Volkmann's Ischemia : Clinical Features, Classification & Treatment

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, and contracture.
• So the established case of VI is called Volkmann's Ischemic Contracture (VIC).

Definition

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

• A 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.

Etiology of Volkmann's Ischemia

Most common: Inappropriate tight bandaging.

• The most common triggering factor in children: Supracondylar fracture.
• The most common triggering factor in adults is crush injuries of the forearm (both bone forearm fractures).
• Other causes in adults
  • Monteggia's fracture
  • Galeazzi fracture
  • Colles fracture
  • Smith's fracture

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Clinical Features of Volkmann's Ischemia 

A 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.

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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.

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Treatment of Volkmann's Ischemia 

If Clinical Signs are +ve

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

Fasciotomy:

A 22-blade is taken

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Deep nick along the flexor compartment of the forearm

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Kept deep into the fascia

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Pressure is released equally

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Intra-compartmental pressure comes down

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Closed with a loose stitch

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 causes irreversible damage.

In a Doubtful Situation

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

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Conservative management

The hand is raised up

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Pressure comes down due to gravity

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Some antiedema agents are given, such as Glycerin magsulf dressing

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Edema comes down

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Normal pressure

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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 the hand is cosmetically improved
    • Hand functioning can’t be improved

• Severe (Tsuge’s Type-III) - FDP + FDS + FPL + Wrist and Thumb flexors
  • Soft tissue procedure is not enough
  • A bony procedure named Seddon's carpectomy is to be performed.
    • The proximal bone of carpels is removed.

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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!