Compartmental syndrome of forearm or Volkmann’s  ischemia

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Compartmental syndrome of forearm or Volkmann’s  ischemia

Defination
Mubarak defined Compartmental syndrome as an elevation of interstitial pressure in a closed osteofascial compartment that results in microvascular compromise and may cause irreversible damage to the contents of the space.

Sites

  • Anterior and deep posterior compartments of the legs
  • Volar compartment of the forearm
  • Buttocks, shoulder,hands,foot,arm and lumbar paraspinous muscles are relatively rare sites
Compartmental syndrome of forearm

Compartmental syndrome of forearm  is one of the most dread complications in orthopaedics and ranges from  mild ischemia to severe gangrene. Early  recognitions and prompt remedial measure’s is the key to successful countering of this problem. Needles to say this is an orthopaedic emergency.


Definition
It is an ischemia necrosis of structure’s contained within the volar compartment of the forearm.

Incidence  and Etiology
It is common in children less than 10 years of age. Supracondylar fractures is the most common cause in children. Crush injuries of the forearm  are the most common cause in adults. Occasionally fracture of both bones of forearm may be the cause. More recently intra-arterial injection in drug  addicts who lie on their forearm for prolonged periods in narcotized conditions are mooted to be a cause. Improper application’s of splints in another important cause.

Usually the flexor muscles of the forearm, especially the flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) and rarely flexor digitorum superficialis (FDS) are involved. (VIC) Volkmann’s ischemic contracture is due to the infarction produced by an arterial spasm of the main artery to an extremity with reflex spasm of the collateral circulation. This produces ischemic of the muscles bellies, which results in necrosis and is later replaced by fibrous tissues causing contratures.

Clinical features
In the acute stages, patient gives history of trauma and after an interval of few hours, severe, poorly localized pain develops in the forearm. The volar aspects of the forearm is swollen,red,warm, tender and tense. Finger’s are held in flexion and attemp to extend the finger increase the pain (stretch pain). Peripheral pulses, which are present initially disappear later. Median nerve is commonly affected more than the ulnar nerve. Box 14.1

Box 14.1: Impending volkmann’s ischemic is detected by 6ps

  • Pain
  • Pallor
  • Paraesthesia
  • Paralysis
  • Pulselessness
  • Positive passive stretch test
Note: In VIC, patient complains of pain out of proportion to the injury.
Management
Acute stage
It is a surgical emergency.  All encircling tight bandages are removed if present. If there is no improvement, record the pressure within the compartment. If it is more than 30mmhg, an emergency surgical decompression is done by fasciotomy. If the pressure is less than 30 mmhg continuous monitoring is done.
compartmental syndrome -by www.physioscare.com
Compartmental syndrome with fasciatomy
 
Established VIC
 
Late cases
If mild, flexion contratures of flexor digitorum profundus and flexors pollicis longus develop, but in severe cases all the finger flexors,thumb and wrist flexors are affected. The forearm is thin and fibrotic. Extensive scar tissue nay be present. Peripheral nerves may be affected, amongst them median nerve is the most commonly involved.  A classiscal claw hand deformity results. This test consists of extending the wrist, which exaggerates the deformities and on flexion the deformities appear less prominent.  Joint contractures and gangrene may also be seen. Here the contracture are well established and the treatment plan depends upon the severity of VIC .
 
Mild type 
  1. Dynamic splinting to maintain finger extension.
  2. Physiotherapy such as active exercises, thermotherapy,etc.
  3. Total excision if single muscle is involved.
Condition seen in established volkmann’s ischemic contracture
  • Claw and deformity
  • Volkmann’s sign
  • Extensive scaring of the forearm
  • Joint and soft tissue contractures
  • Neurological deficits
  • Rarely gangrene
Moderate type
  1. Max page’s muscle sliding operation: This consist of releasing the common flexor origin from the medial epicondyle and passively stretching the fingers. This slides the origin of the muscle down and release the contractures.
  2. Excision of cicatrix
  3. Neurolysis consists of freeing the peripheral nerves from the surrounding fibrous tissues.
  4. Tendon transfers are done, if criteria are met.
Server type
  1. Excision of the scar
  2. Seddon’s carpectomy:  It consists of excising the proximal row of carpal bones therby shortening the forearm to overcome the effect of contracted muscles.
  3. Arthrodesis of the wrist in functional position.
  4. Amputation is done in very severe cases of VIC with gangrene.
 
Serial splinting in VIC
Robert jones described three stages in serial splinting.
Aim: To attain the functional positions of the wirst, which is maximum extension.
Splint
It has three joints at the wrist,MCP and IP joints that can easily adjusted to the desired angles.
Stages
Stages I
  • All the fingers are separately splinted.
  • Maximum extension is obtained and held at the IP joints. Wrist and MCP joints are held in full flexion.
Stages II
  • IP joints are continued to be held in extension.
  • Slowly the MCP joints are extended by a splint.
  • Wrist is held in flexion.

Stages III

  • IP joints are MCP joints are held in extension
  • The wrist is gradually extended with help of a dynamic splint
Adjunctive measures
To improve the extensibility of contracted structures:
  • Limb elevation
  • Active exercises to the unaffected joints
  • Thermotherapy
  • Massage and ultrasonic,etc
  • Vigrous exercise once the function is recovered
Post-surgery physiotherapy measures in VIC
During immobilization 
  • Hand elevation
  • Thermotherapy
  • Active exercises to the unaffected joints
  • Connective splints to prevent recurrence of the contractures.
During mobilization 
  • Active exercise to the shoulder, elbow and forearm muscles
  • Motor and sensory re-education
  • Care of the anesthetic skin
  • Modified splint to obtain better function.

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