Volkmann’s Ischemic Contracture (VIC): Causes, Symptoms, Diagnosis & Management

Volkmann’s Ischemic Contracture (VIC): Causes, Symptoms, Diagnosis & Management

Volkmann’s Ischemic Contracture (VIC) is a severe and disabling complication resulting from untreated or prolonged compartment syndrome of the forearm. It leads to irreversible muscle and nerve damage, resulting in fixed flexion deformity of the wrist and fingers, weakness, loss of sensation, and impaired upper limb function.

The condition was first described by Richard von Volkmann in 1881, highlighting the relationship between ischemia and contractures.

Early recognition of compartment syndrome is essential because Volkmann Contracture is preventable if treated in time.



What is Volkmann’s Ischemic Contracture? (Definition)

Volkmann’s Ischemic Contracture is a permanent shortening (contracture) of forearm muscles caused by ischemia due to increased compartment pressure.
It leads to:

  • Flexion deformity of the wrist

  • Flexion contracture of fingers

  • Loss of hand grip

  • Sensory deficits

  • Muscle fibrosis and necrosis

It usually affects the flexor muscles, particularly the flexor digitorum profundus and flexor pollicis longus.

Epidemiology

  • Most commonly affects children due to supracondylar humerus fractures

  • Can also occur in adults after trauma

  • Preventable with timely diagnosis of compartment syndrome

  • Incidence is decreasing due to early orthopedic care

Causes of Volkmann’s Ischemic Contracture

VIC occurs due to ischemia caused by elevated compartment pressure in the forearm muscles. Common causes include:

1. Supracondylar Fracture (Most Common Cause)

  • Especially in children

  • Tight bandages or casts increase pressure further

2. Forearm Fractures

  • Radius and ulna fractures

  • Crush injuries

  • Fracture-dislocations

3. Vascular Injury

  • Damage to brachial artery

  • Arterial spasm or thrombosis

4. Tight Plaster Casts or Dressings

  • Compression around the forearm blocks venous return

  • Leads to compartment pressure rise

5. Severe Burns

Cause circumferential edema → compression.

6. Prolonged Tourniquet Use

Excess duration or pressure leads to ischemia.

Pathophysiology: How VIC Develops

  1. Acute compartment syndrome → raised pressure > capillary perfusion pressure

  2. Blood flow decreases → muscle ischemia

  3. Ischemia > 6 hours → muscle necrosis begins

  4. Necrotic muscle replaced by fibrous tissue

  5. Fibrosis leads to permanent shortening

  6. Nerve ischemia causes sensory & motor loss

  7. Results in fixed flexion deformity

Clinical Features of Volkmann’s Ischemic Contracture

1. Visible Deformity

  • Wrist in flexion

  • Fingers in claw-like flexion

  • Limited extension

  • Thumb in adduction

2. Pain (Early stage)

  • Severe, disproportionate pain

  • Pain on passive stretching of fingers

3. Motor Deficits

  • Weak grip strength

  • Inability to extend fingers

  • Loss of fine motor skills

4. Sensory Loss

  • Numbness or tingling

  • Median and ulnar nerve involvement

5. Muscle Changes

  • Hard, wooden feeling of forearm

  • Muscle fibrosis

  • Wasting and atrophy

Classification of Volkmann’s Contracture (Tsuge’s Classification)

Type Findings
Mild Finger flexion contracture; no wrist deformity; intrinsic muscle weakness
Moderate Flexion contracture of wrist and fingers; sensory loss may be present
Severe Severe deformity; complete motor & sensory loss; hand function severely impaired

Diagnosis

Diagnosis is mainly clinical, supported by imaging and nerve tests.

1. History & Physical Examination

  • Previous fracture, plaster, or crush injury

  • Claw-like deformity

  • Pain on passive stretch

  • Hard forearm compartments

2. Imaging

X-ray

  • Detects underlying fractures

MRI

  • Shows muscle necrosis, fibrosis

Ultrasound

  • Assesses compartment thickness

3. Doppler Ultrasound

  • To check brachial artery or radial/ulnar artery flow

4. Nerve Conduction Studies

  • Confirm median & ulnar nerve damage

Management of Volkmann’s Ischemic Contracture

A. Emergency Management (Preventive Stage)

Critical in acute compartment syndrome to prevent contracture.

1. Immediate Fasciotomy

  • Gold standard

  • Releases pressure

  • Prevents muscle death

2. Remove Tight Casts or Bandages

3. Restore Blood Flow

  • Vascular repair if artery injured

B. Early Stage Management

1. Physiotherapy

  • Positioning of hand

  • Passive stretching

  • ROM exercises

  • Splinting to prevent deformity

2. Pain Management

  • NSAIDs

  • Ice therapy for swelling

C. Management of Established Contracture

Once fibrosis is present, surgery is often required.

1. Tendon Lengthening

  • Flexor tendons lengthened to improve finger position

2. Muscle Slide Procedures

  • Pronator teres or other muscle sliding techniques

3. Fasciotomy + Neurolysis

  • Decompression of nerves

  • Improves sensation

4. Free Muscle Transfer

Used for severe muscle loss
(e.g., gracilis muscle transfer).

5. Corrective Osteotomy

Improves wrist alignment.

6. Amputation (Rare)

Only in non-salvageable cases.

Physiotherapy Management (Detailed)

Physiotherapy plays a major role before and after surgery.

1. Acute Phase

  • Elevation of limb

  • Gentle ROM within pain-free range

  • Hand splinting in functional position

  • Pain management (TENS, Ice, Hydrotherapy)

2. Subacute Phase

  • Stretching of forearm flexors & intrinsic muscles

  • Strengthening of wrist extensors

  • Grip training with putty

  • Sensory re-education

  • Mirror therapy for motor recovery

3. Chronic Phase

  • Functional hand training

  • ADL practice

  • Isometric to isotonic strengthening

  • Occupational therapy for fine motor control

  • Post-surgical rehab as per surgeon protocols

Complications

  • Permanent disability

  • Sensory loss

  • Claw hand deformity

  • Stiffness

  • Chronic pain

  • Muscle fibrosis

  • Nerve palsy

  • Poor hand function

Prognosis

  • Early diagnosis → full recovery possible

  • Delayed treatment → permanent deformity

  • Severe VIC leads to lifelong disability

PubMed References

  1. Matsen FA 3rd, et al. Compartmental syndrome. A unified concept. Clin Orthop Relat Res. 1975. PMID: 1192643

  2. Mubarak SJ, Owen CA. Compartmental syndrome and Volkmann's contracture. J Bone Joint Surg. 1977. PMID: 200840

  3. Heppenstall RB, et al. Volkmann ischemic contracture: A review. Clin Orthop Rel Res. 1988. PMID: 3279894

  4. Garner MR, et al. Acute compartment syndrome of the extremities. J Am Acad Orthop Surg. 2014. PMID: 24966248

  5. Kumar V, et al. Management of established Volkmann's ischemic contracture. Indian J Orthop. 2009. PMID: 19753173


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