Ischemic contracture of Folkman
Author Ольга Кияница
Folkman's ischemic contracture (ICF) is a constant flexural contracture, most commonly the wrist, which leads to claw strain of the hands and fingers. Forced straightening of fingers is limited and painful.
The disease was classified by Dr. Richard von Volkman, a German physician of the nineteenth century, who for the first time described the pathology [1 - R. Volkmann. Die ischämischen Muskellähmungen und Kontaktura. Centralblatt für Chirurgie, Leipzig, 1881, 8: 801-803] in the article "Noninfectious ischemic states of various facial parts in the limbs".
Folkman's ischemic contracture is diagnosed quite simply because there are criteria for evaluating both clinical manifestations and instrumental methods of investigation. There are various ways of treating a pathology, for example, with the help of massage and physiotherapy. Most often resorting to a surgical method of exposure, which allows you to eliminate or reduce the severity of deformity of the limb.
Video: Folkman ischemic contracture general information and history (Prof. Hanno Millesi, Austria)
In 1881, Richard von Volkman attempted to attribute irreversible contractions of the flexor muscles to the ischemic processes in the forearm, believing that the problem was caused by massive venous congestion and simultaneous arterial insufficiency, which developed secondarily against the background of excessively tight bandage.
In 1906, Hildebrand first used the term "Folkman's ischemic contracture" in relation to any similar compartment syndrome; He was also the first to suggest that increased tissue pressure may be due to ischemic contracture.
In 1909, Thomas reviewed 112 published cases of Folkman contracture and found that fractures are the predominant cause of the development of this pathology. He also noted that rigid bandages, arterial emboli or
arterial insufficiency can also lead to this problem. Since then, much has become known about the etiology of Folkman contracture and, more importantly, about its prophylactic treatments.
In 1914, Murphy was the first to suggest that fasciotomy may reduce the extent of the Fulkman contracture. He also expressed the opinion that tissue pressure and fasciotomy may be associated with the development of contracture.
During the Second World War and subsequently many cases of Folkman contracture occurred due to gunshot wounds that caused fractures. Unfortunately, the arterial spasm accompanying the fracture was considered as a cause;therefore, more attention was paid to treating arterial spasm than to determine the need for fasciotomy.
The recognition of the importance of fasciotomy increased during the Vietnam War, and in 1967, Chandler and Knapp suggested that long-term results could be improved if surgeons combine conventional fasciotomy with arterial reconstruction.
Initially, most studies of ischemic contracture were focused on studies of the upper limb. In 1958, Ellis reported 2% of cases of compartment syndrome with tibial fractures, after which increased attention was paid to contractions of the lower extremities.
Initially, the focus was on the front leg of the leg, but the work of Seddon, Kelly and Whiteside in the mid-1960s demonstrated the existence of four branches in the leg, which led to the need to decompress more than previously thought. Since then, it has been proven that the compartment syndrome has an effect on many areas of the body, including hands, legs, hips and buttocks.
Current research is aimed at reperfusion of ischemic limb. Some advocate the use of hyperbaric oxygen to improve the oxygenation of tissues and prevent further myonecrosis. [2 - Myers RA. Hyperbaric oxygen therapy for trauma: crushing injury, compartment syndrome, and other acute traumatic peripheral ischemia. Int Anesthesiol Clin. 2000; 38 (1): 139-51]
Early detection and prevention of ICFs are still important in preventing severe disability. Frequent repeated courses of treatment are required. Catheters with a miniature transducer can provide continuous and accurate measurements of the internal pressure. Other non-invasive methods for Folkman contracture are currently under study.
During the development of ischemic contracture Folkman involves various flexural muscles, superficial and deep.
The following can affect the surface flexor muscles:
- Pronator Teres (round propagator)
- Flexor carpi radialis (wrist beam flexor)
- Flexor carpi ulnaris (elbow folded wrist)
- Flexor digitorum superficialis (surface folding finger)
- Palmaris longus (long palm muscle)
From deep muscle-flexors to the pathological process can be involved:
- Flexor pollicis longus (long thumb fist)
- Pronator quadratus (square proctor)
- Flexor digitorum profundus (deep flexion finger)
The development of inflammatory bowel movements is closely associated with impaired circulation, resulting in muscle cells beginning to die. Their complete necrosis occurs 4-6 hours after the onset of ischemia, after which connective tissue begins to form, rigid and incapable of contraction. Dying out of nerve fibers due to ischemia occurs after 12-24 hours. In the absence of timely assistance, the ability to move any movement is lost.
Folkman ischemic contracture is usually observed in children with displaced supracondylar fractures of the humerus or fractures of the forearm. This is due to the serious damage to the deep tissues and muscles of the voluntary part, which develops again on the background of increased internal pressure. [3 - Hargens AR; Mubarak SJ. Current concepts in the pathophysiology, evaluation, and diagnosis of the compartment syndrome. Hand clin 1998; 14 (3): 371-83]
The following three degrees of Folkman contracture were described:
- Lightweight (wrist flexors are used)
- Moderate (associated with damage to flexor digitorum profundus, flexor digitorum superficialis, flexor pollicis longus, flexor carpi radialis and flexor carpi ulnaris)
- Heavy (develops with the involvement of flexors and extensors)
Statistics on ischemic contracture of Folkman
- Occurs rarely, with a frequency of about 0.5%.
