10Classification of EstablishedVolkmann’s Ischemic Contractureand the Program for Its Treatment

In spite of the advances made in preventive treat-ment of muscular ischemia at the forearm and hand,there still exist cases produced by many differentcauses and not only depending on the classical com-plications of supracondylar or forearm fractures inchildren or constricting plaster casts.

Muscular ischemia passes through different evolu-rive periods: initial (vascular crisis), evolutive (paraly-sis), and final, or established, contractures. We willhere refer to the established period ony. The clas-sification of the established ischemic contracture andthe general program of correction will be based onthe condition of the intrinsic muscles.

Pathology in the forearm and hand varies in accor-dance with the severity of the vascular deficit on

muscles and nerves, and this gives the final clinicalpicture. In the chart below, we have classified thedifferent localizations of the muscular pathologybased on the cases from our experience.

CLASSIFICATION OF ESTABLISHEDVOLKMANN’S ISCHEMIC CONTRACTURE

(CLASSICAL TYPE)

Many descriptions of the deformity of the classicalmuscular ischemia at the ventral part of the forearmhave been published. In his first edition of Surgery ofthe Hand (19’44) Bunnel133 classified a hand simple orsevere based on the characteristics of the deformity at

Localization of Muscular Ischemia of the Upper Limb Based on 83 cases

Volkmann’sischemiccontracturein the forearm - 38.5%

Classical type- 96.5% (types I, II, and III

f in accordance with the condition of theintrinsic muscles).

Ventral 87%

~" Localized - 3.5% (partial retraction of theflexor digitorum profundus muscle).

Ventral and dorsal - 13%

Interosseous muscles (types I, II, and Ill)

Finochietto’s /~. Adductor potlicis and flexor pollicisintrinsic muscular~ brevisretraction of thehand -- 61.5%~ Lateral thenar muscles (3 cases)

Abductor digiti quinti (1 case)

314

Classification of Established VoIkmann’s Ischemic Contracture (Classical Type) 315

Fig. 10-1. Different types of established Volkmann’s ischemic contracture. Type I with normalintrinsic muscles (simple digital "claw"). Type II with intrinsic paralysis at the fingers (intrin-sic clawhand) and/or the thumb (opposition paralysis). Type III with intrinsic contracture ofthe interosseous and/or thumb muscles. In this drawing the radial side of the hand belongs totype III, and the ulnar side to type II (intrinsic clawhand).

the level of the forearm and hand. Pedemonte(1948), TM a plastic surgeon from Uruguay, dividedthe deformity into two types, the classic or favorable,and the useless hand, depending on the possibilitiesof recovery with reconstructive surgery. Merle D’Au-bign6 (1955)166 also divided the deformity into twotypes: (1) without clawhand, and (2) with cIawhand.Seddon (1956)~°~ considered there to be three groupsof the deformity in accordance with the extensionand severity of the ischemia: group I, with diffuseischemia, without infarct, and where spontaneousrecovery occurs; group II, with typical muscular in-farct and with or without nerve lesion; and group III,with diffuse fibrosis and severe paralysis and de-formity.

Since 1959 we have classified the establishedperiod of the classicial Volkmann’s ischemic paraly-

sis or contracture into three types, based on the condi-tion of the intrinsic muscles of the hand.26a We believetl~at the intrinsic condition of the hand is very im-portant because, depending on the type of deformity,the surgeon obtains a very clear idea of the possibledisorders of the nerves and muscles and which surg~cal program to apply. In type I deformities the intrin-

Clinical Types of Volkmann’s IschemicContractures

Type I-normal intrinsics muscles

Type II-paralytic intrinsics musclesType III-retracted intrinsics muscles

Type IV- combined type

316 Classification of Established Volkmann’ s Ischemic Contracture and the Program for Its Treatment

sic muscles are normal; in type II they are paralyzed;and in type III they are retracted because of ischemiaoWe may include a fourth group that represents acombination of the previous types (Figs. 10-1, and10-2). We have employed this classification for nine-teen years with great usefulness. Nerve reconstruc-tion will not be discussed here.

