CHAPTER 74

COMPARTMENT SYNDROMES AND

VOLKMANN CONTRACTURE
Norfleet B. Thompson

DEFINITION AND MANAGEMENT 3822 Muscle sliding operation

HISTORY 3819 Acute compartment syndrome of flexors for established
ANATOMY 3819 of the forearm 3822 volkmann contracture 3826
ETIOLOGY 3819 Established volkmann Established intrinsic muscle
contracture of the forearm 3825 contractures of the hand 3827
DIAGNOSIS 3820
Adducted thumb 3829

DEFINITION AND HISTORY compartments; however, the deep volar compartment (flexor
Compartment syndrome is a condition in which the circu- digitorum profundus, flexor pollicis longus, and pronator
lation within a closed compartment is compromised by an quadratus) may be solely involved.
increase in pressure within the compartment, causing necrosis In the hand, three palmar and four dorsal interosseous
of muscles, nerves, and eventually the skin because of exces- muscles are each surrounded by a tough, investing fascial
sive swelling. Volkmann ischemic contracture is a sequela of layer, creating individual compartments, as shown by the
untreated or inadequately treated compartment syndrome in injection dissections of Halpern and Mochizuki. The adduc-
which necrotic muscle and nerve tissue have been replaced tor pollicis, thenar, and hypothenar muscles also form three
with fibrous tissue. separate compartments (Fig. 74.2). The neurovascular bun-
In the upper extremity, compartment syndrome is most dles of each digit also are compartmentalized by fascial lay-
common in the forearm. The intrinsic muscle compartments ers, making them vulnerable to excessive swelling (Fig. 74.3).
of the hand also may be involved, and compartment syn-
drome of the upper arm has been reported.
In 1881, Volkmann stated in his classic paper that the par- ETIOLOGY
alytic contractures that could develop only a few hours after Numerous injuries have been shown to result in compart-
injury were caused by arterial insufficiency or ischemia of the ment syndrome, including crush injuries, prolonged exter-
muscles. He suggested that tight bandages were the cause of nal compression, internal bleeding (especially after injury
vascular insufficiency. This concept of extrinsic pressure as the in patients with hemophilia), fractures, excessive exercise,
primary cause of paralytic contracture persisted for some time burns, snake bites, and intraarterial injections of drugs or
in the English literature. In 1909, Thomas studied 107 paralytic sclerosing agents. Infections also have been noted to increase
contractures and found that some developed following severe pressures within compartments.
contusions of the forearm in the absence of fractures, splints, or Elliott and Johnstone found that 18% of forearm com-
bandages. The idea was established that extrinsic pressure was partment syndromes were caused by fractures, and 23% were
not the sole cause of the ischemia. In 1914, Murphy reported caused by soft-tissue injuries without fractures. Although
that hemorrhage and effusion into the muscles could cause isolated distal radial fractures rarely were associated with
internal pressures to increase within the unyielding deep fascial compartment syndrome (0.3%), an ipsilateral elbow injury
compartments of the forearm, with subsequent obstruction of resulted in forearm compartment syndrome in 15% of
the venous return. In 1928, Jones concluded that Volkmann patients. Historically, supracondylar humeral fractures were
contracture could be caused by pressure from within, from most frequently associated with forearm compartment syn-
without, or from both. Eichler and Lipscomb outlined the early drome in children; however, Grottkau et al. found that fore-
technique of fasciotomy as the primary surgical treatment. arm fractures were actually more commonly associated (74%
vs. 15%). In children, supracondylar humeral fractures with
an associated neurovascular or floating elbow injury signifi-
ANATOMY cantly increase the risk of compartment syndrome.
Four interconnected compartments of the forearm are rec- Acute compartment syndrome of the intrinsic muscles of
ognized (Fig. 74.1): (1) the superficial volar compartment, the hand, resulting in contracture or necrosis of the muscle
(2) the deep volar compartment, (3) the dorsal compart- bellies such as those in the larger muscles in the forearm, can
ment, and (4) the compartment containing the mobile wad occur after compression injuries of the hand without fracture.
of Henry (brachioradialis and extensor carpi radialis longus Compartment syndrome has been noted in neonates follow-
and brevis). The volar compartments are most commonly ing intrauterine malposition or strangulation of the extremity
involved, but the dorsal and mobile wad compartments can by the umbilical cord.
be involved alone or in addition to the volar compartments. It Direct trauma, crushing of the upper arm, shoulder dislo-
is usually difficult to clinically differentiate between isolated cation, avulsion of the triceps muscle, pneumatic tourniquet
or combined involvement of the deep and superficial volar use, and arteriography have all been reported as causes of

3819
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3820 PART XVIII THE HAND

compartment syndrome. Intravenous regional anesthesia has intracompartmental pressure increases, capillary blood perfu-
also been implicated as a cause when hypertonic saline is used sion is reduced to a level that cannot maintain tissue viability.
to dilute an anesthetic. The increase in interstitial pressure overcomes the intravascu-
Although more common in the lower extremity, chronic lar pressure of the small vessels and capillaries, which causes
exertional compartment syndrome (CECS) may also involve the walls to collapse and impedes local blood flow. In a canine
the upper extremity. CECS most commonly affects the volar model, muscle necrosis was shown to occur with a rise in pres-
forearm compartment and the first dorsal interosseous mus- sure to within 20 mm Hg below the diastolic pressure. Local
cle in the hand. It is most frequently diagnosed in competitive tissue ischemia leads to local edema, which increases the intra-
off-road motorcyclists. It has also been reported in kayakers compartmental pressure. This cycle of increasing muscle isch-
and elite rowers and may occur in adolescents after puberty. emia was depicted by Eaton and Green, as shown in Figure 74.4.
Any situation that causes a decrease in compartment size, The tolerance of tissue to prolonged ischemia varies
an increase in compartment pressure, or a decrease in soft- according to the type of tissue. Functional impairment in
tissue compliance can initiate compartment syndrome. As the muscles has been demonstrated after 2 to 4 hours of ischemia,
and irreversible functional loss occurs after 4 to 12 hours.
Nerve tissue shows abnormal function after 30 minutes of
Superficial
volar compartment
ischemia, with irreversible functional loss after 12 to 24 hours.
Radius
PL
FCR
BR DIAGNOSIS
PT Mobile A crush injury or fracture of the forearm or elbow, especially
wad in the supracondylar area of the humerus, should raise sus-
FDS
FDS picion that a forearm compartment syndrome may develop.
FCU FPL ECRL

