compartment syndrome and volkmann ischemic contracture

Compartment syndrome and Volkmann’s ischemic contracture: the real emergency of a swollen limb

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Compartment syndrome and Volkmann’s ischemic contracture: the real emergency of a swollen limb

compartment syndrome and volkmann ischemic contracture

Marco Castenetto

Volkmann’s ischemic contracture (also referred to as compartment syndrome), is a pathological contracture of the muscles of an anatomical compartment (e.g. forearm).

An anatomical compartment is a structure in which there is a group of one or more muscles with nerves, vessels, tendons, ligaments, etc., surrounded by a structure called fascia, which is relatively inextensible.


Volkmann’s disease is the final outcome of the compartment syndrome, characterized by increased pressure within the anatomical portion and irreversible muscle necrosis.

The leg and forearm are the most commonly affected structures.

The increase in pressure in the tissues causes an increase in venous pressure.

The drastic decrease in vascular perfusion causes the tissues to receive less blood, up to an insufficient level to guarantee its vitality.

Acute, undiagnosed Volkmann disease can lead to necrosis (death) of muscle and nerve tissue within 4 to 8 hours.

The muscle fibers contract permanently and the muscle is replaced by scar tissue, and the nerves suffer permanent dysfunction.

Clinically speaking, it is defined as the “five P” syndrome (1):

  • Pulselessness;
  • Pain;
  • Pallor;
  • Paresthesia (alteration of sensitivity);
  • Paralysis.


What causes Volkmann’s ischemic contracture:

The venous slow blood condition (stasis), increases the intracompartmental pressure, the tissues no longer receive a sufficient amount of oxygen (anoxia) and the local damage created affects the organism both from the physical and biochemical point of view.

It is an event that can occur following bleeding and external compressions (bandages, plaster casts, etc.).

The resulting edema can lead to:

  1. Complete and lasting ischemia, with consequent total necrosis and gangrene outcome;
  2. Complete ischemia with partial necrosis, leading to Volkmann’s syndrome.

The causes can be attributed to:

Fractures (3):

  • Tibial shaft fracture;
  • Soft tissue injuries;
  • Distal radius fracture;
  • Crush syndrome;
  • Forearm diaphyseal fracture;
  • Femoral shaft fracture;
  • Tibial plateau fracture;
  • Hand fractures;
  • Fractures of the tibial pilon;
  • Foot fractures;
  • Ankle fracture;
  • Elbow fracture dislocation;
  • Pelvic fracture;
  • Humeral shaft fracture.

Conditions that increase the volume of anatomical structures:

  • Soft tissue injury;
  • Crush syndrome (4);
  • Exercise (5);
  • Fluid infusion (including arthroscopy) (6);
  • Osteotomy (7);

Systemic hypotension;

Chronic peripheral vascular disease (subjects with this type of disease are at risk, since their poor tissue perfusion leads to moderate ischemia and edema formation, which increase the pressure in the compartment).

Symptoms of Volkmann’s ischemic contracture:

The symptoms that characterize Volkmann’s disease are:

  • Too much Pain compared to the trauma;
  • Paraesthesia or hypoesthesia (complete or partial reduction of sensation) in the foot or hand (for example, of the deep peroneal nerve in the foot and the median nerve in the hand);
  • Fingers flexion with the impossibility of extension;
  • Extreme pain when stretching the long muscles passing through the compartment (extension of the fingers in the forearm and plantar flexion of the ankle and toes);
  • The inability to make a fist or to bring the toes into a hammer shape as a sign of paralysis (in dorsiflexion of the foot, the toes are directed towards the face).

Inability to make a fist or to hammer toes and dorsiflexion of the foot

How the diagnosis of compartment syndrome is made:

A patient who has very severe pain in the leg or forearm is usually examined very closely.

The examination begins removing the cast and any other retainers to carefully evaluate the muscle compartments.

When the padding is removed, the structures are normally soft, not taut or stiff.

The motor and sensitive functions of the peripheral nerves and the degree of stretching of the muscles are subsequently evaluated.

The primary test for evaluating Volkmann’s ischemic contracture is the intrinsic minus hand and consists of finger extension with a flexed wrist.

The tissue pressure is then evaluated and, if it exceeds 40 mmHg, the limb must be immediately surgically decompressed.

Peripheral pulses may always be present, but tend to become progressively weaker, until they disappear (3).

The most important exams are arteriography and Doppler.

The instrumental tests during the evaluation of compartment syndromes are doppler and arteriography

If suspected acute compartment syndrome, when venous pulses are absent, arteriography is usually indicated.

Doppler ultrasound is instead very useful in clinical research involving chronic compartment syndrome.

What therapy is used in compartment syndrome:

Since muscle necrosis can develop between four to eight hours, even the little suspect requires a treatment, especially if the initial diagnosis confirms the intracompartmental pressure.

Volkmann’s syndrome in the acute phase is a true emergency and therefore an event that must be resolved as soon as possible.

The first approach consists in the immediate removal of any cause that can increase the intracompartmental pressure (casts, restraints, orthoses, bandages).

If constant extremity pressure monitoring does not reveal the complete remission of symptoms, surgical decompression should be performed.

The single most effective surgical treatment for acute compartment syndrome is fasciotomy.

The basic principle of the fasciotomy consists in the opening of the entire anterior structure that goes from the elbow to the carpal tunnel with a very large incision.

Once the limb has been opened, the surgical team decompresses the individual muscle bellies, superficial and deep, to investigate and evaluate the vitality, to avoid infections and muscle necrosis.

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(1) Greenspan, Adam. Orthopedic Imaging: A Practical Approach. Lippincott Williams & Wilkins; 4th edition, 2004.

(2) Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M.; Tornetta, Paul; Rockwood And Green’s Fractures In Adults, 7th Edition. Lippincott Williams & Wilkins, 2010.

(3) Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment and outcome. J Paed Orthop 2001;21:680- 688

(4) Mathews PV, Perry JJ, Murray PC. Compartment syndrome of the well leg as a result of the hemilithotomy position: a report of two cases and review of literature. J Orthop Trauma 2001;15:580-583.

(5) McKee MD, Jupiter JB. Acute exercise-induced bilateral anterolateral leg compartment syndrome in a healthy young man. Am J Orthop 1995;24:862-864.

(6) Belanger M, Fadale P. Compartment syndrome of the leg after arthroscopic examination of a tibial plateau fracture. Case report and review of the literature. Arthroscopy 1997; 13:646-651.

(7) Gibson MJ, Barnes MR, Allen MJ, et al. Weakness of foot dorsiflexion and changes in compartment pressures after tibial osteotomy. J Bone Joint Surg Br 1986;68:471-475.

(8) Federico A. Grassi, Ugo E.Pazzaglia, Giorgio Pilato, Giovanni Zatti. Manuale di ortopedia e traumatologia. Elsevier; seconda edizione 2012.



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