1881 Richard von Volkmann published an article in which he attempted to ascribe irreversible contractures of the flexor muscles of the

hand to ischemic processes in the forearm. He believed that the problem was caused by massive venous stasis and simultaneous arterial insufficiency secondary to overly tight bandages. 1906 Hildebrand first used the term "Volkmann ischemic contracture" to describe the final result of any untreated compartment syndrome, and he was the first to suggest that elevated tissue pressure may be causally related to ischemic contracture. 1914 Murphy was the first to suggest that fasciotomy might prevent Volkmann contracture. He also suggested that tissue pressure and fasciotomy were related to the development of contracture.

A condition which is characterized by ischemic necrosis of the structures contained within the volar compartment of the forearm associated with crippling contractures and varying degrees of neurologic deficit
Patho

Volkmann ischemic contracture is usually seen in children with displacedsupracondylar fractures of the humerus or forearm fractures.[6, 7, 8, 9] It results from severe injury to the deep tissues and muscles of the volar compartment secondary to increased compartmental pressures. [10, 11] Three types of Volkmann contracture have been described: mild, moderate, and severe. The mild type involves wrist flexors. The moderate type involves injury to the flexor digitorum profundus, flexor digitorum superficialis, flexor pollicis longus, flexor carpi radialis, and flexor carpi ulnaris. The severe type involves both the flexors and the extensors. A variant of Volkmann ischemic contracture known as pseudo-Volkmann contracture has also been described in the literature. This is due to tethering of the flexor digitorum profundus secondary to fractures of the ulna. It has been described to occur 2 days to 16 years after the closed reduction of fractures of the shafts of the radius and ulna. None of the patients had nerve palsies or undue pain after reduction of the fractures.[12] A routine check of the passive range of motion of all fingers immediately after closed reductions of fractures of the radius and ulna is recommended. If muscle tethering is detected, repeat manipulation of the fracture is required to release the muscle. If unsuccessful, surgical release through a small incision should be attempted to normalize the length, excursion, and function of the flexor digitorum profundus. Function can be restored by untethering the muscle and its tendons from the ulnar fracture by means of early manipulation or late localizedmyotenolysis. Some argue about which compartment pressure readings are indications for fasciotomy. However, most agree that patients with compartment pressures exceeding 30 mm Hg should be taken to the operating room for emergency fasciotomy. The relevant anatomy of Volkmann contracture includes the superficial and deep flexor muscles.

Superficial flexor muscles

Pronator teres - Median innervation Flexor carpi radialis - Median innervation Flexor carpi ulnaris - Ulnar innervation Flexor digitorum superficialis - Median innervation Palmaris longus - Median innervation

Deep flexor muscles

Flexor pollicis longus - Median (anterior interosseous) innervation Pronator quadratus - Median (anterior interosseous) innervation Flexor digitorum profundus - Median (anterior interosseous) and ulnar innervation

Treatment

Initial treatment for Volkmann contracture consists of removal of occlusive dressings or splitting or removal of casts. Analgesics are the mainstay for symptomatic relief in chronic cases. Surgical Emergency fasciotomy is required to prevent progression to Volkmann ischemic contracture. Decompression is performed via the volar or dorsal approach. Medial nerve decompression throughout its course is essential, especially in high-risk areas, including deep to the lacertus fibrosus; between the humeral and ulnar heads of the pronator teres, the proximal arch, and deep fascial surface of the flexor digitorum superficialis; and in the carpal tunnel.[15, 16, 17, 18, 19, 20, 21] Once contracture has occurred, treatment depends on the type of Volkmann ischemic contracture present. In the mild type, dynamic splinting, physical therapy, tendon lengthening, and slide procedures are used to improve function. In the moderate type, tendon slide, neurolysis (M and U), and extensor transfer procedures are used. The severe type requires more extensive and radical intervention. Extensive debridement of damaged muscle with multiple releases of scar tissue and salvaging procedures often are required. Severe contractures require the release of contracted tendons at the musculotendinous junction and tendon transfers performed at a later date. The preferred transfers involve the brachioradialis, which often is transferred to the flexor pollicis longus to regain thumb motion. For finger flexion, the extensor carpi radialis longus commonly is transferred to the flexor digitorum profundus. If no motor function is present secondary to muscle necrosis and fibrosis, free muscle can be used for transplantation.

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