Functioning Free Muscle Transplantation to Restore Finger Movement for Sequalae of Volkmann Ischemic Contracture.

Volkmann ischemic contracture (VIC) is a devastating condition that results from neglected compartment syndrome, which leads to prolonged ischemia, irreversible tissue necrosis, and various degrees of muscle and nerve damage, causing serious motor and sensory functional implications for the limb and a spectrum of diseases associated with worsening deformities. A thorough understanding of the anatomy and VIC pathophysiology is needed to plan an appropriate strategy. Functioning free muscle transplantation (FFMT) can restore finger movement in a paralyzed limb but requires a three-staged approach to maximize the benefits of FFMT, leading to meaningful finger extrinsic function.

Neonatal Limb Compartment Syndrome: A Comprehensive Review.

PURPOSE: Neonatal limb compartment syndrome (NLCS) is a rare and potentially limb-threatening condition defined as an increased pressure within a confined limb compartment. Clinicians may fail to distinguish NLCS from other mimicking conditions. Misdiagnosis is possible due to a low index of suspicion for this condition, which may delay appropriate and urgent treatment. A comprehensive review of the available literature was performed to explore common themes in NLCS and identify gaps in the evidence to guide future studies. METHODS: A literature search was conducted in PubMed, Scopus, and Google Scholar electronic databases to identify original articles and reviews in English or French. Studies were selected by two independent reviewers who extracted descriptive data including the delivery history and complications, the timing of diagnosis, the location of the lesion, and the management strategy. RESULTS: A total of 43 reports describing 86 cases of neonatal compartment syndrome were published between 1980 and 2021. The male-to-female ratio was 6:7. Compartment syndrome was mainly located in the upper extremity (95.3%). Clinical features including swelling (41%), sentinel skin lesion (94.2%), extremity cyanosis (89.5%), and necrotic fingers (7%) were observed. The treatment strategy was either surgical decompression (32.6%) or nonsurgical management (68.6%). Sequelae occurred at a rate of 16.6%, 81.3%, and 75.9% after early fasciotomy (< 24 hours), late fasciotomy, and nonsurgical management, respectively. CONCLUSIONS: Sentinel skin lesions and flaccid paralysis are the most observed clinical features and represent key clues for diagnosis. Neither radiography, Doppler ultrasound, nor magnetic resonance imaging has demonstrated any advantage in guiding the appropriate management of NLCS and may delay appropriate treatment. Despite nonsurgical management and late fasciotomy (> 24 hours) being the most described treatments, the lowest rate of sequelae was observed when decompression was performed within the first 24 hours. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Longstanding Volkmann ischemic contracture of the forearm following traditional bonesetter practice successfully treated with combined flexor origin slide and tendon transfer: A case report.

INTRODUCTION AND IMPORTANCE: The Volkman ischemic contracture (VIC) of the forearm is a sequel of the compartment syndrome of the forearm. There were no studies reported the outcome of surgical treatment for VIC, particularly the muscle origin slide procedure, in treating the VIC that had been developed more than 20 years. CASE PRESENTATION: We reported a 34 years old right-hand dominant painter with fingers flexion contracture, decreased hand mobility and sensation on her right hand. She had history of closed right forearm fracture when she was 10 years old that was treated by a traditional bonesetter. A week afterward, she experienced clinical presentation of compartment syndrome. Not long thereafter, the pain subsided but she started to have stiffness and discomfort in her forearm and hand condition. Twenty-four years later, she wants to get treatment for her hand. We diagnosed her with VIC, moderate degree based on Tsuge Classification. We then performed flexor origin slide procedure and tendon transfer. In 1.5 year of follow-up, a satisfactory functional outcome was noted. CLINICAL DISCUSSION: Flexor origin slide was the preferred treatment if the flexors still retain adequate strength. During the surgery, severe degeneration of FPL and FDP was found. Therefore, we performed tendon transfer to increase the grip strength. CONCLUSION: VIC is not uncommon following fracture treated in the traditional bonesetter. For moderate VIC, the flexor origin slide procedure and tendon transfer could still give benefit, even in the case of treatment delay of more than 20 years from onset.

