Volkmann Contracture Treatment & Management

Initial treatment for Volkmann contracture consists of removal of occlusive dressings or splitting or removal of casts. Analgesics are the mainstay for symptomatic relief in chronic cases.

Emergency fasciotomy is required to prevent progression to Volkmann ischemic contracture. Decompression is performed via the volar or dorsal approach. Medial nerve decompression throughout its course is essential, especially in high-risk areas, including deep to the lacertus fibrosus; between the humeral and ulnar heads of the pronator teres, the proximal arch, and deep fascial surface of the flexor digitorum superficialis; and in the carpal tunnel.^{[15, 16, 17, 18]}

Once contracture has occurred, treatment depends on the type of Volkmann ischemic contracture present. In the mild type, dynamic splinting, physical therapy, tendon lengthening, and slide procedures are used to improve function. In the moderate type, tendon slide, neurolysis (M and U), and extensor transfer procedures are used. The severe type requires more extensive and radical intervention. Extensive debridement of damaged muscle with multiple releases of scar tissue and salvaging procedures often are required.

Severe contractures require the release of contracted tendons at the musculotendinous junction and tendon transfers performed at a later date. The preferred transfers involve the brachioradialis, which often is transferred to the flexor pollicis longus to regain thumb motion. For finger flexion, the extensor carpi radialis longus commonly is transferred to the flexor digitorum profundus. If no motor function is present secondary to muscle necrosis and fibrosis, free muscle can be used for transplantation.

Muscle viability in Volkmann contracture can be assessed by using what commonly is referred to as the 4 C s: color, consistency, contractility, and capacity to bleed.

Both physical therapy and occupational therapy are vital to the improvement of range of motion and the return of function in patients with Volkmann contracture.

Complications related to fasciotomies for Volkmann contracture include the following^{[19, 20]} :

• Altered sensation within the margins of the wound (77%)
• Dry, scaly skin (40%)
• Pruritus (33%)
• Discolored wounds (30%)
• Swollen limbs (25%)
• Tethered scars (26%)
• Recurrent ulceration (13%)
• Muscle herniation (13%)
• Pain related to the wound (10%)
• Tethered tendons (7%)

The appearance of the scars can affect patients. In one study, 23% kept the wound covered, 28% changed hobbies, and 12% changed their occupation.^[19]

Cubitus varus, or gunstock deformity, is the most common complication in Volkmann contracture. This results in the loss of the carrying angle of the upper extremity. Cubitus varus has been reported in as many as 25-60% of patients. The rate depends on the management. With the use of percutaneous pinning, the rate of this complication has decreased to less than 10%.

With valgus or varus deformities in the coronal plane, remodeling is unlikely, if at all possible. Nerve injuries occur in 7% of cases, with common involvement of the radial, median, and ulnar nerves. Most deficits are seen at the time of injury. Fortunately, neuropraxias resolve with conservative management.^[21] Motor function returns at 7-12 weeks, followed by the recovery of sensation, which may take more than 6 months.

Reportedly, 10% of children with supracondylar fractures temporarily lose the radial pulse. Fortunately, this most often is due to swelling and not to direct brachial artery injury. Reducing the fracture usually helps to return the arterial flow.

Current research is aimed toward reperfusion of the ischemic extremity. Some have advocated the use of hyperbaric oxygen to improve the oxygenation of the tissues and to prevent further myonecrosis.^[22] Early detection and prevention are still important in preventing severe disability. Frequent repeat examinations are required. Miniature transducer-tip catheters may allow continuous and accurate measurements of intracompartmental pressures.^[10] Other noninvasive techniques for Volkmann contracture are currently under investigation.