Type I: Contracture of the Forearm Muscles WithNormal Intrinsic Muscles (Simple "Claw"Deformity)

In this group the median and ulnar nerves are ingood condition, and, in the majority of cases, this isthe most simple condition to treat. The wrist and fin-gers are deformed in flexion, giving the picture of asimple "claw," and usually without joint stiffness(Fig. 10-5). In some patients the metacarpophalangealjoints may be in hyperextension in spite of normalintrinsic muscles, simulating an intrinsic paralysisclawhand. This deformity is produced during the at-tempt of finger extension and depends on a tenode-sic effect produced by the long extensor tendon andthe retention produced by the retracted long flexordigital muscles (Fig. 10-2, A and A’).

In some cases of type I deformity, especially inchildren, even after the deformity has been correctedsevere intrinsic dominances may result. This is avery difficult digital dysfunction to treat, and some-times so difficult that one would prefer to deal withan intrinsic paralysis.

Type II: Contracture of the Forearm Muscles WithIntrinsic Paralysis (Typical Intrinsic-MinusClawhand and Opponens Paralysis)

In this type of deformity the intrinsic paralysisdepends on the lesion of the median or ulnar nervesor both. Clawhand usually is severe because of theflexion position of the wrist and contracture of thelong flexor muscles of the fingers (Fig. 10-6). In mostfavorable cases the intrinsic "claw" is simple, but inthe majority of cases the contracture of the forearmmuscles is associated with severe intrinsic paralysis

and complications at the digital joints (complicatedcIawhand). The most frequent complication is stiff-ness of the flexed interpha,langeal joints while themetacarpophalangeal joints are stiff in extension (to-tally rigid cIawhand). Another frequent complicationat the middle joint is the stretching of the extensormechanism produced by the permanent flexion posi-tion of the joints. Inability to extend the interpha-langeai joint due to digital dysfunction is seldomseen, but we have had two cases in our experience(see classification of the intrinsic clawhand deform-ity in Chap. 5).

Paralysis of the intrinsic muscle of the thumb maydepend on paralysis of the lateral and/or medialthenar muscles (Figs. 10-2, B and B’, and 10-6).

In this group of established Voikmann’s contrac-ture with intrinsic paralysis there are frequent severenerve lesions that complicate the surgical restorationof function of the hand because of sensory distur-bances. Definitive median nerve lesion represents asevere impairment for hand function and deservesparticular efforts for restoration.

Type III: Contracture of the Forearm Muscles WithIntrinsic Contracture (Intrinsic-Plus Clawhand andIntrinsic-Plus Thumb)

Type III contracture is rare. The fingers are in thetypical intrinsic muscle contracture because of retrac-tion of the interosseous muscles. The metacarpo-phalangeal joints are in flexion and the proximal in-terphalangeal joints are in extension. The distalinterphalangeal joint shows a marked flexion de-formity due to contracture of the flexor digitorumprofundus tendon (Fig. 10-2, C and D). The interos-seous retraction is usually localized in the radialfingers. The wrist is also in flexion contracture. In-trinsic muscles of the thumb may also be contracted(Fig. 10-7).

Type IV: Combined Type

Often the types of deformity are combined, usuallytypes I and II. Opposition paralysis may be corn-

Fig. 10-2. A and A’. Type I contracture with mild retractionof the flexor muscles of the wrist and digits in a 10-year-oldgirl. The patient had the habit of extending the wrist (a)and metacarpophalangeal (b) to produce interphalangealflexion by the passive effect of the retracted long flexormuscles (c) of the fingers (tenodesic effect).

B and B’. Volkmann’s contracture with severe flexioncontracture of the wrist. Intrinsic paralysis of the radialdigits of the hand (type II) and complete extension of the

ulnar fingers (type I). Looking at the hand we have to sup-.pose that the median nerve is damaged. Flexion of the fin-gers was good.

C and D. Volkmann’s ischemic contracture with intrinsicparalysis at the ulnar side of the hand (type II) and Fino-chietto’s intrinsic retraction at the radial side (type III). Thedistal joints of the index and middle fingers are perma-nently flexed because of the retraction of their flexor digi-torum profundus muscles at the forearm.