Anomalous retrogressive palmaris longus.

An interesting case of unusual unilateral variant of palmaris longus (PL) tendon of forearm was noticed by us. We found two bellies of PL as well as their different insertions. These observations will help in understanding morphological variations of this muscle and its clinical implications. PL is a fusiform muscle in the superficial flexor group of muscles of forearm. It originates from medial epicondyle of humerus by common flexor tendon. We found PL having one origin, i.e., from medial epicondyle from common tendinous origin of flexor muscles and then it divided to form two bellies having two long tendons distally. Understanding of presence or absence or anomalies of PL is not only important for medical professionals but also for evolutionary biologists. Awareness of anatomy and variations of flexor tendons is important for health care practitioners for the correct diagnosis and management of pain, disease, and trauma of forearm and hand.

Résumé Nous avons remarqué un cas intéressant de variante unilatérale inhabituelle du tendon du long palmaire (PL) de l'avant-bras. Nous avons retrouvé deux ventres de PL ainsi que leurs différentes insertions. Ces observations aideront à comprendre les variations morphologiques de ce muscle et ses implications cliniques. Le PL est un muscle fusiforme du groupe des muscles fléchisseurs superficiels de l'avant-bras. Il provient de l'épicondyle médial de l'humérus par le tendon fléchisseur commun. Nous avons trouvé que le PL avait une origine, c'est-à-dire de l'épicondyle médial provenant de l'origine tendineuse commune des muscles fléchisseurs, puis il s'est divisé pour former deux ventres ayant deux longs tendons distalement. Comprendre la présence, l'absence ou les anomalies de PL est non seulement important pour les professionnels de la santé mais également pour les biologistes évolutionnistes. La connaissance de l'anatomie et des variations des tendons fléchisseurs est importante pour les praticiens de la santé afin de diagnostiquer et de gérer correctement la douleur, la maladie et les traumatismes de l'avant-bras et de la main. Mots-clés: Palmaris longus, greffe tendineuse, variation, contracture ischémique de Volkmann.

Diagnostics and Treatment of Volkmann Ischemic Contracture in a Seven-Year-Old Child.

A 7-year-old boy presented 6 weeks after open reduction and crossed Kirschner wire (K-wire) fixation of a supracondylar humerus fracture. Previous treatments had restored skeletal anatomy without documented complications. However, the patient would not move the entire arm, including his forearm and hand. Any passive movement led to anxious adverse reactions, and there was partial numbness of all fingers. After intensive physio- and occupational therapy supported by nerve stimulation and psychological counseling, anxiety-related functional deficits of the shoulder and elbow resolved to reveal the severe Volkmann contracture of the right hand developed fully. Electroneurography, X-ray, magnetic resonance imaging of the forearm, and ultrasonography showed nonfunctional ulnar and a partially disturbed radial motor nerve distal to the elbow along with damaged flexor muscles of the forearm after compartment syndrome. In addition, damage to the median nerve at the elbow level was diagnosed. After intense conservative therapy, we partially resected fibrotic fascia of the superficial flexor compartment, freed ulnar and median nerves, and performed staircase-like releases of tendons and tenotomies. We achieved a full range of motion of all fingers and markedly improved the range of motion of the wrist. The Disabilities of the Arm, Shoulder and Hand scores for function improved from 80 to 16 at the 2-year follow-up postoperatively, but some impairments of fine motor function persisted. Subtle symptoms of a developing compartment syndrome need to be recognized. Overlooked and untreated, a consecutive Volkmann contracture can turn the extremity nonfunctional. Intensive physical, psychological, and surgical therapy in a specialized center can restore function but requires endurance and perseverance throughout the lengthy recovery.

Management of Volkmann's Ischemic Contracture: Case Series of 32 patients.

