TITLE VOLKMANN’S ISCHAEMIC CONTRACTURE: A CASE REPORT OF NEGLECT BY DR. OMONDI AFULO DR. PHILEMON ODUOR HAND AND ORTHOPEDIC SURGEONS KENYATTA NATIONAL HOSPITAL

Definition Volkmann`s Ischemic contracture is a permanent shortening of the forearm muscles resulting from injury that gives rise to a claw-like deformity of the hand, wrist and fingers. The contractures are classified as mild, moderate and severe depending on the extent of soft tissue damage that has occurred. Treatment outcome depends on the severity of the contracture

CASE REPORT A 40 year old male presented at a local health facility with a history of direct trauma at work. He sustained left forearm closed injury with few skin bruises. Examination findings revealed deformity and crepitus . X-rays done confirmed fracture radius and ulna. Management involved a complete above elbow plaster of paris then allowed home on analgesics. The next day, he started experiencing severe pain inside the plaster and finger swelling. On seeking for help, he was reassured and went back home.

CASE REPORT 1 CONTD At 72 hours, the pain and swelling worsened. The patient sought for a second opinion. He was noted to have severe compartment syndrome. The POP was split and the forearm was found to be oedematous and blistering. He was taken to theatre and fasciotomy was done. He had extensive muscle necrosis in all the compartments of the forearm which were excised. The final outcome was a case of severe volkmann’s ischaemic contracture. He requires extensive reconstructive surgery.

CASE REPORT 2 A 10 year old boy fell from a mango tree and injured his elbow. Taken to a nearby hospital and diagnosed with type 3 supracondylar fracture of the elbow. Managed with above elbow POP and allowed home on treatment. Pain and swelling worsened within 24 hours. Taken back to the hospital and put on more analgesics and reassured. At 5 days, fingers noted to turn dark and blistering. Patient taken to another hospital and diagnosed with compartment syndrome

CASE 2 CONTD POP removed and whole arm found gangrenous below the elbow. Patient ended up with below elbow guillotine amputation. Stump later refashioned and ended up with above elbow amputation. Patient awaits prosthesis.

Historical Background In 1881, Richard Von Volkmann described irreversible contracture of the hand and forearm muscles. In 1906, Hildebrand first used the term Volkmann`s ischaemic contracture. In 1909, Thomas reviewed 112 published cases of volkmann contracture and found closed fractures to be the most common cause. In 1914, Murphy was the first to suggest fasciotomy might prevent volkmann contracture.

AETIOLOGY AND CLINICAL PRESENTATION Any process that leads to raised intra compartment pressure can lead to compartment syndrome: Bleeding into closed compartments e.g haemophiliacs Increased capillary permeability e.g Burns Bites e.g. Snake , Insect etc History of trauma Features of impending ischaemia : cynosis Five Ps : Pain,Pallor,Pulselessness, Paraesthesia, Paralysis Tissue firmness and induration of the forearm

Clinical presentation MILD MODERATE Involves the superficial volar group of muscles. There is partial ischemia of the muscles resulting in flexion contractures of 2-3 fingers. Sensory changes are minimal Intrinsic muscles are not affected Affects deep flexor muscles and intrinsic muscles. Median and Ulna nerves function compromised. Severe flexion deformity and contracture of the fingers and thumb.

CLINICAL PRESENTATION AND DIAGNOSIS SEVERE DIAGNOSIS Affects both flexor and extensor forearm muscles Impaired sensory and motor feedback Severe deformity and wasting of the hand and forearm. Severely dry and wrinkled skin with ulceration. Injection of a minute volume of saline in a closed compartment using miniature transducer tip catheter. Pressure above 10-30 mm Hg above patient diastolic pressure is an indication for fasciotomy.

Management Removal of tight occlusive dressings. Split plaster cast, elevation of the limb. Use of generous analgesics. Emergency fasciotomy to prevent progression to volkmann`s contracture. Established contracture treatment depends on the degree of damage to soft tissues.

Management (contd) Dynamic splinting Functional training and active use of the affected muscles. At 3 months following injury, muscle release. Tendon lengthening . Muscle slide procedures . Excision of fibrotic muscles Neurolysis of median and ulna nerves Tendon Transfer

Complications and outcome Related to fasciotomy include; Neurovascular injuries, dry scaly skin, tethered tendons, swollen limbs, muscle herniation. Cubitus valgus ( gunstock deformity). Nerve injury occurs with prevalence of the radial nerve followed by median and ulna nerves.Neuropraxia resolves within 7-12 weeks (motor) and upto 6 months(sensory) THE END