Classification of Established Volkmann’s Ischemic Contracture (Classical Type) 317

318 Classification of Established Volkmann" s Ischemic Contracture and the Program for Its Treatment

Fig. 10-3. These photographs show some peculiar situa-tions in ischemic muscle contracture at the forearm.

A and B. Retraction of the flexor profundus muscles of thering and middle fingers due to a severe injury at the level ofthe forearm and arm that produced~a partial impairment ofthe circulation of the upper limb. It was impossible to ex-tend passively the central fingers. This was corrected bytendinous lengthening (localized ventral Volkmann’s is-chemic contracture in the forearm).

C. Severe Volkmann’s contracture of all the long flexormuscles of the digits and of the muscles of the dorsal com-partment of the forearm. This combination produces per-manent flexion of the digits with extension of the wrist.This represents a very difficult problem to resolve becausethere are very few muscles available to use as transfers(ventral and dorsal Volkmann’s ischemic contracture in theforearm).

involves the radial fingers (3 cases; Fig. 10-2, C and D,and Fig. 10-7).

bined with normal interossei and lumbricals or in-trinsic-minus clawhand with a normal thumb. Also,the paralytic clawhand may involve only some fin-gers while the others show normal intrinsic action asin Figure 10-2, B and B’. In general it is preferable todeal with the motor problem of an ulnar nerve"claw" than with a severe median nerve lesionwhich generally means a difficult problem for resto-ration of adequate sensibility. When types II and IIIare combined, the interosseous contracture usually

SIGNS OF THE DIFFERENT TYPES OFCONTRACTURE

Specific signs define each particular situation. InVolkmann’s type I, extension of the fingers is ob-tained by increasing wrist flexion. In type II, the fin-gers actively tend to extend when the wrist is flexedand hyperextension of the proximal phalanx is pre-vented (Bouvier’s maneuver). Interphalangeal exten-sion is negative in some cases of interphalangealcomplications of clawhand (see Chap. 5, Fig. 5-9). Volkmann’s type III, proximal interphalangeal flex-ion increases only after the metacarpophalangealjoints are passively flexed, as in all intrinsic contrac-tures of the fingers. In these cases passive extensionof the proximal phalanx increases hyperextension ofthe middle joint and flexion of the distal joint.

SURGICAL TREATMENT

Several clinical factors determine the choice of themost adequate surgical procedure: type of digital de-formity; deformation of carpal bones after growingperiod; functional condition and degree of retraction ofthe long digital flexor muscles; sensory impairment;clawhand complications; and thumb contracture.

We shall consider the program of surgical treat-ment in accordance with the type of deformity or in-trinsic muscular condition of the hand.

Type I

Type I deformities are the most favorable cases forcorrection of the deformity and restoration of hand

(Text continues on p. 323)

Surgical Treatment 319

Fig. 10-4. These drawings represent the classical excision-reconstruction procedure to correct muscle ischemiccontracture at the forearm.

A. Excision of the fibrotic or infarcted profundus muscles of the forearm. The size of the infarct may vary accord-ing to the severity of the circulatory impairment. Usually the principal damage is at the flexor digitorum pro-fundus and the flexor pollicis longus. In the drawing the flexor carpi radialis (f.c.r.) and the flexor carpi ulnaris(f.c.u.) tendons have been lengthened, and also the flexor pollicis longus (f.p.l.). This basic program may bechanged according to the particular condition of each patient.

B. Reconstruction. Repair of the lengthened tendons and transfer of the extensor carpi radialis longus(e.c.r.l.) to the distal stumps of the flexor digitorum profundus tendons (f.p.). Frequently during this muscularreconstruction the principal nerves, median and/or ulnar, are freed or repaired in cases of type II or type IIIdeformities.

Fig. 10-5. A. Typical type I classical ventral Volkmann’sischemic contracture.

B. The muscular infarct was at the flexor digitorum pro-fundus muscle (a). The median nerve (b) was included scar tissue. The flexor superficialis was retracted but invery good functional condition. Due to this pathology theinfarct was excised and the reconstruction was accom-plished by the transfer of the flexor superficialis, which isdivided at the level of the wrist, to the distal stump of theflexor digitorum profundus. This represents a "Z" length-ening between the flexor superficialis and flexor profundusdigital tendons (intertendinous lengthening)3~2

C, D, and E. Functional result was good.

