Approach Considerations
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 contracture. There is some disagreement regarding which compartment pressure readings are indications for fasciotomy; however, most agree that patients with compartment pressures exceeding 30 mm Hg should be taken to the operating room for emergency fasciotomy. [22] There are no absolute contraindications for immediate decompression for Volkmann contracture in the acute setting.
Nonoperative Therapy
Both physical therapy and occupational therapy are vital to the improvement of range of motion (ROM) and the return of function in patients with Volkmann contracture.
Surgical Therapy
To prevent the development of Volkmann contracture, decompression is performed via the volar or the dorsal approach. Decompression of the medial nerve throughout its course is essential, especially in the following high-risk areas [23, 24, 25, 26, 27, 28, 29] :
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Deep to the lacertus fibrosus
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Between the humeral and ulnar heads of the pronator teres (PT), the proximal arch, and the deep fascial surface of the flexor digitorum superficialis (FDS)
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In the carpal tunnel
Once contracture has occurred, treatment depends on the degree of Volkmann contracture present, as follows:
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Mild - Dynamic splinting, physical therapy, tendon lengthening, and slide procedures are used to improve function [30]
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Moderate - Tendon slide, neurolysis (M and U), and extensor transfer procedures are used
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Severe - More extensive and radical intervention is required, often involving extensive debridement of damaged muscle with multiple releases of scar tissue and salvaging procedures
Severe contractures necessitate the release of contracted tendons at the musculotendinous junction and tendon transfers performed at a later date. The preferred transfers involve the brachioradialis, which is often transferred to the flexor pollicis longus (FPL) to regain thumb motion. For finger flexion, the extensor carpi radialis longus (ECRL) is commonly transferred to the flexor digitorum profundus (FDP). If no motor function is present secondary to muscle necrosis and fibrosis, free muscle can be used for transplantation. [31, 32]
Muscle viability in Volkmann contracture can be assessed by using what commonly is referred to as the four Cs: color, consistency, contractility, and capacity to bleed.
Although treatment of Volkmann contracture can be challenging, surgery can often yield good functional results and allow return to professional activities. [33]
Complications
Complications related to fasciotomy for Volkmann contracture include the following [34, 35] :
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Altered sensation within the margins of the wound (77%)
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Dry, scaly skin (40%)
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Pruritus (33%)
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Discolored wounds (30%)
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Swollen limbs (25%)
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Tethered scars (26%)
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Recurrent ulceration (13%)
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Muscle herniation (13%)
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Pain related to the wound (10%)
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Tethered tendons (7%)
The appearance of the scars can affect patients. In one study, 23% of patients kept the wound covered, 28% changed hobbies, and 12% changed their occupation. [34]
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Volkmann contracture. Supracondylar fracture.
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Volkmann contracture. Supracondylar fracture.
