Volkmann’s contracture

Volkmann’s contracture is a deformity of the hand, fingers, and wrist caused by prior trauma—often fractures, burns, crush injuries, or arterial injury. The condition arises when blood flow to the forearm musculature and nerves is reduced, resulting in ischaemia and tissue damage. This leads to shortening and scarring of the musculature—particularly the flexors of the hand and fingers¹ ².

Clinically Relevant Anatomy

Volkmann’s contracture primarily affects the muscles of the forearm flexor group, especially after injury in the supracondylar region of the humerus, which can compromise circulation in the brachial artery. This results in damage to nerves and musculature, typically:

Superficial flexors:

• Pronator teres (median nerve)

• Flexor carpi radialis (median nerve)

• Flexor carpi ulnaris (ulnar nerve)

• Flexor digitorum superficialis (median nerve)

• Palmaris longus (median nerve)

Deep flexors:

• Flexor pollicis longus, pronator quadratus, and flexor digitorum profundus—all mediated by the median nerve³ ⁴

Epidemiology and Causes

Volkmann’s contracture is rare, with an incidence of around 0.5%. The condition is caused by an increase in pressure within a fascially enclosed muscle group, leading to compromised blood supply—known as compartment syndrome.

Common precipitating causes:

• Supracondylar humerus fractures

• Animal bites

• Burns or bleeding disorders

• Overtraining or improperly placed injections in the forearm⁴ ⁶

Symptoms and Clinical Presentation

Volkmann’s contracture develops from acute compartment syndrome and is characterised by the classic “5 Ps”:

• Pain: early and severe, particularly on passive stretch of the flexors

• Pallor: skin appears pale and cool

• Pulselessness: especially in distal segments of the limb

• Paraesthesias: tingling/numbness due to nerve compression

• Paralysis: motor weakness or loss⁴

Typical findings:

• Wrist held in palmar flexion

• Claw-like fingers

• Pain on palpation

• Reduced sensation and strength in the affected limb⁷

Examination and Classification

The condition can be graded by severity:

• Mild: contracture in 2–3 fingers, no sensory deficit

• Moderate: all fingers flexed, thumb in palmar position, diminished sensation

• Severe: all muscles of the forearm affected (flexors and extensors)

Diagnostics

Intrakompartmenttrykk (ICP) er gullstandard for diagnostisering. Måles med:

• Wick-kateter

• Trykktransdusere

• Nålemanometri

Kirurgisk behandling vurderes hvis:

• Absolutt trykk >30 mmHg

• Diastolisk trykk minus ICP <30 mmHg

• Middelarterietrykk minus ICP <40 mmHg¹²

Differensialdiagnose

Intracompartmental pressure (ICP) is the gold standard for diagnosis. Measured with:

• Wick catheter

• Pressure transducers

• Needle manometry

Surgical treatment is considered if:

• Absolute pressure >30 mmHg

• Diastolic pressure minus ICP <30 mmHg

• Mean arterial pressure minus ICP <40 mmHg¹²

Differential Diagnosis

• Pseudo-Volkmann’s contracture: functional or neurogenic cause without true muscular shortening⁹

Functional Outcome Measures

Range of motion and strength:

• Active/passive ROM of elbow, wrist, and fingers

• Sphygmomanometer for strength testing at elbow/shoulder

• Hand grip strength (dynamometer)

• Pinch strength: key pinch, three-point pinch (Preston pinch gauge)

Sensation:

• Von Frey testing

• Two-point discrimination

• Moberg pick-up test for functional sensibility

Fine motor skills and ADL:

• MAND (McCarron Assessment of Neuromuscular Development)

• Jebsen Hand Function Test

Medical Management

Prevention is the most important measure to avoid development of Volkmann’s contracture. Rapid identification and treatment of elevated pressure within the muscle compartment can prevent permanent damage. The most common cause is supracondylar humerus fractures, and ensuring optimal healing of these is essential.

With intracompartmental pressure (ICP) >30 mmHg, immediate fasciotomy is recommended. This is an acute medical emergency and involves:

• Removal of all dressings down to skin level

• Surgical opening of the fascia to relieve pressure

Fasciotomy is performed to preserve tissue viability and prevent the development of compartment syndrome and contracture¹ ².

Surgical Interventions After Contracture

Moderate contracture:

• Tendon gliding and neurolysis (of the median and ulnar nerves)

• Tendon transfers to regain length and control

Severe contracture:

• Debridement of necrotic musculature

• Scar release and salvage procedures

• In some cases, amputation or reconstructive surgery may be necessary

Postoperative rehabilitation is crucial to restore function and motion.

Physiotherapy Management

Physiotherapy plays a key role both after surgery and in mild to moderate contracture. The main goals are to:

• Prevent further stiffness and scar formation

• Restore range of motion

• Strengthen weakened musculature

• Re-establish balance between flexors and extensors

Interventions:

• Passive stretching and joint mobilisation

• Active movement training to stimulate motor control

• Progressive splinting to correct positions

• Tendon gliding and gentle soft-tissue massage for tissue mobility

• EMG training (electromyographic biofeedback) can enhance patient–therapist interaction and improve muscle activation⁴ ⁶

With correct treatment and good multidisciplinary follow-up, many patients can achieve functional improvement, even in moderate injuries.

Clinical Summary

Early diagnosis and rapid treatment are essential to prevent permanent damage. In acute compartment syndrome, decompression must occur immediately. When contracture has developed, surgery combined with targeted physiotherapy is the best strategy to restore function and prevent further loss¹³.

Sources

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