320

Fig. 10-6. A and B. Severe type II Volkmann’s contracture of the radial and ulnar sides of the hand after a crush in-jury at the elbow and forearm. The fingers were in a marked intrinsic clawhand but still without joint complica-tions.

C and D. Result after excision-reconstruction of the retracted muscles of the forearm according to the programdescribed in the text and in Figure 10-4. The median and ulnar nerves were freed. Nerve release and correction ofdigital deformities should be early indications in severe ischemic contractures (evolutive period).

During a second surgical stage the clawhand was corrected by a metacarpophalangeal capsuloplasty, and theopposition paralysis by an oppenens transfer using the extensor indicis proprius tendon around the ulnar sideof the wrist (see Chap. 6, Fig. 6-3).

321

Fig. 10-7. A and B. Severe ischemic retraction after a compound fracture of the elbow. Intrinsic paralysis (claw-hand) at the ulnar fingers and intrinsic ischemic retraction at the radial side of the hand.

C. Six years after the accident, the muscular infarct 5 cmo in length was still present, without invasion of scartissue.

D, E, and F. Result after excision-reconstruction at the forearm and simultaneous release of the retracted in-terosseous muscles of the index and middle fingers, adductor pollicis, and flexor pollicis brevis of the thumb.The first web was reconstructed by a rotatory flap (see Chaps. 6 and 9).

322

function, and this is due to the normal condition ofthe intrinsic muscles and normal cutaneous sensibil-ity. All surgical correction is directed exclusively tothe pathology at the forearm. The surgical procedurewe prefer is the excision of the retracted infarcted orfibrotic muscles, and the functional reconstruction bytendon transfers and tendinous lengthening (excision-reconstruction procedure). The muscles to be used inthe transfer need to be in good functional condition(grade 4) and preferrably belong to the synergisticgroup. This method has been employed and devel-oped by Parkes (1951)182 and Seddon (1956).2°~

The basic technique consists in "Z" lengthening ofthe principal flexor tendons of the wrist (flexor carpiradialis and ulnaris) and the .flexor pollicis Iongus.When this last muscle is completely fibrotic or para-lyzed it is sectioned and then activated by thetransfer of the brachioradialis. The palmaris Iongus,retracted or paralyzed, is excised.

The flexor digitorum sublimis tendons are excised com-pletely to the limit of the forearm incision. The ten-dons of the flexor digitorum profundus are partially ex-cised at their musculotendinous junction, whichavoids the retraction of the distal stump of the ten-dons into the carpal tunnel and permits their activa-tion by tendon transfers. If the flexor tendons of thefingers are only divided, it is possible to observe par-tial recurrence of the deformity.

After the hand deformity is completely correctedthe lengthened wrist flexor tendons are repaired. Theextensor carpi radialis longus is transferred to the distalstumps of the flexor digitorum profundus tendons.

The described technique may vary in relation todifferent pathologic conditions. There are cases inwhich the flexor muscles of the wrist are not re-tracted. In severe pronation contractures it is neces-sary to excise, the distal part of the pronator teresmuscle. Occasionally the flexor superficialis musclesare partially retracted and with good voluntary con-traction. In this situation their tendons are divideddistally, above the wrist, and transferred to reinforcethe reconstructed flexor profundus tendon. One ofthese tendons can be used to activate the flexorpollicis longus tendon.

We indicate the method of excision-reconstructionof the forearm when the following conditions arepresent: mild or severe retraction of the long flexormuscles; available muscles to be used as transfers;and moderate or no voluntary contraction in the fin-ger flexor muscles after sufficient time for recovery.

In patients with types II and III of the deformitythe forearm reconstruction must also be indicatedafter maximum spontaneous muscular recovery butbefore definitive articular stiffness of the fingers oc-curs. To save passive mobility of the joints of the fingers

Surgical Treatment 323

is of fundamental importance in correction of Volk-mann’s contracture.

In our opinion the only indication for the classicalmuscle slide operation in this type. of patient is whenthe flexion contracture of the digits is mild and thevoluntary power of the flexor muscles is significantlypreserved.