FDP SUP
ECRB Transverse
retinacular
ECU EDC
A ligament
Deep volar
compartment EDQ
Ulna Incision
Dorsal compartment
FIGURE 74.1 Cross-section through upper third of forearm. A, Cleland
Anconeus muscle; BR, brachioradialis; ECRB, extensor carpi radialis ligament
Neurovascular
brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi
bundle
ulnaris; EDC, extensor digitorum communis; EDQ, extensor digiti
quinti; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDP, flexor Grayson
digitorum profundus; FDS, flexor digitorum sublimis; FPL, flexor ligament
pollicis longus; PL, palmaris longus; PT, pronator teres; SUP, supi-
nator. FIGURE 74.3   Cross-section through finger.

Dorsal
interosseous
muscles C
Dorsal interosseous
B muscles
Adductor Dorsal interosseous
pollicis muscle fascia

First D
metacarpal
Hypothenar
muscles
A

Thenar
muscles Palmar
Flexor pollicis interosseous
longus tendon muscles
FIGURE 74.2 Cross-section through hand. Dorsal and volar interosseous compartments and
adductor compartment to thumb (B and C); thenar and hypothenar compartments (A and D).

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 CHAPTER 74 COMPARTMENT SYNDROMES AND VOLKMANN CONTRACTURE 3821

Histamine regard to the overall clinical picture. Forearm measurements

release can be obtained from the superficial and deep volar compart-
Muscle
ischemia ments, and the mobile wad and dorsal compartments. The
Arterial occlusion
location for pressure monitoring using a needle manometer
Arterial spasm Capillary is commonly the middle third of the forearm for both flexor
permeability
compartments and for the dorsal extensor compartment. The
Venous deep flexor compartment is measured just anterior to the
Trauma obstruction ulna. The mobile wad of Henry may be entered in the midline
Intramuscular
of its bulk. Hand measurements may be obtained from the
edema thenar, hypothenar, adductor pollicis, and interosseous mus-
cles. Digital pressures are not routinely obtained.
Vasospastic
antidromic reflex In 1975, Whitesides et al. described a technique for mea-
Intramuscular suring compartment pressures using an 18-gauge needle,
pressure saline syringe, three-way stopcock, and a mercury manometer;
Venous, lymphatic, however, a handheld pressure monitoring device or an arterial
and arterial
compression line monitoring system, connected to either a straight nee-
dle, a side-port needle, or slit catheter, is currently preferred.
FIGURE 74.4 Traumatic ischemia-edema cycle in Volkmann Boody and Wongworawat compared the intracompartmental
contracture. pressure monitoring system, an arterial line manometer,
and the Whitesides apparatus, each with a straight needle, a
side-port needle, and a slit catheter, and found that the arte-
Early diagnosis of impending ischemia is essential because rial line manometer with a slit catheter was the most accu-
irreversible damage can occur quickly. Commonly described rate technique. The handheld pressure monitoring system also
characteristics of compartment syndrome in adults include was found to be accurate. Side-port needles and slit catheters
the five “P’s”: pain with passive stretch of the involved com- were more accurate, whereas straight needles tended to over-
partment (or pain out of proportion to examination), pares- estimate the pressure. We most commonly use the Stryker
thesias, pallor, paralysis, and pulselessness. Increasing pain handheld pressure monitoring device to determine intracom-
that is out of proportion to the injury and worsens with pas- partmental pressures. The arterial line monitoring system is
sive stretching of the involved muscles is an early indication useful if continuous monitoring is desired.
that a compartment syndrome is developing. The volar and/ To use the handheld pressure monitoring device (Stryker),
or dorsal forearm is tender and tense with swelling, and sen- the needle is placed firmly onto the chamber stem, a prefilled
sibility of the fingertips may be diminished. Two-point dis- syringe is placed into the remaining chamber stem, and the
crimination and 256-cycle vibratory testing can be helpful chamber is firmly seated into the device. The needle is held at 45
in determining nerve ischemia. Paralysis of involved muscle degrees from horizontal and the system is purged of excess air.
function and loss of the radial and/or ulnar pulse present as When the unit is turned on, the display should read 0 to 9 mm
late findings unless there is direct arterial injury. Hg. To calibrate the system, the zero button should be pressed
Diagnosis of compartment syndrome in an individual and the display should read 00. The needle is then inserted into
interosseous muscle can be difficult. The hand is swollen and the desired compartment, and no more than 0.3 mL of solu-
tense, and the fingers are held almost rigid in a partially flexed tion is injected. The device then displays the pressure of the
position with the wrist in neutral. Any passive movement of compartment. In an experimental model, Doro et al. showed
the fingers that causes metacarpophalangeal joint extension that measurement of intramuscular glucose levels can identify
usually causes considerable pain. The adductor compartment compartment syndrome with high sensitivity and specificity.
of the thumb can be tested by pulling the thumb into palmar
abduction and stretching the adductor muscle. The thenar
muscles rarely are involved. Diagnosis in obtunded and pediat-
ric patients is more difficult. In children, the five “P’s” are con- MEASURING COMPARTMENT
sidered less reliable. Bae et al. advocated using the three “A’s”
(increasing analgesic requirements, unremitting agitation, and PRESSURES IN THE FOREARM
anxiety) as more reliable indicators of developing pediatric AND HAND USING A HANDHELD
compartment syndrome. Compartment syndrome in a neonate
may manifest as a sentinel bullous or ulcerative skin lesion, usu- MONITORING DEVICE
ally over the dorsum of the forearm, wrist, or hand. Unilateral
aplasia cutis congenita also must be considered in this setting. TECHNIQUE 74.1
When compartment syndrome is suspected and the nec-
essary equipment is available, compartment pressures should (LIPSCHITZ AND LIFCHEZ)
be obtained to confirm the diagnosis. Compartment pres-
sures over 30 mm Hg or within 30 mm Hg of the diastolic MEASURING FOREARM COMPARTMENT PRESSURE
pressure (delta P) are indicative of compartment syndrome. n Place the compartment to be measured at heart level.
The delta P value compares the compartment pressure to the n Use adequate local analgesia infiltrated into the skin only,
diastolic blood pressure and thus controls for variation in a taking care to avoid the underlying muscle and fascia, to
patient’s blood pressure. All involved compartments should control discomfort and pressure spikes.
be measured, and the results should be interpreted with

