Volkmann's Ischemic Contracture of the Foot and Ankle: Evaluation and Treatment of Established Deformity

Abstract

Fibrotic contracture of skeletal muscle can follow weeks or months after the severe ischemic insult of compartment syndrome. Commonly known as Volkmann's ischemic contracture, the affected limb often becomes dysfunctional and painful, and may lose sensibility. The pathogenesis of the muscle contracture includes prolonged ischemia, myonecrosis, fibroblastic proliferation, contraction of the cicatrix, and myotendinous adhesion formation. Resultant shortening or overpull of involved muscles leads to stiffness and deformity. Simultaneously, nerve injury from initial ischemia or subsequent soft tissue fibrotic compression leads to muscle paresis or paralysis of the involved compartment and of those muscles more distally innervated. The resultant deformity is thus a combination of varying degrees of contracture and weakness depending on which muscles and nerves are affected. Deformity and functional impairment in the foot and ankle secondary to ischemia are determined by many factors, including: (1) which leg compartment, if any, has been affected and to what degree extrinsic flexor or extensor overpull is exhibited, (2) degree of nerve injury sustained causing weakness or paralysis of extrinsic or intrinsic foot and ankle muscles (3) which foot compartment, if any, has been affected and to what degree intrinsic overpull is exhibited, and (4) degree of sensory nerve injury leading to anesthesia, hypoesthesia, or hyperesthesia of the foot. Therefore, a variety of clinical presentations can be encountered following compartment syndrome of the leg and foot. Treatment is based on an appreciation of the pathoanatomy of the deformity. Nonoperative therapy is aimed at obtaining or preserving joint mobility, increasing strength, and providing corrective bracing and accommodative footwear. Operative management is usually reserved for treatment of residual nerve compression or severe and problematic deformities. Established surgical protocols are performed in a stepwise fashion, to include: (1) release of residual or secondary nerve compression, (2) release of fixed contractures, using infarct excision, myotendinous lengthening, muscle recession, or tenotomy, (3) tendon transfers or arthrodesis to increase function, and (4) ostectomy or amputation for severe, refractory deformities.

Compartment Syndrome of the Lower Leg and Foot

“…However, it seems unclear to which extent results from animal studies can be transferred in the clinical situation. Muscle tissue reacts to ischemia with scar formation resulting in the formation of myotendinous adhesions and contractures [78]. Muscle contracture results in stiffness and deformity distal to the affected compartment.…”

“…Untreated compartment syndrome with ischemia of the lower leg or foot may lead to muscle contractures resulting in deformity and functional impairment [78]. Additionally, nerve damage may cause weakness or paralysis of the affected muscles and a dysfunctional painful extremity.…”

“…Additionally, nerve damage may cause weakness or paralysis of the affected muscles and a dysfunctional painful extremity. While nonoperative treatment aims at preserving joint mobility, salvaging of late sequelae of compartment syndrome may require nerve decompression and surgical correction of deformities (soft tissue releases, tendon transfers, realignment osteotomies, joint fusions) [78].…”

Nerve Injury and Repair in the Foot and Ankle

“…9,21,28,66,70,107 The tibial and/or peroneal nerves are commonly injured from open fractures, compartment syndromes, penetrating trauma, or knee dislocations. 88,97 The tibial nerve is obviously vulnerable to injury in severe tarsal tunnel syndrome. In the foot, branches of the superficial peroneal nerve (medial dorsal cutaneous nerve and intermediate dorsal cutaneous nerves), the sural nerve (lateral dorsal cutaneous nerve), terminal branches of the deep peroneal nerve, and the distal saphenous nerve can be injured from laceration, compression, or iatrogenic trauma.…”

“…d 92750 51,66, syndromes, an compression syn romes.' , , 68,[75][76][77][78]85,88,107 In the hip and thigh, the sciatic nerve is frequently injured or at risk from hip dislocation, traction injuries, or retractor placement in the treatment of pelvis fractures. 14,19,20,107 In the leg, the common peroneal nerve is susceptible to injury from blunt trauma or traction following proximal tibial corrective osteotomy.…”