INTRODUCTION: Volkmann's contracture condition is of high prevalence in our population and is linked to therapeutic faults. The treatment and its results are determined according to the severity of the lesions. METHODS: This retrospective study was performed in three centers and was conducted over 30 years (1987-2018); it included 32 patients. The disabilities of the arm, shoulder and hand (DASH) score and the Weber test were used to evaluate the functional outcome looking at mid and long-term results. RESULTS: Thirty-two patients were treated for Volkmann's Ischemic Contracture (VIC). The age ranged from 4 to 58 years, with 19 patients aged under 15. Wrist fracture was the predominant cause in 16 cases. Fourteen patients obtained a completely functional hand, seven good functional results, four fair functional results, and seven poor results. DISCUSSION: In comparison with other studies, we noticed significant differences: apart from the dominant male sex and right side, this is one large case series conducted over 30 years (1987-2018) looking at mid-and long-term results. All the patients presented with severe or moderate lesions on the first visit. In our study, the wrist fracture is predominant compared to elbow fractures and soft trauma. X-rays are especially helpful and are a first-line investigation for identifying displaced fractures and other associated lesions. Our study population is not large, and the treatment methods are varied, so it is impossible to provide statistically relevant correlations between the treatment method and outcome. But this work is based on the experience of more than 30 years, which makes it possible to help adequate decision making according to the state of the lesions. This study is a level IV case series.

Technical considerations and outcome of free functioning gracilis muscle transfer for finger flexion in patients with Volkmann's Ischemic Contracture.

INTRODUCTION: Severe Volkmann's Ischemic Contracture (VIC) is a reconstructive challenge for the surgeon because of the loss of entire flexor muscle mass and lack of powerful wrist extensors for restoration of finger flexion. In such cases, free functioning muscle transfer (FFMT) using gracilis is our choice. We herein summarize the technical considerations to achieve a successful outcome and report functional outcome achieved in our series. PATIENTS AND METHOD: Between 2007-2018, 22 patients of VIC underwent gracilis FFMT for restoration of finger flexion. FFMT was done as a second stage following an initial stage of neurolysis/excision of fibrotic flexor muscles/contracture release/flap cover in these patients. Cases were retrospectively reviewed and their functional outcome at a minimum of one-year follow up was analyzed. Follow-up duration ranged from 2-13 years (average-4 years). At the final follow up, the motor and sensory recovery was evaluated using the Medical Research Council Grading and their function using Disabilities of the Arm, Shoulder, and Hand (DASH) score. RESULTS: The average age at surgery ranged from 3-45 years (average-18.4 years). All the transferred muscles survived. Secondary procedures to further improve the hand function were done in nine patients. The motor recovery for finger flexion was graded as M2 in two, M3 in nine and M4 in 11 cases. These 20/22 patients who recovered M3/M4 finger flexion expressed high satisfaction with the operation while other two also felt that they were better after the surgery. DASH score was available for 13 patients and it averaged 13.21 (Range-1.8-34.5). Grip strength was available for 10/22 patients and it averaged 10.5 kg (range-0-21kg) amounting to 24% of the normal side. The sensory recovery was graded as S4 in two, S3 in 17 and S2 in three cases. CONCLUSION: Gracilis FFMT is a reliable option for restoration of finger flexion in patients with severe VIC. Outcome is better when done after an early preliminary stage of excision of fibrosed muscles and neurolysis which allows recovery of intrinsic function and sensation. FFMT is best carried out 3-6 months after the first stage with supple skin and good passive range of movement in the fingers.

Clinical and Demographic Profile of Volkmann's Ischemic Contractures Presenting at National Institute of Rehabilitation Medicine, Islamabad, Pakistan.