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3822 PART XVIII THE HAND

To measure the volar compartment pressure, insert the

n  done but was not, loss of muscle and nerve tissue carries a
needle just ulnar to the palmaris longus, through the su- high risk for a poor functional outcome. In one study, a delay
perficial fascia to a depth of 1 cm. Confirm proper needle in diagnosis was the most important determining factor for
depth by observing a rise in pressure during external poor outcome. Compartment pressure should be monitored
compression of the volar forearm or passive extension of in young patients with injury to the forearm diaphysis or dis-
fingers. The deep volar compartment may be measured tal radius, or in patients with significant soft-tissue injury and
just anterior to the ulna on the flexor side of the forearm, a bleeding diathesis. Normal function was regained in 68%
taking care to avoid the neurovascular bundle. of patients in one study when fasciotomy was performed
To measure the dorsal compartment, insert the needle
n  within 12 hours of the onset of compartment syndrome.
just radial to the border of the ulna to a depth of 1 to 2 When performing a volar fasciotomy, a volar curvilinear inci-
cm. Confirm placement by external compression of the sion is used; this allows release of the lacertus fibrosus proxi-
dorsal compartment with passive flexion of the wrist. mally and the carpal tunnel distally. The interval between the
To test the mobile wad, identify the radialmost portion
n  flexor carpi ulnaris and the flexor digitorum sublimis is used
of the forearm and insert the needle perpendicular to the for release of deep and superficial compartments. The dor-
skin to a depth of 1 to 1.5 cm. A rise in pressure is identi- sal forearm fascia is released through the interval between
fied by external pressure or passive flexion of the wrist. the extensor carpi radialis brevis and the extensor digitorum
communis. The mobile wad of Henry can be released through
MEASURING HAND COMPARTMENT PRESSURE this same incision.
Insert the needle perpendicular to the skin.
n 

Evaluate the compartments individually. Pressure mea-

n 

surements are not obtained from the digits, but at the

site of maximal swelling of the thenar, hypothenar, and
interosseous compartments. FOREARM FASCIOTOMY AND
If a single compartment pressure is elevated, release all
ARTERIAL EXPLORATION
n 

compartments and the carpal tunnel.

To measure the dorsal interosseous compartment pres-
n 

sure, insert the needle through the dorsal hand 1 cm TECHNIQUE 74.2
proximal to the metacarpal head until it rests in the mus-
cle belly. To judge the depth, it is helpful to place identifi-
n For the volar fasciotomy (Fig. 74.5B), make an anterior
able marks on the needle at depths of 1.0, 1.5, and 2.0 curvilinear skin incision medial to the biceps tendon,
cm. crossing the elbow flexion crease at an angle. Carry the
To measure the adductor pollicis compartment pressure,
n  incision distally and radially over the brachioradialis, then
insert the needle on the radial side of the second meta- distally and ulnarward, eventually coursing medial to the
carpal in the substance of the thumb-index web space. palmaris longus. Cross the wrist flexion crease at an angle
To measure the thenar and hypothenar spaces, insert the
n  and continue in the midline of the palm to allow for a car-
needle at the junction of the glabrous and nonglabrous pal tunnel release. Curving the incision at the wrist ulnarly
skin over the maximal bulk of the muscle compartment. will decrease the risk of injury to the palmar cutaneous
Advance the needle at least 5 mm below the enveloping branch of the median nerve. The underlying subcutane-
fascia for pressure assessment. ous tissues should be spread longitudinally, protecting the
   lateral and medial antebrachial cutaneous nerves and the
palmar cutaneous branch of the median nerve.

MANAGEMENT
ACUTE COMPARTMENT SYNDROME OF
THE FOREARM
Impending tissue ischemia may be considered when the tis-
sue pressure reaches between 30 and 20 mm Hg below the dia-
stolic blood pressure. A higher pressure is a strong indication A
that fasciotomy should be recommended. In a hypotensive
patient, the acceptable pressure is lower. Fasciotomy should
be performed in (1) normotensive patients with positive clin-
ical findings and compartment pressures of greater than 30
mm Hg, and when the duration of the increased pressure is
unknown or thought to be longer than 8 hours; (2) uncoop-
erative or unconscious patients with compartment pressures B
of greater than 30 mm Hg; (3) patients with low blood pres- FIGURE 74.5 Incisions used in forearm for severe Volkmann
sure and compartment pressures of greater than 20 mm Hg; contracture. A, Extensive opening of fascia of the forearm dorsum
and (4) patients with a delta P value of less than 30 mm Hg. in dorsal compartment syndromes. B, Incision used for anterior
As a general rule, when in doubt, the compartment should forearm compartment syndromes in which skin and underlying
be released. If it proves later to have been unnecessary, only fascia are released completely throughout. SEE TECHNIQUES 74.2,
a scar will result. However, if a fasciotomy should have been 74.5, AND 74.6.