Occasionally we have employed an intertendinouslengthening between the flexor digitorum superfi-cialis tendons and the flexor digitorum profundustendons (Fig. 10-5).

Postoperative reeducation is very simple after theexcision-reconstruction procedure because the ex-tensor carpi radialis muscle is a synergist of fingerflexion. The brachioradialis is a very efficient transferto activate the flexor pollicis longus tendon.

It is interesting to point out that in some cases-particularly in children-the postoperative reeduca-tion is not so simple due to the presence of differentabnormal patterns of finger flexion. One of thesehabits, as previously mentioned, is the intrinsic domi-nance that produces an intrinsic-plus type of digitalflexion and favors adhesions of the reconstructedlong digital flexor tendons.

Another pathologic habit of digital flexion is thesituation in which the patient flexes the interpha-langeal joints by a tenodesic action with the long digi-tal flexor tendons through wrist extension and hy-perextension of the metacarpophalangeal joints. Tobreak this abnormal pattern, a splint is used to main-tain the wrist in neutral extension and the metacar-pophalangeal joints in mild flexion, and full excur-sion of the transferred tendons is encouragedthrough correct movements.

Type II

In the group of patients with type II deformity, theintrinsic muscles depending on the median and/orthe ulnar nerves are involved. The surgical programis divided into two surgical stages. During the firststage the retracted muscles of the forearm are cor-rected. As in type I deformity, excision-reconstruc-tion is the operation we prefer. During the postoper-ative period finger reeducation is encouraged duringseveral months and splinting is indicated to avoidthe "claw" of the fingers.

The second surgical stage consists in the reconstruc-tion of the intrinsic paralysis. The method employeddepends on the possibility of available muscularmotors to be employed as transfers and the type ofdeformity at the level of the fingers and thumb.

Clawhand, without important complications suchas definitive joint stiffness or stretched extensor ap-paratus of the middle joints, is treated like any other

324 Classification of Established Volkmann" s Ischemic Contracture and the Program for Its Treatment

General Surgical Program in EstablishedVolkmann’s Contracture

Type I-Forearm excision-reconstruction

Type II-First stage: forearm excision-reconstructionSecond stage: intrinsic paralysis restoration

Type III-Simultaneous forearm excision-reconstructionand intrinsic release

interphalangeal joints. This is a very unfavorable sit-uation to correct.

Paralysis of the intrinsic muscles of the thumb ispreferably corrected by tendon transfers. The exten-sor indicis proprius around the ulnar of the wrist isan excellent motor to regain opposition in thesecases. If there is a concomitant retropulsion defor-mity of the thumb, this must be corrected previous toor simultaneously with the opponens transfer (seeChap. 6).

intrinsic paralysis by active or passive surgical pro-cedures. The "lasso" operation and the metacarpo-phalangeal capsuloplasty (see Chap. 5) are the opera-tions of our choice. If a motor is available-usuallythe brachioradialis-the indirect "lasso" techniqueis indicated. The muscular motor is prolonged withthe distal stumps of flexor superficialis or tendongrafts, and these tendons are fixed at the vaginal liga-ment of the fibrous sheath of the flexor tendons ofeach finger. When no motors are available, metacar-pophalangeal capsuloplasty with bony fixation is agood indication (Fig. 10-6). In cases of clawhand withdefinitive interphalangeal stiffness, joint fusion infunctional position is indicated. If the metacarpo-phalangeal joints are also stiff, a capsulectomy or ex-cision-arthroplasty with flexible implants is indi-cated with simultaneous fusion of the proximal

Type III ~

In the patient with type III deformity the contrac-ture of the muscle of the forearm and of the intrinsicmuscles must be corrected during the same surgicalprocedure. It would be impossible to obtain digitalfunction with contracted intrinsic muscles.

The technique of the operation to release the in-terossei depends on the severity of the contracture.In mild cases the classical technique of intrinsic lat-eral bands and triangular interosseous laminae ex-cision (distal intrinsic release) is indicated; but in caseswith flexion contracture of the metacarpophalangealjoints the interosseous tendons are excised at thelevel of the neck of the metacarpal bones (proximal in-trinsic release). These techniques have been describedin Chapter 9.