case of VI is called Volkmann's Ischemic Contracture (VIC).

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Definition 

Elevation of interstitial pressure in a closed Osseo-fascial compartment that results in microvascular compromise and eventual contracture of muscles

  • Compartment means a closed space between bones.
  • Interstitial pressure also called intracompartmental pressure 
  • Normal interstitial pressure 10-20 mmHg (same as the intraocular pressure)
  • If interstitial pressure > 10-20 mmHg it is called Volkmann's Ischemia.

Common Sites of Volkmann's Ischemia  

Most common: Volar (flexor) compartment of the forearm.

  • 2nd Most common: Anterior and deep posterior compartments of the legs.
  • Rare sites: Buttocks, shoulder, hand, foot, arm and lumbar paraspinal muscles are relatively rare sites.
Important Information 

Compartment syndrome is an orthopedic emergency.

If compartment syndrome isn’t treated quickly, it will be converted to Volkmann's Ischemic Contracture (VIC).

Compartment syndrome is reversible.

VIC is irreversible (the limb is lost).

Etiology of Volkmann's Ischemia

Most common: Inappropriate tight bandaging.

Important Information

 To avoid inappropriate bandaging, PoP is given as a slab at the beginning, not a cast.

Slab: PoP covers 2/3rd and simple bandage covers 1/3rd.

Cast: PoP covers the entire circumference.

If there is no pain or no increase in the intracompartmental pressure, only then the slab is converted to cast.
  • Most common triggering factor in children: Supracondylar fracture.
  • Most common triggering factor in adults: Crush injuries of the forearm (both bone forearm fracture).
  • Other causes in adults
    • Monteggia's fracture
    • Galeazzi fracture
    • Colles fracture
    • Smith's fracture

Clinical Features of Volkmann's Ischemia 

Common sign is pain.

  • Earliest sign: When fingers are passively extended, severe pain along the flexor axis of the forearm (stretch pain).
  • Late signs (entered Volkmann's Ischemia phase)
    • Pulselessness - Fabile or diminished pulse
    • Numbness
    • Tingling

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Classification of Volkmann's Ischemia 

  • Tsuge classification (depends on the muscles involved)
  • 3 types
    • Type-I: Involvement of flexor digitorum profundus (FDP) only.
    • Type-II: Involvement of FDP + flexor digitorum superficialis (FDS) + flexor pollicis longus (FPL).
    • Type-III: Involvement of FDP + FDS + FPL + Wrist and Thumb flexors.
Important Information 

The first or most common muscle involved is FDP.

In Type-III it gives Volkmann's sign +ve.

Volkmann's Sign

Volkmann's Sign
  • Fingers, thumb, and wrist are all flexed.
  • When the wrist is passively flexed, the fingers get extended spontaneously.
  • Volkmann's sign may be both -ve or +ve in Tsuge’s Type-I.
  • But Volkmann's sign is +ve in Tsuge’s Type-III.

Also Read: Rotator Cuff Injury: Causes, Symptoms, Risk Factors, Diagnosis, Treatment and Complications

Treatment of Volkmann's Ischemia 

If Clinical Signs are +ve

  • Stretch pain, pulselessness, numbness, tingling are seen.
  • Emergency fasciotomy to be performed.

Fasciotomy:

A 22 blade is taken

Deep nick along the flexor compartment of the forearm

Kept deep into the fascia

Pressure is released equally

Intra compartmental pressure comes down

Closed with a loose stitch

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Process

Pressure raised → Compresses the vessels → Causing more necrosis to the muscle → Fasciotomy → Pressure decreased → From Volkmann's Ischemia it won’t proceed to VIC.

Only necrosis is the irreversible damage.

In a Doubtful Situation

  • It is assessed by using a special manometer which has a cannula.
    • If pressure is > 30 mmHg - Immediate Fasciotomy.
    • If pressure is < 30 mmHg - Conservative management.

Also Read: Scoliosis: Causes, Symptoms, Risk Factors, Diagnosis, Treatment and Complications

Conservative management

Hand is raised up

Pressure comes down due to gravity

Some antiedema agents are given like Glycerin magsulf dressing

Edema comes down

Normal pressure

In an Established IVC

  • Mild (Tsuge’s Type-I) - Only FDP
    • Turn buckle’s splint (Volkmann’s splinting)
  • Moderate (Tsuge’s Type-II) - FDP+FDS+FPL
    • Max page’s operation
      • Cutting a tight muscle
      • Release the muscle tendon
      • And hand is cosmetically improved
      • Hand functioning can’t be improved
Important Information  

Once it is IVC, functioning can’t be reversed. It must be prevented at the stage of Volkmann's Ischemia only.
  • Severe (Tsuge’s Type-III) - FDP + FDS + FPL + Wrist and Thumb flexors
    • Soft tissue procedure is not enough
    • Bony procedure named Seddons carpectomy is to be performed.
      • Proximal bone of carpels is removed.

Also Read: Bursitis: Causes, Symptoms, Risk Factors, Diagnosis, Treatment and Prevention

And that is everything you need to know about Volkmann's Ischemia to boost your Orthopedics preparation. For more interesting and informative posts like this keep following our blog! 


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