Understanding Volkmann Contracture and Pseudo-Volkmann Contracture: Insights into Symptoms, Causes, Diagnosis, and Treatment

Overview of Volkmann Contracture: Symptoms and Causes

Volkmann contracture, named after the German surgeon Richard von Volkmann, is a serious condition that arises from ischemia (lack of blood flow) to the forearm muscles, primarily due to compartment syndrome. This contracture leads to irreversible muscle necrosis and spasticity, resulting in the characteristic flexion deformity of the wrist and fingers. Patients suffering from Volkmann contracture typically present with a “claw-like” hand position where the fingers are flexed towards the palm, and wrist flexion is maintained.

Symptoms of Volkmann Contracture

The symptoms of Volkmann contracture vary depending on the severity and duration of ischemia but generally include:

Flexion Deformity: The predominant feature is a flexion deformity of the wrist and fingers.
Loss of Function: There is significant loss of motor function in the affected limb.
Sensory Deficits: Patients may experience numbness, tingling, or loss of sensation due to nerve involvement.
Pain: Although established contractures are typically painless, acute ischemic events present with severe pain.

Causes of Volkmann Contracture

The primary cause of Volkmann contracture is prolonged ischemia, often due to compartment syndrome, which can occur in various scenarios:

Trauma: Fractures of the forearm bones can lead to swelling and increased pressure in the muscle compartments.
Tight Bandaging: Overly tight casts or bandages can inhibit blood flow.
Vascular Compromise: Conditions that affect blood vessels, such as thrombosis or embolism, can also lead to ischemic injuries.

In children, Volkmann contracture may develop during or after a traumatic event, such as a fracture, if not treated promptly and appropriately (Stevanovic & Sharpe, 2024).

Differentiating Pseudo-Volkmann Contracture: Understanding Tendon Entrapment

Pseudo-Volkmann contracture is a less common condition that mimics Volkmann contracture but has distinct underlying mechanisms. Unlike Volkmann contracture, which results from ischemic damage to muscle tissues, pseudo-Volkmann contracture is characterized by mechanical entrapment of the flexor tendons due to scar tissue or bony abnormalities.

Symptoms of Pseudo-Volkmann Contracture

The clinical presentation of pseudo-Volkmann contracture includes:

Inability to Extend Fingers: Patients are unable to extend the fingers when the wrist is in a neutral or extended position, but extension is possible when the wrist is flexed.
Flexion Deformity: Similar to Volkmann contracture, a flexion deformity may be observed, especially affecting the ring and little fingers.
Absence of Ischemic Symptoms: Unlike Volkmann contracture, pseudo-Volkmann does not present with pain or ischemic signs during examination.

Causes of Pseudo-Volkmann Contracture

Pseudo-Volkmann contracture typically arises from:

Tendon Adhesions: Adhesions form between the flexor tendons and surrounding tissues, often following trauma or surgical intervention.
Malunion of Fractures: Bony malalignment can lead to physical entrapment of tendons.
Chronic Inflammation: Conditions that lead to chronic inflammation in the forearm can result in tendon adhesion and subsequent contractures (Muacevic et al., 2024).

Diagnostic Approaches for Volkmann and Pseudo-Volkmann Contractures

Accurate diagnosis of both conditions is crucial for determining the appropriate treatment.

Diagnostic Techniques

Clinical Examination: A thorough physical examination is performed to assess the range of motion, strength, and presence of other neurological deficits.
Imaging Studies:
- MRI: Magnetic resonance imaging can provide detailed insights into the muscular and soft tissue integrity, helping to differentiate between muscle necrosis and tendon entrapment.
- Ultrasound: This non-invasive technique can also help visualize tendon movement and detect adhesion or entrapment.
Electromyography (EMG): This test can assess nerve function and help identify any neuropathic involvement in the affected areas.

Classification of Contractures

The Tsuge classification is used to categorize established Volkmann contractures into mild, moderate, and severe types based on the extent of muscle involvement. This classification is essential for guiding treatment strategies (Stevanovic & Sharpe, 2024).

Effective Treatment Strategies for Volkmann Contracture and Tendon Entrapment

The treatment of both Volkmann and pseudo-Volkmann contractures requires a tailored approach depending on the severity of the condition and the patient’s functional needs.

Treatment of Volkmann Contracture

Surgical Intervention: In established cases, surgical intervention is often necessary.
- Muscle Excision: Necrotic muscle tissue may need to be excised to improve functional outcomes.
- Tendon Transfers: Tendon transfer techniques are used to restore functional movement to the hand.
- Free Functional Muscle Transfer: In severe cases, functional muscle transfer procedures can provide improved function (Stevanovic & Sharpe, 2024).
Rehabilitation: Post-operative rehabilitation is vital to maximize recovery and restore range of motion. Physical therapy should focus on stretching and strengthening exercises, often beginning as soon as the surgical site has healed sufficiently.

Treatment of Pseudo-Volkmann Contracture

Surgical Release: Surgical intervention may involve releasing the entrapped tendons to restore their mobility. This procedure can often lead to quick recovery of function in the fingers.
Physical Therapy: Following surgical intervention, a structured physical therapy program is essential to facilitate recovery and prevent adhesion formation.

Rehabilitation and Recovery: Ensuring Optimal Outcomes After Treatment

Rehabilitation following treatment for both types of contractures is critical to achieving maximum functional recovery.

Rehabilitation Techniques

Therapeutic Exercises: Continuous assessment and personalized therapeutic exercise plans are essential for maintaining mobility and preventing stiffness.
Splinting: Use of splints may be necessary post-surgery to protect the surgical site while allowing passive movement.
Patient Education: Educating patients on the importance of adhering to therapy and exercise regimens can significantly impact recovery outcomes.

Expected Outcomes

With appropriate surgical intervention and rehabilitation, many patients achieve significant improvements in hand function. Long-term follow-up and ongoing therapy play crucial roles in preventing recurrence and maximizing hand dexterity.

FAQ

What is Volkmann contracture?

Volkmann contracture is a condition characterized by irreversible muscle necrosis and resulting contractures in the forearm, often due to prolonged ischemia from compartment syndrome.

How does pseudo-Volkmann contracture differ from Volkmann contracture?

Pseudo-Volkmann contracture involves mechanical entrapment of tendons without ischemia, while Volkmann contracture results from ischemia leading to muscle damage.

What are the treatment options for Volkmann contracture?

Treatment options include surgical excision of necrotic tissue, tendon transfers, and rehabilitation programs tailored to restore hand function.

Can pseudo-Volkmann contracture be treated without surgery?

In some cases, pseudo-Volkmann contracture can be treated with conservative methods, including physical therapy, but surgical release may be necessary for severe cases.

What is the prognosis for patients with these contractures?

The prognosis varies; however, with timely diagnosis and appropriate treatment, many patients can regain significant function in their hands.

References

Stevanovic, M., & Sharpe, F. E. (2024). Refinements in the Treatment of Volkmann Ischemic Contracture of the Forearm: A Thematic Review. Plast Reconstr Surg Glob Open. https://pubmed.ncbi.nlm.nih.gov/10887438/
Muacevic, A., Adler, J. R., Mestarihi, S., Saab, A., Almigdad, A., Hurani, K., Haddad, S., & Bani Melhem, K. (2024). Pseudo-Volkmann Contracture: A Case Report. Cureus. https://doi.org/10.7759/cureus.57607
Treatment of a neglected flexor digitorum profundus entrapment after closed reduction of both bone forearm fracture: A case report. (2021). JDRS. https://doi.org/10.52312/jdrs.2021.389