168: VOLKMANN ISCHEMIC CONTRACTURE

CONDITION/DISORDER SYNONYMS

• Forearm, anterior compartment syndrome

• Volkmann contracture

• Volkmann ischemic contracture

ICD-9-CM CODE¹

• 958.6 Volkmann ischemic contracture

ICD-10-CM CODE²

• T79.6 Traumatic ischemia of muscle

PREFERRED PRACTICE PATTERN³

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation

KEY FEATURES

Description

• Flexion contracture of the wrist, resulting in claw-like deformity

• Obstruction of brachial artery near the elbow

  • Obstruction commonly caused by compartment syndrome or fracture

• Three levels of severity

  • Mild: Contracture of two or three fingers only, only limited sensation deficit

  • Moderate: All fingers (including thumb) contracted in flexed position; wrist may be in flexion and slight sensation loss

  • Severe: All muscles in the forearm affected (flexors and extensors)

• Arteriolar compression occurs and causes muscle and nerve ischemia

  • Acute, sensory changes develop after 30 minutes of ischemia

  • Acute, irreversible nerve damage in 12 to 24 hours

  • Acute, irreversible muscle changes (i.e., necrosis) in 3 to8 hours

Essentials of Diagnosis

• Diagnosis is typically made by clinical examination and compartment pressure measurement

• Severe pain that is not alleviated by elevation or pain medication

  • Pain increases with passive/active range of motion and compression

• Distal pulses are diminished/absent

• Strength and sensation are diminished

• Edema in affected limb

General Considerations

• Occurs in the flexor/volar compartment of the forearm

  • Flexor digitorum profundus becomes fibrotic and shortened

  • Flexor pollicis longus becomes fibrotic and shortened

• Classic P’s

  • Pain

  • Pallor

  • Pulselessness

  • Paresthesias

  • Paralysis

• Complications

  • Infection

  • Contractures

  • Deformity

  • Amputation

  • Acidosis

  • Hyperkalemia

  • Myoglobinuria

  • Acute renal failure and shock

Demographics

• Younger age, high-energy/high-velocity trauma, and systemic hypotension associated with an increased risk of traumatic accident

• More common in children

• High-risk patients include:

  • Soft-tissue injury in males aged <35 years with bleeding disorder or receiving anticoagulants

  • Crush injury patients

  • Patients with prolonged limb compression

• Individuals using circumferential wraps, restrictive dressings, casts, or immobilizer are at an increased risk

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