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 CHAPTER 74 COMPARTMENT SYNDROMES AND VOLKMANN CONTRACTURE 3823

Divide the lacertus fibrosus proximally and evacuate any

n 
POSTOPERATIVE CARE The arm is elevated for 24-48
hematoma. hours after surgery. If closure is not possible within 5 days,
In patients with suspected brachial artery injury, expose
n 
a split-thickness skin graft should be applied. Alternatively,
the brachial artery and determine if there is free blood closure of fasciotomy wounds can be accomplished grad-
flow. If the flow is unsatisfactory, remove the adventitia to ually, using vessel loops that are progressively tightened
expose any underlying clot, spasm, or intimal tear. Resect postoperatively during dressing changes. Wound closure
the adventitia, if necessary, and anastomose or graft the using this method usually can be accomplished in 2 weeks
artery. (Fig. 74.6). A vacuum-assisted wound closure system may
Release the superficial volar compartment throughout its
n 
be used to assist in wound management. The splint is
length with open scissors, freeing the fascia over the su- worn until the sutures are removed, or as determined by
perficial compartment muscles. fracture care requirements.
Identify the flexor carpi ulnaris and retract it with its
n 
  
underlying ulnar neurovascular bundle medially, and
then retract the flexor digitorum superficialis and me-
dian nerve laterally to expose the flexor digitorum pro-
fundus in its deep compartment. Check to see if the
overlying fascia or epimysium is tight and incise it lon-
gitudinally.
If the muscle is gray or dusky, the prognosis for recovery
n  HAND FASCIOTOMIES
may be poor; however, the muscle may still be viable and
should be allowed to perfuse. TECHNIQUE 74.3
Continue the dissection distally by incising the transverse
n 

carpal ligament along the ulnar border of the palmaris Make two dorsal parallel incisions through the skin overly-
n 

longus tendon and median nerve. ing the second and fourth metacarpals, beginning at the
In cases of median nerve palsy or paresthesia, observe the
n  level of the metacarpophalangeal joints and extending
median nerve along the entire zone of injury to ensure just distal to the wrist (Fig. 74.7A). Make each incision
that it is not severed, contused, or entrapped between down to the musculofascial area.
the ulnar and humeral heads of the pronator teres. If it is, Incise the fascia and release the compression of the dis-
n 

a partial pronator tenotomy is necessary. tended muscles by allowing them to extrude into the
In a patient with a supracondylar fracture, reduce the frac-
n  wound if necessary. Through the two dorsal incisions, all
ture, pin it with Kirschner wires, and control the bleeding. four dorsal interosseous compartments, all three palmar
Do not close the skin at this time; anticipate secondary
n  interosseous compartments, and the adductor compart-
closure later. ment can be released.
If the median nerve is exposed within the distal forearm,
n  Identify each muscle individually to ensure that a com-
n 

suture the distal, radial-based forearm flap loosely over plete release is achieved. Passively flex the metacarpo-
the nerve. phalangeal joints and extend the proximal interphalan-
Check the dorsal compartments clinically or repeat the
n  geal joints to stretch the muscles, ensuring that all are
pressure measurements. Usually, the volar fasciotomy adequately released.
decompresses the dorsal musculature sufficiently, but if Release the thenar and hypothenar compartments by
n 

involvement of the dorsal compartments is still suspected, making additional palmar radial and palmar ulnar inci-
release them also. sions along the glabrous and nonglabrous intervals to al-
Make the incision distal to the lateral epicondyle between
n  low for their separate decompression.
the extensor digitorum communis and extensor carpi radi- Release the carpal tunnel through a palmar midline inci-
n 

alis brevis, extending approximately 10 cm distally. Gently sion.

undermine the subcutaneous tissue and release the fascia Do not attempt to debride the interosseous muscles at
n 

overlying the mobile wad of Henry and the extensor reti- this point. If the fingers are tensely swollen and capil-
naculum. lary refill is delayed, continue with digital fasciotomies
Apply a sterile moist dressing and a long-arm splint. The
n  through midlateral incisions along the radial border of
elbow should not be allowed to flex beyond 90 degrees. the ring and small fingers and the ulnar border of the
index and long fingers (Fig. 74.7B).
In general, it is prudent to release all compartments, in-
n 

cluding the carpal tunnel if any of the hand compart-

ments are involved.
Do not attempt to close the wounds at this time. They
n 

may be permitted to granulate and heal, or after the

swelling has decreased, they can be closed secondarily.
A vacuum-assisted wound closure system may be used to
assist in wound management.
  

FIGURE 74.6 Vessel loop shoelace technique for fasciotomy

closure. SEE TECHNIQUE 74.2.

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3824 PART XVIII THE HAND

Incision

Neurovascular
Cleland bundle
Transverse
retinacular ligament
ligament
A B

FIGURE 74.7 A, Longitudinal incisions over second and third metacarpals. B, Midaxial incision
of finger. SEE TECHNIQUE 74.3.

if needed. The deep flexor compartment is not released in

the endoscopic approaches.
CHRONIC EXERTIONAL
COMPARTMENT SYNDROME OF THE
FOREARM MINI-OPEN FOREARM FASCIOTOMY
Because CECS of the forearm is rare, statements regard-
ing diagnosis and management are inherently provisional.
TECHNIQUE 74.4
Most experience with the condition involves competitive
motocross riders who develop symptoms described as
(HARRISON ET AL.)
n With the patient supine and the arm abducted on an
“arm pump,” which includes severe pain, tightness, weak-
arm table, exsanguinate the limb and apply a tourni-
ness, and difficulty controlling bike handles. Cessation of
quet.
activity typically leads to symptom resolution within 20 to
30 minutes. The diagnosis is made primarily by history and
EXTENSOR COMPARTMENT RELEASE
confirmed with compartment pressure measurements after
Mark a line between the lateral epicondyle and Lister’s
n 
the activity. Pedowitz et al. proposed diagnostic pressure
tubercle and measure it at the junction of the middle and
measurements for CECS as a resting compartment pres-
distal thirds.
sure of greater than 15 mm Hg, a compartment pressure
Make a skin incision from 5 cm distal to the epicondyle
n 
of 30 mm Hg or greater 1 minute after exercise, or greater
to 5 cm proximal of the two thirds mark (Fig. 74.8A); the
than 20 mm Hg at 5 minutes after exercise. A recent study
incision usually is about 8 cm long.
has proposed a TRest (or time to return from peak measure-
Perform a fasciotomy along the septum between the mo-
n 
ment to the patient’s own baseline compartment pressure)
bile wad and the extensor digitorum communis to release
of 14.5 minutes as another potential screening tool. Man-
both extensor compartments.
agement of CECS initially consists of rest and adjustments
Once all structures have been identified, extend the fas-
n 
to the racing technique and bike setup. If nonoperative
cial incisions proximally and distally to fully release from
treatment fails after a trial of at least 3 months, fasciot-
the epicondyle to the musculotendinous junction.
omy has been shown to allow a return to the sport in most
patients. Fasciotomy may be performed through multiple
FLEXOR COMPARTMENT RELEASE
techniques, including open, mini-open, and endoscopic. It
n Draw a line between the medial epicondyle to the junc-
seems that all techniques produce adequate results, allow-
tion of the palmaris longus at the distal wrist crease and
ing surgeon preference to guide the choice of technique.
mark it at two thirds of its length for extensor compart-
Mini-open and endoscopic techniques may allow quicker
ment release.
recovery and improved cosmesis, but open methods
improve exposure and allow formal nerve decompression