BACKGROUND: Established Volkmann's ischemic contractures (VICs) represent the eventuality of neglected acute compartment syndrome (ACS) of the forearm. This study assessed the clinical and demographic presentation of VICs. METHODS: This study was conducted at Department of Plastic Surgery, National Institute of Rehabilitation Medicine, Islamabad, Pakistan over a period of three years and included all patients of either gender who presented with VICs and analyzed various corrective procedures instituted as surgical remedies. RESULTS: Among 37 included patients, 83.78% were male and 16.21% were female (mean age: 16.51±9.1 years). The underlying causes of the initial traumatic insults were tight bandages employed by traditional bone setters for treating forearm fractures (83.78%), high voltage electric burns involving hands/forearms (13.51%) and supracondylar fracture with vascular compromise (2.70%). Majority of patients belonged to Holden type 2 (97.29%) and Tsuge type 2 VICs (48.68%). The most common sufferers of VICs were young, illiterate males coming from rural regions. Treatment for forearm fractures by traditional bonesetters constituted the most common underlying cause. Most of the patients were managed with combination of procedures including tendon transfers, excision of the fibrosed muscles, tenolysis and neurolysis of median and ulnar nerves. Tendon transfers were the commonest corrective procedures instituted. CONCLUSION: This study highlighted the gravity of this largely preventable but neglected catastrophe and there is a need to institute robust preventive measures to address the issue. Emphasis should be on creation of public awareness and robust education of health care providers to ensure correct primary management of upper limb trauma.

Nerve Lesions in Volkmann Ischemic Contracture.

Volkmann ischemic contracture (VIC) is a late sequela of acute compartment syndrome and consists of extensive muscle necrosis, fibrosis, contracture, and variable degrees of neural dysfunction. The outcome depends on successful restoration of muscle and neural function. The timing of surgery is often determined by the development of contractures and is delayed in the interest of observing some spontaneous recovery and infarct maturation. This period of observation may be detrimental to nerve function with gradual formation of scar tissue and worsening constrictive neuropathy. Early intervention appears to be more effective in preventing further nerve damage and restoring protective sensation. In this article, common features of compartment syndrome, frequently seen nerve lesions, and the effect of timing of surgical intervention on the outcome of VIC were reviewed in the light of the current basic and clinical science literature.

The case of missing skin: Congenital Volkmann ischemic contracture.

Congenital Volkmann ischemic contracture (CVIC) is an exceedingly rare neonatal compartment syndrome caused by intrauterine ischemia and external compression. It presents at birth with necrotic cutaneous lesions and neurologic impairment, typically in a distal upper extremity. Diagnosis and treatment are often delayed in neonates, leading to long-term neurologic sequelae. We present a rare case of CVIC in order to raise awareness of its presentation and management in hopes of improving outcomes.

Reconstruction of a Chronic Volkmann Contracture following Forearm Revascularization with Burkhalter's Procedure and Fractional Flexor Tendon Lengthening after a Failed Stiles-Bunnell Transfer.

Volkmann ischemic contracture is a cause of limb dysfunction that can lead to varying amounts of limb deformity, stiffness, and paralysis. Several procedures have been used to improve limb function in these patients. An 11-year-old male patient sustained a domestic accident with a glass door, resulting in a severe soft tissue trauma to his proximal third of the right forearm with damage to flexor muscles and tendons, complete section of median and ulnar nerves, and radial and ulnar arteries. He was submitted to immediate repair of the radial artery and median and ulnar nerves. Ulnar artery was not repairable due to extensive soft tissue loss. Despite surgical treatment and successful revascularization, postoperatively he developed a postreperfusion syndrome, and in consequence an ischemic contracture. To improve his condition, simultaneous Burkhalter's procedure and fractional flexor tendon lengthening were used after a previous failed Stiles-Bunnell transfer. After 6 months, a good result was obtained, with restoration of a more anatomical hand rest position, improved arc of motion, and significant improvement of hand function with DASH (Disabilities of the Arm, Shoulder and Hand) score improving from 59 to 43 despite a slight reduction in grip strength. Opposition to the ring or little finger tip with the interphalangeal joint (IPJ) of the thumb extended was observed. The combination of fractional flexor tendon lengthening and Burkhalter's procedure is a reliable and simple procedure in cases of Volkmann's ischemic contracture and combined median and ulnar nerve palsy, without significant complications.

Volkmann's ischemic contracture: An unusual complication of arterio-venous fistula.

Native arterio-venous fistulae (AVF) are vascular access of first choice for chronic hemodialysis. However, AVF are also associated with many adverse events like: primary or secondary failure, infection, lymphedema, stenosis, thrombosis, and ischemia of distal extremities. The most common ischemia related complications of AVF are: ischemic neuropathy and steal syndrome with its consequences like pain and peripheral necrosis. Ischemic muscle contracture is a rare complication of AVF. Herein, we are reporting a case of Volkmann's ischemic contracture developing after creation of brachiocephalic AVF.

