The Volkmann Ischemic Contracture of the Forearm is Preventable

Abstract

The acute compartment syndrome of the forearm is rare and may therefore be easily missed. Although many clinicians will not see such a patient during their entire career, profound knowledge of the symptoms is required to recognize the syndrome in time. Besides immediate identification of the compartment syndrome early surgical treatment is mandatory to avoid its devastating consequences. Then the functional results can be good, but if the correct diagnosis is missed a Volkmann's ischemic contracture will invariably develop. This paper aims to attend the reader to this diagnostic pitfall. Two patients with a compartment syndrome of the forearm are described to illustrate both ends of this diagnostic challenge. Pathophysiological, anatomical and clinical aspects, classification and therapeutic modalities are reviewed.

Clinical review: Volkmann’s ischaemic contracture

“…First noted in 1869 by one of the fathers of orthopaedic surgery, Richard von Volkmann (1830-1889), the term 'Volkmann's ischaemic contracture' was later coined in 1881 [1], with the surgeon having noted ''that the pareses and contractures of limbs following application of tight bandages are caused not by pressure paralysis of nerves… but by the rapid and massive deterioration of contractile substance'' [2].…”

“…Upon examination, the hand is likely to be warm and the muscle compartments of the forearm may feel tense. Passive stretching of the fingers and wrist exacerbates the pain (as it raises intra-compartmental pressure) [1]. Sensory loss in the distribution of the nerves within the affected compartments can be a useful early sign [21] and special attention must be paid in particular to patients suffering supracondylar fractures of the humerus with median nerve involvement, as the patient will be unable to acknowledge pain in the volar compartment [18] (Table 3).…”

“…The treatment options for an ischaemic contracture centre on the improvement or restoration of sensory and motor function of the wrist and hand, and pain reduction, by re-establishing the circulation to affected muscles and nerves [1,4]. Treatment depends on the severity of the contracture, which can be classified according to Tsuge and Seddon and divided into conservative or surgical options.…”

Acute Compartment Syndrome of the Upper Extremity

“…If emergency fasciotomy is performed in time and correctly, the patient has a favorable chance of full recovery [5,[11][12][13][14][15]. Therefore fasciotomy has to be performed within the first four hours of ischemia, because later on irreversible necrosis will occur [16] and after several days Volkmann's ischemic contracture develops, that was first described by Volkmann in the late nineteenth century [17].…”

“…This is mostly made up of case reports. To summarize them: independent of the etiology, good results are reported for early diagnosis and fasciotomy whereas delayed treatment leads to poor results and complications [15,20,[22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38].…”