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 CHAPTER 74 COMPARTMENT SYNDROMES AND VOLKMANN CONTRACTURE 3825

Make a skin incision from 5 cm distal to the epicondyle to

n  mass, with flexion contractures usually involving only
5 cm short of the two thirds mark (Fig. 74.8B). two or three fingers. Sensory changes usually are mild or
Split the fascia in line with the incision to release the su-
n  absent. Intrinsic muscle contractures and joint contractures
perficial flexor compartment. are absent. During the early stages of a mild contracture,
Develop the interval between the flexor digitorum super-
n  dynamic splinting to prevent wrist contracture, functional
ficialis and flexor carpi ulnaris down to the deep fascia. training, and active use of the muscles may be helpful. After
Identify the ulnar nerve and release the deep fascia over
n 

the flexor digitorum profundus, taking care to protect the

nerve and its branches.
Extend the fascial releases proximally from the epicondyle
n 

and distally to the musculotendinous junction.

  
A

ESTABLISHED VOLKMANN CONTRACTURE

OF THE FOREARM
If compartment syndrome is untreated or inadequately
treated, compartment pressures continue to increase until
irreversible tissue ischemia occurs. Volkmann ischemic
contracture is the result of several different degrees of tis-
sue injury; however, the earliest changes usually involve
the flexor digitorum profundus muscles in the middle
third of the forearm (Fig. 74.9). The typical clinical pic- B
ture of established Volkmann contracture includes elbow FIGURE 74.8 Incision for mini-open release of extensor compart-
flexion, forearm pronation, wrist flexion, thumb adduction, ment (A) and flexor compartment (B). (Redrawn from Harrison JWK,
metacarpophalangeal joint extension, and finger flexion. Thomas P, Aster A, et al: Chronic exertional compartment syndrome of the
A mild contracture, also termed localized Volkmann forearm in elite rowers: a technique for mini-open fasciotomy and a report
contracture, results from partial ischemia of the profundus of six cases, Hand 8:450, 2013.) SEE TECHNIQUE 74.4.

Radial
recurrent Brachialis
artery
Brachial artery
Common
interosseous Ulnar
artery recurrent Median nerve
Radial artery artery
Pronator teres
Lacertus Ulnar artery
Recurrent (humeral head)
interosseous fibrosus (cut)
Pronator teres Pronator teres
artery (ulnar head)
Anterior Biceps tendon
interosseous Radial artery
artery

Posterior Ulnar artery

interosseous Flexor digitorum
artery sublimis
Brachioradialis
Interosseous
membrane

A B C
FIGURE 74.9 Anatomy of Volkmann ischemia. A, “Collateral circulation” of elbow does not
communicate with vessels within flexor compartment. These elbow collaterals join radial and ulnar
arteries proximal to pronator teres, the proximal guardian of flexor compartment. B, Brachial artery
and median nerve enter forearm through tight opening formed by biceps tendon insertion laterally
and pronator teres muscle medially and are tightly covered by lacertus fibrosus. Proximal angula-
tion, hematoma, or muscle swelling within this cruciate tendon-muscle portal is capable of major
compression of neurovascular bundle. C, Radial artery, arising from brachial artery, passes distally
superficial to pronator teres and all flexor muscles. It is not crossed by any structure along this route.
Ulnar artery passes beneath pronator teres and lies in deepest portions of compartment. Median
nerve usually passes between humeral and ulnar heads of fleshy pronator teres, and, emerging, it
becomes compressed against firm arcuate band of flexor sublimis origin (see text).