Volkmann's Ischemic Contracture with Atrophic Non-union of Ulna Managed by Bone Shortening and Transposition of Radial Autograft.

INTRODUCTION: Volkmann's ischemic contracture (VIC) is a complex and variable flexion deformity of wrist and fingers resulting from fibrosis and contracture of flexor muscles of forearm. It is caused by ischemic injury to the deep tissues enclosed in the tight unyielding osteo-facial compartments secondary to neglected acute compartment syndrome. VIC may be associated with malunion or non-union of forearm fractures. To the best of our knowledge, this article is the first case report of VIC associated with atrophic non-union of ulna managed by shortening of forearm bones combined with transposition of intercalary auto graft from the fellow bone. CASE REPORT: A seven year old boy presented with flexion deformity of wrist and hand with inability to use his left hand since three and half months subsequent to an injury to his left forearm due to fall from a tree of six feet height. The patient was diagnosed and treated by a native traditional bone setter for his Radius and Ulna fracture of left forearm with massaging and tight bandaging. On examination there was wasting of left forearm with positive Volkmann's sign, flexion contracture of wrist with loss of grip strength and tenderness over the upper and middle third junction of left ulna with a palpable gap. The radiograph of forearm revealed atrophic non-union of left ulna. In order to tackle both the issues, shortening osteotomy of radius with transposition of tubular radius intercalary graft onto ulna was done. Radius was fixed with a dynamic compression plate and Ulna was fixed with a rush nail effecting overall two and half centimetres shortening of both bones of forearm. This approach has addressed both atrophic non-union of ulna and VIC in a single stage and gave excellent functional outcome till the last follow-up of three years from the date of surgery. CONCLUSION: Bone shortening and transposition of auto-graft from the fellow bone may prove to be an excellent treatment modality for VIC with associated non-union of involved compartmental bones in properly selected and executed cases.

Free myocutaneous flap transfer to treat congenital Volkmann's contracture of the forearm.

The purpose of this study is to report our experience with free functional muscle transfer procedures for the late sequelae of the rare condition of congenital Volkmann's ischaemic contracture of the forearm. Four children, with an average age of 9.5 years (range 1.5-17), were treated and were followed for a mean of 6 years (range 1-14). Two patients had dorsal forearm contractures, and two had both flexor and extensor forearm contractures. We carried out free functional muscle transfers to replace the flexor or extensor muscles. The functional result was assessed according to the classification system of Hovius and Ultee. All patients had wrist contractures and skeletal involvement with limb length discrepancy that influenced the outcome. All five transferred muscles survived and improved the function of the hand in three of the four patients. LEVEL OF EVIDENCE 4.

Neonatal volkmann ischemic contracture: case report and review of literature.

Background Neonatal Volkmann ischemic contracture in newborns is a devastating condition with lifelong consequences. Case Report We report a neonate born with necrotic skin lesions and bullae on right dorsal thenar aspect of hand, who subsequently developed compartment syndrome requiring fasciotomy. Review and Conclusion Necrotic skin lesions with/without swelling, bullae are invariably present at birth in these patients and should be recognized as a sentinel finding of underlying tissue ischemia/compartment syndrome. Early recognition and prompt surgical intervention can be limb saving. A range of radiologic abnormalities and contractures were noted in upto 84% of such patients followed long term. Hence, we recommend close follow-up until occurrence of epiphyseal fusion in these patients.

