Compartmental syndrome of forearm or Volkmann’s ischemia
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.
- 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 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.
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.
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
- Positive passive stretch test
|Compartmental syndrome with fasciatomy|
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 .
- Dynamic splinting to maintain finger extension.
- Physiotherapy such as active exercises, thermotherapy,etc.
- Total excision if single muscle is involved.
- Claw and deformity
- Volkmann’s sign
- Extensive scaring of the forearm
- Joint and soft tissue contractures
- Neurological deficits
- Rarely gangrene
- 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.
- Excision of cicatrix
- Neurolysis consists of freeing the peripheral nerves from the surrounding fibrous tissues.
- Tendon transfers are done, if criteria are met.
- Excision of the scar
- Seddon’s carpectomy: It consists of excising the proximal row of carpal bones therby shortening the forearm to overcome the effect of contracted muscles.
- Arthrodesis of the wrist in functional position.
- Amputation is done in very severe cases of VIC with gangrene.
- 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.
- IP joints are continued to be held in extension.
- Slowly the MCP joints are extended by a splint.
- Wrist is held in flexion.
- IP joints are MCP joints are held in extension
- The wrist is gradually extended with help of a dynamic splint
- Limb elevation
- Active exercises to the unaffected joints
- Massage and ultrasonic,etc
- Vigrous exercise once the function is recovered
- Hand elevation
- Active exercises to the unaffected joints
- Connective splints to prevent recurrence of the contractures.
- 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.