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3826 PART XVIII THE HAND

3 months, the involved muscle-tendon units can be released

and lengthened. When multiple tendon units are involved, EXCISION OF NECROTIC MUSCLES
however, a muscle sliding operation is preferable to length-
ening of multiple tendons, wrist resection, or other possi- COMBINED WITH NEUROLYSIS OF
ble procedures. If involved, the pronator teres may require MEDIAN AND ULNAR NERVES FOR
excision.
A moderate contracture usually involves not only the SEVERE CONTRACTURE
long finger flexors, but also the flexor pollicis longus and This is a salvage procedure that may result in only modest
possibly the wrist flexors. Median and ulnar nerve sensory improvement. If the contracture is diffuse but incomplete
changes and intrinsic minus deformities are present. In this throughout all digital and wrist flexors, the muscle sliding
instance, the muscle sliding operation, careful neurolysis of technique may be considered (see Chapter 72).
the median and ulnar nerves without injuring their branches,
and the excision of any fibrotic muscle mass encountered TECHNIQUE 74.5
can be done. When no useful movement of the finger flexors
has been retained, volar transfers of dorsal wrist extensors, Make an extensive volar forearm incision (Fig. 74.5) and
n 
such as the brachioradialis and extensor carpi radialis longus, excise all avascular masses of the flexor profundus and
and a complete release of the wrist and finger flexors may be sublimis muscles, leaving any muscle that might survive
required. or appears viable.
A severe contracture involves the flexors and exten- Perform a neurolysis of the median and ulnar nerves. The
n 
sors of the forearm. Fractures of the forearm bones and median nerve usually is affected and may have an hour-
scars on the skin also may be present. Sensory feedback glass deformity in the midforearm. Neuroma excision and
is usually impaired because the nerves are strangulated secondary nerve grafting may be necessary.
by the contracted and scarred muscles surrounding them. Correct finger and wrist flexion deformities by dividing
n 
The preferred treatment in these instances is early exci- the involved flexor tendons at the musculotendinous
sion of all necrotic muscles, combined with complete junctions and excising the fibrotic muscle. At this time,
median and ulnar neurolysis to restore sensibility and at least the functional position of the hand will have
possibly intrinsic function. Although one author recom- been restored.
mended this be done no sooner than 3 months but no At a second-stage procedure, any viable extensor muscles
n 
later than 1 year after the ischemic event, others have rec- can be transferred to the finger flexors. At least one wrist
ommended surgical intervention within 3 weeks to pre- extensor must be retained, however. Otherwise, any wrist
vent additional contractures from developing. Tendon flexor or extensor muscle can be transferred to power
transfers to restore function should be performed as the profundus and flexor pollicis longus tendons. Most
a secondary procedure. These may include transfer of commonly, the brachioradialis is transferred to the flexor
the brachioradialis to the flexor pollicis longus and the pollicis longus and the extensor carpi radialis longus to the
extensor carpi radialis longus to the flexor digitorum flexor digitorum profundus of all four fingers.
profundus tendons. If motors to restore finger flexion are   
unavailable, a free innervated muscle transfer using the
gracilis muscle may be considered (see Chapter 63). In
one long-term study (32 years), substantial improvement
was noted with excision of fibrotic muscle, neurolysis, and
tendon or free gracilis transfers; however, tendon length-
ening alone was rarely satisfactory. For severe Volkmann TWO-STAGED FREE GRACILIS
ischemic contracture, Oishi and Ezaki recommended a TRANSFER
two-stage procedure with initial muscle debridement
and neurolysis, followed by a free-functioning gracilis
transfer after return of sensation and intrinsic function TECHNIQUE 74.6
to the hand. Satisfactory results have also been reported
using a free medial gastrocnemius myocutaneous flap for (OISHI AND EZAKI)
reconstruction in patients with established Volkmann
contracture. FIRST STAGE
Widely expose the volar forearm compartment from the el-
n 

bow to the wrist (see Fig. 74.5B) and elevate the skin flaps.
MUSCLE SLIDING OPERATION OF FLEXORS FOR Identify and mobilize the ulnar nerve at the elbow. After
n 

ESTABLISHED VOLKMANN CONTRACTURE isolating and protecting the median nerve and brachial ar-
The muscle sliding operation was first described by Page tery at the antecubital fossa, dissect the median and ulnar
in 1923 and was endorsed by Scaglietti in 1957. It has nerves and vascular structures all the way from the elbow
been used for Volkmann and other contractures caused to the wrist to free adherences to fibrotic necrotic muscle.
by conditions such as brain damage and burns. In cases Debride all the involved muscle, including the deep lay-
n 

of Volkmann contracture, usually the muscle is fibrotic ers. Sometimes the only structures remaining after de-
and noncontractile, and a muscle sliding operation alone bridement are the median and ulnar nerves, the vascular
is rarely indicated. structures, and the tendon ends.

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 CHAPTER 74 COMPARTMENT SYNDROMES AND VOLKMANN CONTRACTURE 3827

Perform any necessary nerve grafting or vascular recon-

n  of extension and slight overcorrection of the normal fin-
struction at this point. ger cascade.
Keep the proximal ends of the flexor tendon as long as
n  Flex the wrist to ensure that the tenodesis allows the fin-
n 

possible (it is helpful to suture the proximal ends of the gers to extend appropriately.
flexor digitorum profundus and the flexor pollicis longus Close the skin flaps and immobilize and elevate the upper
n 

together for later identification). In young or small chil- extremity. Failure to elevate the extremity could jeopar-
dren, suture these ends to an area proximal to the carpal dize flap viability.
tunnel to prevent retraction into the carpal tunnel.
Close the skin and immobilize the arm in a cast for 3
n  POSTOPERATIVE CARE The patient is placed in a warm
weeks to allow the wound to heal. After removal of the room and started on one low-dose (81 mg) aspirin per
cast, begin passive range-of-motion exercises to the fin- day. The dressing is changed, and the Doppler device is
gers and wrist. The patient is observed over the ensuing removed at 6-7 days with the patient under anesthesia.
6 months for muscle and sensory recovery. The upper extremity is immobilized for 4 weeks, and then
range-of-motion exercises are begun. Protective splinting
SECOND STAGE is used for the first few months. Muscle function may take
For the second-stage procedure, a two-person team ap- up to 6 months to return.
proach is used; one is responsible for exposing the forearm,   
including the neurovascular structures and tendinous ends,
and the other for harvesting the gracilis muscle.
Identify the brachial artery in the forearm and follow it dis-
n  ESTABLISHED INTRINSIC MUSCLE
tally to determine its suitability or that of any of its branch- CONTRACTURES OF THE HAND
es. Also identify a vein for anastomosis because the venae Proper surgical release of established intrinsic muscle contrac-
comitantes or subcutaneous veins may not be suitable. tures depends on the severity of the contractures. When the
Identify the anterior interosseous branch, and in the distal
n  contractures are mild (Fig. 74.10), the metacarpophalangeal
forearm, identify and prepare the ends of the flexor digi- joints can be passively extended completely, but while they are
torum profundus and flexor pollicis longus tendons. held extended, the proximal interphalangeal joints cannot be
In the lower extremity, expose the gracilis muscle with or
n  flexed (positive intrinsic tightness test); in these instances, the
without an accompanying skin paddle. If a skin paddle is distal intrinsic release of Littler may be indicated (Fig. 74.11).
necessary, use only the proximal two thirds of overlying In contractures that are more severe, the interosseous
skin because the blood supply to the distal third of skin muscles are viable but contracted, and the intrinsic tight-
overlying the muscle is unreliable. ness test is positive. Active spreading of the fingers may be
Tag the anterior surface of the gracilis muscle with sutures
n  possible. In these instances, the contracted muscles may be
at 2-cm intervals to correctly identify the resting tension released from the metacarpal shafts by a muscle sliding oper-
of the muscle. ation (Fig. 74.12A).
Identify the neurovascular bundle and dissect it. Careful
n 

dissection is mandatory because the anterior branch of

the obturator nerve runs superiorly from the muscle.
When the forearm recipient site has been prepared, re-
n 

lease the origin and divide the neurovascular bundle.

