Write a short note on Volkmann's Ischaemic Contracture.

WHY the Hand Claws — and WHY It Is Entirely Preventable

One of the most tragic and entirely avoidable conditions in orthopaedics is explained by understanding what happens to muscle that has been allowed to die inside a closed compartment. It is the end result of an untreated compartment syndrome — classically of the forearm, following a supracondylar fracture OF the humerus in a child (from brachial artery injury or spasm, or a tight plaster), and also of the leg. The ischaemic muscle — particularly the deep flexor compartment (flexor digitorum profundus and flexor pollicis longus), which lies furthest from the surface and is most vulnerable — undergoes necrosis and is replaced by inelastic fibrous tissue, which then contracts and shortens. Because the muscles that contract are the flexors of the fingers, the hand is pulled into a fixed, clawed, flexed position. And a beautiful and diagnostic physical sign follows directly from the anatomy: the deformity is worse when the wrist is extended (which stretches the shortened flexors) and improves when the wrist is flexed (which relaxes them) — the volkmann'S sign. The concurrent nerve ischaemia adds sensory loss and intrinsic muscle paralysis. The condition is preventable, and is a failure of care.

WHY the Supracondylar Fracture Is the Classic Culprit

Understanding why a supracondylar fracture of the humerus in a child is the classic cause makes the whole condition memorable, and explains why these children are watched so anxiously. The fracture is extension-type in over 95% of cases: the distal fragment is displaced posteriorly, and its sharp proximal spike is driven anteriorly — directly into the antecubital fossa, where the brachial artery and the median nerve lie immediately in front of it. The artery may be contused, kinked, trapped in the fracture, or thrown into spasm — and even if it is not divided, the resulting ischaemia and reperfusion cause massive swelling within the tight forearm compartments. Add to this the traditional treatment — a flexed elbow in a tight plaster, which further compresses the antecubital fossa — and the conditions for disaster are complete. Hence the rules that govern the management of every supracondylar fracture: document the radial pulse and the function of the median (including the anterior interosseous — ask the child to make an 'OK' sign), radial and ulnar nerves before and after any manipulation; do not flex the elbow beyond 90° in plaster; admit and observe closely; and treat escalating pain as compartment syndrome until proved otherwise.

The end-stage of missed compartment syndrome — wholly preventable.

• Volkmann'S ischaemic contracture is the end result of an untreated compartment syndrome — classically of the forearm after a supracondylar fracture OF the humerus in a child (brachial artery injury or spasm, or a tight plaster); also of the leg.
• Ischaemic muscle (especially the deep flexor compartment — FDP and FPL) undergoes necrosis and is replaced by fibrous tissue, which contracts → a fixed, clawed, flexed hand, with sensory loss and intrinsic paralysis from concurrent nerve ischaemia.
• Volkmann'S sign: the finger deformity worsens on extending the wrist (stretching the shortened flexors) and improves on flexing it — diagnostic.
• IT IS entirely preventable: recognise compartment syndrome early (pain out of proportion; pain ON passive stretch — do not wait for the pulse to disappear); split any tight cast down TO skin; and perform urgent complete fasciotomy.
• Once established, treatment is difficult and results are poor: splinting and physiotherapy for mild cases; and for severe cases — muscle slide (Max Page) operation, excision of infarcted muscle, tendon lengthening or transfer, and neurolysis. Prevention is everything.