Volkmann contracture is an ischemic contracture that affects the flexor muscles of the forearm. Soft tissue shortening occurs as part of the condition, particularly in the muscles. Volkmann contractures are often the result of inadequate blood supply and damage to the nerves.
What is a Volkmann contracture?
In Volkmann contracture, nerve damage occurs as a result of so-called supracondylar fractures, such as in childhood. Often, constricting casts, edema, extensive hematoma, or foreign material are triggers for the contracture. The condition is characterized by a flexion deformity or claw hand. Volkmann contracture occurs due to the deficiency of blood supply to muscle groups on the arm. As a result of insufficient blood supply, the corresponding muscle tissue dies. As a result, it shortens and Volkmann contracture may form.
Causes
Volkmann contracture can develop as a result of various triggers. Usually, damage to the arteries and nerves of the affected forearm leads to neurologic and muscular deficits. Thus, the condition is due to ischemia or nerve compression. Even after humerus fractures localized above the condyle, single fragments may damage the ulnar nerve, the median nerve, and the brachial artery due to compression. The development of a Volkmann contracture is favored by certain factors. These include a cast that is too tight and unsplit, late fitting with irreversible damage to the soft tissues, or inadequate reduction after fractures, which can result in direct vascular injury. Necrosis and atrophy of the musculature occur in the forearm because of inadequate supply.
Symptoms, complaints, and signs
Volkmann contracture is usually associated with a series of symptoms and complaints that occur sequentially. Initially, the contracture is usually noticeable by an acute onset of pain. Subsequently, pressure-sensitive, hard tissue forms. The first signs of reduced blood flow appear. Finally, the affected patient experiences movement restrictions, which can intensify. In the early stages of Volkmann’s contracture, pain occurs in the forearm, which may be associated with numbness and a feeling of coldness in the fingers. In addition, there is a weakening of the pulse, which in most cases occurs together with a blue discoloration of the skin (cyanosis). As the disease progresses, the muscles of the forearm and hand atrophy. As a result, flexion and pronation contractures of the hand develop. The base joints of the fingers are hyperextended and the middle and end joints of the fingers show a claw position (flexion). The thumb of the affected hand is fixed in an extended position. In Volkmann contracture, the electrical excitability of diseased muscles is extinguished.
Diagnosis and course of the disease
In the context of the diagnosis of a Volkmann contracture, various methods of examination exist. At the first signs of the disease, a specialist should be consulted immediately, who will discuss the symptoms and medical history together with the affected patient. Subsequently, clinical and radiological methods of diagnosis are available. First, the treating physician checks for the presence of characteristic symptoms of a Volkmann contracture. For example, the patient must state whether sensitivity in the affected area is reduced. Symptoms such as the claw position of the finger joints are obvious and lead to the confirmation of the diagnosis. Ultimately, the diagnosis of Volkmann contracture can be confirmed by X-ray examinations if a bone fracture has occurred and the affected arm is in a cast. Radiographs may show evidence of potential inadequate reduction of the fracture, suggesting Volkmann contracture.
Complications
First and foremost, Volkmann contracture results in severe pain. This can occur in the form of pain at rest or as pain on exertion, so that the affected person is significantly restricted in their everyday life. Pain at rest can lead to sleep problems, especially at night, and thus to psychological upsets or irritability on the part of the affected person. Furthermore, the pain spreads to the shoulders or neck.Due to the reduced blood supply, Volkmann’s contracture also leads to paralysis or to various sensory disturbances, so that the patient suffers from severe movement restrictions in his daily life. The pulse can also be weakened by Volkmann’s contracture, so that the skin turns blue due to the reduced oxygen supply. Furthermore, the muscles will also weaken if the condition is not treated. The treatment of Volkmann contracture always depends on the exact cause and on the injury. As a rule, no complications occur if the disease is recognized and treated early. In the worst case, the muscle tissue may die if left untreated and cannot be restored. However, Volkmann contracture does not negatively affect or reduce the patient’s life expectancy. Even after successful treatment, patients are dependent on various therapies.
When should you see a doctor?