Ántrax cutáneo complicado con fascitis necrotizante y síndrome compartimental / Cutaneous anthrax complicated by necrotizing fasciitis and compartment syndrome

El ántrax o carbunco cutáneo es una zoonosis producida por el Bacillus anthracis, caracterizado por una úlcera necrótica, indolora, que cura generalmente espontáneamente y sin complicaciones. Presentamos el caso de un paciente varón agroganadero que presentó una úlcera necrótica rodeada de lesiones ampollares serohemáticas en cara ventral del antebrazo derecho y múltiples vesículas satélites purulentas, asociada a un edema extenso y dolor incapacitante del miembro afectado. Al ingreso, los exámenes revelaron leucocitosis (15 000/mL), CPK total (1 730 U/L) y prueba positiva de reacción en cadena de polimerasa (PCR) para Bacillus anthracis. Se diagnosticó síndrome compartimental y se realizó fasciotomía de emergencia. El reporte quirúrgico fue fascitis necrotizante, por finger test. En el seguimiento se evidenció contractura isquémica de Volkmann leve. Se debe plantear como diagnóstico el síndrome compartimental ante el dolor incapacitante, porque nos permitirá una intervención quirúrgica oportuna a fin de evitar perder la extremidad comprometida.

Introduction: Cutaneous anthrax is a zoonosis caused by Bacillus anthracis characterized by painless necrotic ulcer that usually heals spontaneously and without complications. The case of a farmer and cattle breeder male patient who presented a bullous serosanguineous ulcer surrounded by necrotic lesions in the ventral right forearm and multiple purulent satellite vesicles associated with extensive edema and disabling pain in the affected limb is reported. On admission, examinations revealed leukocytosis (15 000/ mL), total CPK (1 730 U/L) and positive test for Bacillus anthracis by polymerase chain reaction (PCR). Compartment syndrome was diagnosed and emergency fasciotomy was performed. Surgical report was necrotizing fasciitis by finger test. Mild Volkmann ischemic contracture was found during follow-up. Diagnosis of compartment syndrome should be considered when disabling pain is present to decide prompt surgical intervention in order to avoid losing the limb involved.

Volkmann Ischemic Contracture Due to Traditional Practice.

An 11-year-old boy presented with three days' history of blunt trauma to the left shoulder due to a fall to the ground. The boy was taken to the traditional practitioner, who applied a very tight bandage over a piece of cartoon on the upper left humerus, which resulted in progressive pain and swelling of the whole left upper limb and impairment of movement and sensation. The tight bandage was removed after 48 h and fasciotomy was performed at Aljamhuri Hospital in Taiz, Yemen. The child was brought to our hospital after the family was informed about the need for left forearm amputation. We performed four sessions of debridement of the dead muscles and soft tissues of the flexor and extensor compartments of the left upper limb. After three months, the left upper limb healed with fixed flexor contracture of the elbow and wrist joint. Manipulation and release of adhesions and subsequent skin grafting was performed and the elbow joint was kept in extension, the wrist in the neutral position, and the interphalangeal joints in flexion. Although the limb was saved, its aesthetic appearance was retained, and some sensation was achieved, the lost motor function of the forearm (including the hand) was irreversible.

The Volkmann Ischemic Contracture of the Forearm is Preventable.

The acute compartment syndrome of the forearm is rare and may therefore be easily missed. Although many clinicians will not see such a patient during their entire career, profound knowledge of the symptoms is required to recognize the syndrome in time. Besides immediate identification of the compartment syndrome early surgical treatment is mandatory to avoid its devastating consequences. Then the functional results can be good, but if the correct diagnosis is missed a Volkmann's ischemic contracture will invariably develop. This paper aims to attend the reader to this diagnostic pitfall. Two patients with a compartment syndrome of the forearm are described to illustrate both ends of this diagnostic challenge. Pathophysiological, anatomical and clinical aspects, classification and therapeutic modalities are reviewed.

Analysis of therapeutic effects of muscle sliding operation treating volkmann ischemic contracture of forearm / 临床外科杂志

Objective To investigate therapeutic effects of muscle sliding operation treating Volkmann ischemic contracture of the forearm. Methods 32 cases Volkmann ischemic contracture were classified two types: the single type and the complex type. Three approaches were employed to treat different types which were single muscle sliding operation, muscle sliding plus skeletal operation, muscle sliding operation plus neurolysis.Results 29 cases were followed up, which excellent and good was 93.7 percent.Conclusions Muscle sliding operation was effective management for Volkmann ischemic contracture, and the skeletal operation or neurolysis could managed for the complex type in the meantime.