If a vein graft is deemed necessary, microvascular anasto-
n 

mosis of the vein graft to the gracilis artery can be done

on a back table using an operating microscope.
Suture the proximal gracilis to the medial epicondyle us-
n 

ing nonabsorbable suture. Note the location of the ulnar

nerve before carrying out this step. Also, take care to posi-
tion the muscle so as not to cause undue tension on the
upcoming microvascular work.
Using an operating microscope, perform anastomoses of
n 

the artery, vein(s), and nerve. Examine the anterior inter-

osseous nerve under the operating microscope and cut it
back until good fascicles are seen. The closer the nerve
coaptation is to the muscle, the shorter the distance nec-
essary for reinnervation.
Place an implantable Doppler probe around the artery for
n 

postoperative monitoring. After assessment of adequate

flow, suture the flexor digitorum profundus ends to each
other and to the gracilis muscle at its resting tension (marked
earlier).
Suture the flexor pollicis longus tendon to a separate por-
n  FIGURE 74.10 Abduction contracture of fifth finger in patient
tion of the gracilis muscle with the wrist in 10-20 degrees who developed fibrosis in abductor digiti quinti, probably secondary
to ischemic myositis from compressive bandage.

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3828 PART XVIII THE HAND

Transverse
fibers

Oblique
Sagittal fibers
A bands

B
FIGURE 74.11 Littler release of intrinsic contracture. A, Extensor
aponeurosis at level of metacarpophalangeal joint consists of long
extensor tendon, transverse fibers (which flex the metacarpopha-
langeal joint), and oblique fibers (which extend the interphalangeal
joint). Crosshatched part is resected from each side of hood. B,
Appearance of aponeurosis after release. SEE TECHNIQUE 74.7.

B
In the most severe contractures, the intrinsic muscles not
only may be contracted, but also necrotic and fibrosed, so any FIGURE 74.12 A, Method of stripping and advancing interos-
useful muscle excursion is absent. In these instances, the ten- seous muscles to slacken them, allowing proximal finger joints to
don of each muscle must be divided to release the contrac- extend and distal two to flex. Interosseous muscles of two clefts
tures (Fig. 74.12B). Other procedures, such as capsulotomies have been stripped. Stripping of interossei is done only when
and tendon transfers, also may be necessary. muscles still retain considerable function. Nerve supply should be
spared. B, Complete intrinsic tenotomy for severe intrinsic contrac-
tures in which nonfunctioning interosseous muscle remains.

RELEASE OF ESTABLISHED INTRINSIC

POSTOPERATIVE CARE Active motion of the interpha-
MUSCLE CONTRACTURES OF THE langeal joints is begun the day after surgery, and the splint
HAND and sutures are removed at 10-14 days.
  
TECHNIQUE 74.7
(LITTLER)
The same procedure is done on any finger as needed.
n 

Make a single midline incision on the dorsum of the proxi-

n  RELEASE OF SEVERE INTRINSIC
mal phalanx, extending from the metacarpophalangeal
joint to the proximal interphalangeal joint to allow good
CONTRACTURES WITH MUSCLE
exposure of both sides of the extensor aponeurosis. Incise FIBROSIS
the insertion of the oblique fibers of the extensor aponeu-
rosis into the extensor tendon; make the incision parallel TECHNIQUE 74.8
with the tendon (Fig. 74.11A).
Preserve the transverse fibers to avoid hyperextension of the
n  (SMITH)
metacarpophalangeal joint with its resultant clawhand defor- Make a dorsal transverse incision just proximal to the
n 

mity and limitation of extension of the interphalangeal joints. metacarpophalangeal joints.

After adequate excision of the oblique fibers, the proximal
n  Resect the lateral tendons of all the interossei and the
n 

interphalangeal joint should have full passive flexion with abductor digiti quinti at the level of the metacarpopha-
the metacarpophalangeal joints in neutral (Fig. 74.11B). langeal joints. If these joints remain flexed, retract the
Close the incision.
n  sagittal bands distally, and divide each accessory collateral
Apply a volar plaster splint from the elbow to the middle
n  ligament at its insertion into the volar plate.
of the proximal phalanges, immobilizing the metacarpo- Free the volar plate from its attachments to the base of the
n 

phalangeal joints in extension and permitting full motion proximal phalanx, and with a blunt probe, separate any ad-
of the interphalangeal joints. hesions between the volar plate and the metacarpal head.