Since Volkmann contracture usually cannot heal itself, the affected person is definitely dependent on examination and treatment by a physician. This is the only way to prevent or limit further complications and discomfort. The sooner a doctor is consulted, the better the further course is usually. A doctor should be consulted in the case of Volkmann contracture if the affected person suffers from severe restrictions in movement. As a rule, this also results in very severe pain, which can severely restrict the quality of life and daily routine of the affected person. Sensory disturbances or paralysis in the forearms can also indicate Volkmann contracture and should be examined by a doctor if they occur over a longer period of time and do not disappear on their own. Likewise, a blue discoloration of the affected region often also indicates this disease. In the first instance, a general practitioner or an orthopedist can be consulted. Further treatment then depends on the severity of the symptoms. In an emergency or if the pain is very severe, a hospital may also be visited.
Treatment and therapy
With regard to the therapy of Volkmann contracture, various treatment methods are available, which the treating physician weighs up depending on the severity of the disease, the exact localization and the individually displayed symptoms. If the affected arm is in a cast, the constricting bandages must be removed immediately. In connection with this, it may be necessary to perform a fascia splitting of the affected parts in the course of a surgical intervention. If the cause of the Volkmann contracture is an injury, this injury must first be treated. In some cases, it may be necessary to repair damaged blood vessels. If a hematoma occurs that is located within a tendon sheath, this must be opened in the course of a surgical procedure. The bruise must be flushed out in the process. The operations must be followed by adequate aftercare. For this purpose, intensive physiotherapeutic exercises are usually required in order to regain optimal function of the muscles. If a particularly large amount of muscle tissue has died off as a result of the Volkmann contracture and is subsequently permanently shortened, this can lead to permanent movement restrictions. In principle, it is already too late for causal therapy after a Volkmann contracture. The impairment of the affected patient’s quality of life can be reduced by physiotherapy. By means of surgical placement of so-called arthrodesis in the elbow region, affected patients can be treated symptomatically.
Prevention
Preventive measures related to Volkmann contracture exist and are primarily directed toward adequate treatment of fractures in the forearm. Supracondylar humerus fractures should be reduced as soon as possible and in a gentle manner. When applying plaster casts, care should be taken to split them. In this way, the development of Volkmann contractures can be sensibly and effectively prevented and permanent damage avoided.
Aftercare
The extent of aftercare for Volkmann contracture is basically based on the therapeutic measures initiated by the specialist. Surgery or independent healing may be specified for the therapy of the disease on the part of the attending specialist.If the lower leg or forearm is affected, the specialist will initiate surgery. In the case of surgery, aftercare focuses on closing the surgical wound and mobilizing the affected muscles. This is because it is generally not possible to close the wound with a suture during the operation. Alternatively, the wound is closed by a special wound covering (temporary skin replacement or vacuum sealing). The suture closure takes place approximately one week after the operation. Intensive physiotherapy exercises and physiotherapeutic treatments (for example, stimulation current) are usually used to mobilize the affected muscles. In individual cases, however, the movement of the fingers or hand (for example, making a fist) may remain restricted. In addition, the performance of the affected muscles does not fully regenerate during follow-up care. On average, a reduction in performance of 6 to 19 percent can be expected. Nonoperative therapy may be fixed for a Volkmann contracture caused in the thigh by contusion trauma. In this case, the condition can heal on its own within a year. In addition to mobilization of the affected muscles, intensive clinical, neurological, and laboratory monitoring of the affected person is required in this case.
What you can do yourself
If a Volkmann contracture is suspected, the constricting casts must be removed. Surgical fascia splitting may be needed. The tendon and muscle damage caused can be treated by physiotherapy. Regular training of the affected muscles is required. The appropriate measures in each case are based on the severity and localization of the contracture. A sports physician or physiotherapist can name training methods which can be carried out independently by the affected person at home. As a rule, positioning splints must be worn at night to prevent further strain on the muscles. Since the forearm muscles, which allow the hand to bend, are severely weakened, no vehicle may be driven after a Volkmann contracture. Physical work is only possible with restrictions. The early search for an alternative occupation facilitates the re-entry into working life. In the late stage of the disease, healing of the damaged muscle parts is no longer possible. Self-help measures are limited to relieving the pain by means of cooling, massages and the wearing of splints, and to not placing a heavy load on the affected arm. Because of the persistent physical limitations, therapeutic reappraisal of the triggering event and its consequences is recommended.