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 CHAPTER 74 COMPARTMENT SYNDROMES AND VOLKMANN CONTRACTURE 3829

If maintaining extension of the proximal phalanx is dif-

n  can cause a secondary contracture of the others; rarely is there
ficult after soft-tissue release, insert a Kirschner wire contracture of only one. Causes of some injuries include scarring
obliquely through the metacarpophalangeal joint with of the skin, burns, infection, crush injuries, congenital webbing,
the joint in maximal extension. When the phalanx is ex- paralysis, Dupuytren contracture, and faulty immobilization.
tended, ensure that its base articulates properly with the The proper treatment of a contracted web is determined
metacarpal head before inserting the wire. by which structures of the web are involved; little is accom-
If passive flexion of the proximal interphalangeal joints
n  plished by releasing the skin alone when deeper structures,
is incomplete with the metacarpophalangeal joints ex- such as muscle, fascia, or joint capsule, also are contracted.
tended, resect the lateral bands at the distal half of the When the skin alone is contracted from a hypertrophic scar
proximal phalanges through separate dorsal incisions. after a surgical incision or a laceration along the border of the
web, it sometimes can be released by a Z-plasty or a local flap.
POSTOPERATIVE CARE Passive and active flexion exer- The four-flap Z-plasty is a commonly utilized technique to
cises of the proximal interphalangeal joints are begun within expand the first web space when the predominant causative
1 day of surgery. The Kirschner wires are removed at about factor involves the skin. It is described in Chapter 64.
3 weeks. Crushing injuries, infections, or deep burns result in exten-
   sive fibrosis within the thumb web that cannot be treated by
release of the skin alone; rather, the scarred components of the
contracted skin, muscle, fascia, and capsule must be excised with
ADDUCTED THUMB care to avoid damaging the radial artery near the carpometacar-
Only complete loss of the thumb causes more disability in the hand pal joint. This excision produces a deep fissure that must be filled
than a fixed severe adduction of the thumb (web contracture). The with skin and subcutaneous fat to provide an elastic function-
thumb is the only digit with the ability to bring its terminal sen- ing web. This may be accomplished by dorsal rotation or a slid-
sory pad over the entire surface of any chosen finger or over the ing flap with supplemental skin grafting (Figs. 74.13 and 74.14).
distal palmar eminence. The saddlelike first carpometacarpal joint
provides the circumductive movement of the thumb necessary for
pinch or grasp functions. The intrinsic muscles of the thumb and
the extrinsic flexors and extensors all are important in the balanced
control required to perform these functions effectively. The short
abductor muscle positions and stabilizes the thumb metacarpal for
pinch; the adductor muscle supplies the power for pinch by acting
on the proximal phalanx; the long extrinsic flexor muscle positions
the distal phalanx in varying degrees of flexion and consequently
controls the type of pinch, whether it be fingernail-to-fingernail
opposition or pulp-to-pulp opposition with another digit. The
thumb web must be supple if these important movements of
the thumb are to be possible. Any contracture of the thumb web A B
causes limited opposition of varying degrees. In severe contrac- FIGURE 74.13 One method of releasing dorsal skin of adducted
ture, the thumb is in a position of adduction and external rotation. thumb (see text) (Brand and Milford). A, Skin incision. B, Skin
The thumb web consists of skin, subcutaneous tissue, muscle, grafting covers defect after release has been accomplished by
fascia, and joint capsule. Contracture of any one of these tissues undermining dissection.

A B C
FIGURE 74.14 Cross-arm flap coverage of deepened thumb web. A, Web space deepening after
skin division and muscle recession. B, Position of hand with triangular distal flap (b) sutured into dorsal
thumb web defect. Outline of proximal triangular flap (a) that will be used for palmar web coverage.
C, Web space reconstruction after transfer of palmar flap at second-stage operation 3 weeks later.

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3830 PART XVIII THE HAND

If the adjacent tissue is unsuitable for transfer, several other Garcia-Mata S: Chronic exertional compartment syndrome of the forearm in
options are available to treat moderate-to-severe first web space adolescents, J Pediatr Orthop 33:832, 2013.
contractures. Rotational axial pattern flaps include reverse pos- Gondolini G, Shiavi P, Pogliacomi F, et al.: Long-term outcome of mini-open
surgical decompression for chronic exertional compartment syndrome of
terior interosseous artery flap, reverse radial forearm flap, or a
the forearm in professional motorcycling riders, Clin J Sport Med 2017,
groin flap (described in Chapter 65). A free lateral arm flap may [Epub ahead of print].
also be used (described in Chapter 63). The cross-arm flap has Gottlieb M, Adams S, Landas T: Current approach to the evaluation and
been described as well. It is fashioned as a double triangle, one management of acute compartment syndrome in pediatric patients,
on the dorsal surface and one on the volar surface of the web, to Pediatr Emerg Care 35(6):432, 2019.
eliminate any line of scar paralleling the border of the web. The Griffart A, Gautheir E, Vaiss L, et al.: Functional and socioprofessional out-
first and second metacarpals are fixed in the desired position with come of surgery for Volkmann’s contracture, Orthop Traumatol Surg Res
Kirschner wires. When motion in the carpometacarpal joint can 105(3):423, 2019.
be restored, any necessary tendon transfers for apposition can be Harrison JW, Thomas P, Aster A, et al.: Chronic exertional compartment
done later, but if motion cannot be restored the carpometacar- syndrome of the forearm in elite rowers: a technique for mini-open fasci-
otomy and a report of six cases, Hand (N Y) 8:450, 2013.
pal joint must be arthrodesed to maintain the new position of the
Hashimoto K, Kuniyoshi K, Suzuki T, et al.: Biomecanical study of the
thumb permanently. digital flexor tendon sliding lengthening technique, J Hand Surg Am
Paralysis of the muscles of apposition can result in sec- 40(10):1981, 2015.
ondary contracture of the skin and joint capsule, and in con- Hosseinzadeh P, Hayes CB: Compartment syndrome in children, Orthop
tracture of the thumb web, requiring release by a Z-plasty or Clin North Am 47(3):579, 2016.
using a local flap and a skin graft as described by Brand and Hosseinzadeh P, Talwalkar VR: Compartment syndrome in children:
Milford (see Fig. 74.13). Contracted fascia and bands of mus- diagnosis and management, Am J Orthop (Belle Mead NJ) 45(1):19,
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joint must be done at the same time. Humpherys J, Lum Z, Cohen J: Diagnosis and treatment of chronic exer-
Occasionally, a useless index finger may provide a fil- tional compartment syndrome of the forearm in motorcross riders, JBJS
Rev 6(1):e3, 2018.
leted pedicle with which a satisfactory thumb web can be
Kalyani BS, Fisher BE, Roberts CS, Giannoudis PV: Compartment syndrome
constructed in one stage. This procedure not only widens the of the forearm: a systematic review, J Hand Surg [Am] 36A:535, 2011.
web, in that the index metacarpal is excised, but also provides Kenny EM, Egro FM, Russavage JM, et al.: Primary closure of wide fasci-
skin that can be repositioned over a nearby defect or scar (see otomy and surgical wounds using rubber band-assisted external tissue
discussion of filleted graft in Chapter 65). expansion: a simple, safe, and cost-effective technique, Ann Plast Surg
81(3):344, 2018.
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3831.e2 PART XVIII THE HAND

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