Any process that leads to increased pressure can lead to compartment-syndrome. For example, reducing the size of the unit without changing the volume of the contents leads to an increase in pressure. This change may be secondary in closing fascial defects, limiting external pressure, or excessively heavy bandages.
Many processes lead to an increase in the amount of content without an appropriate increase in the size of the department, thereby leading to an increase in pressure. Bleeding into a closed department may be associated with severe vascular damage or with congenital / acquired violation of the blood coagulation process.
The increased capillary permeability through which the inflammatory arterial hypertrophy also develops can be caused by:
- physical exercises;
- introduction of intraarterial drugs;
- surgical operations;
- convulsions and eclampsia;
- injuries (without significant vascular damage).
Exercise, venous obstruction (venous thrombosis) and the use of a long tire on the leg may increase the capillary pressure. Muscular hypertrophy or neoplastic processes often increase the volume of the contents of the department and, consequently, the internal pressure. Finally, infiltrative infusions are the iatrogenic cause of this condition.
The clinical picture of the ischemic contraction of Folkman often involves five symptoms:
- Pain that increases with passive tension
- No pulse
Additionally, the following features can be determined:
- Compacted limb tissue with palpation
- Sealing in the area of the forearm
Of all the signs, pain sensation is one of the earliest symptoms.
In a physical examination, the pain, more pronounced against passive tension, is the most reliable evaluation criterion.In addition, densification of tissues, often determined during palpation, is often noted. Paresthesia and paralysis are late symptoms.
Video: Volkmann's Ischemic Contracture Classic
If there is suspicion about the contracture of Folkman, then, apart from a thorough physical examination, including the affected limb, questions about the previous injury or states and manipulations that could damage the arm or leg are being asked.
Studies that are conducted for the examination of patients with suspected ICF:
- X-ray of the patient's limb
- Neurological tests of muscles and nerves, allowing to check their function
First of all, an X-ray of the humerus, elbow and forearm is made. With its help, the magnitude of the displacement of supracondylar fractures and combined radial, as well as elbow fractures is estimated.
The initial treatment of the Folkman contracture is to remove occlusive dressings or gypsum.
Analgesics are included in the symptomatic treatment associated with the reduction / elimination of painful sensations in chronic illness.
In some cases, it is not possible to quickly restore lost limb functions, but do not despair. Recovery may require perseverance and longer time.
Additionally, you can use:
- Circulatory massage of the patient with limb in an inclined position.
- Thermotherapy (hot baths, paraffin)
- Active or passive mobilization of all joints, as far as possible (if the pain is not too pronounced)
Phasciotomy is necessary to prevent the progression of the Folkman contracture. There are some disagreements as to how much pressure in the chamber is an indication for fasciotomy; however, the majority of researchers agree that patients with a pressure in the chamber over 30 mm Hg. Art. should be delivered to the operating room for emergency fasciotomy.
There is no absolute contraindication for immediate decompression with Folkman contracture in acute condition.
Both physical therapy and professional therapy are vital for increasing the range of motion and recovery in patients with Folkman's contracture.
To prevent the development of Folkman contracture, decompression is performed through a voluntary or dorsal approach. Decompression of the mediastinal nerve throughout its length is important, especially in the case of contracture in the following areas of increased risk
- Deep located fibrous plate
- Between the shoulder and elbow heads of the circular promoter, proximal arch and deep fascia of the surface flexor of the fingers.
The treatment of ischemic contractions of Folkman depends on the severity of the clinical signs:
- With a slight degree of expression - the dynamic tire (splint therapy), physical therapy, tendon lengthening and slip procedures are used
- With a moderate degree of disease - tendon dilatation, neurolysis and extensor transfer procedures are used.
- Severe ICF - more extensive and radical intervention is necessary, in particular, a thorough treatment of the damaged muscle with multiple removal of scar tissue and reconstruction manipulations is carried out
The viability of the muscles with Folkman contracture can be evaluated using four indicators: color, consistency, contractility and bleeding ability.
Cubitus varus, or deformation of the elbow, is the most common complication in the contraction of Folkman. It develops in 25-60% of patients. When using percutaneous pinning, the frequency of this complication is reduced to 10% or less.
Complications are most often associated with fasciotomy, which is used to eliminate Folkman contracture. The following adverse changes are most often evolving:
- Violation of sensations in the wound area (77% of cases)
- Dry, flaky skin (40%)
- Itching (33%)
- Wound formation (30%)
- Limb swelling (25%)
- Scar formation (26%)
- Repetitive ulceration (13%)
- Muscle hernia (13%)
- Pain associated with wound (10%)
The formation of scars can affect the patients' lives. In one study, 23% of patients suffered from a preserved wound, 28% had to change their hobby, and 12% changed their occupation. [4 - Fitzgerald AM; Gaston P; Wilson Y; Quaba A;McQueen MM. Long-term sequelae of fasciotomy wounds. Br J Plast Surg. 2000; 53 (8): 690-3]
To prevent the development of ischemic contracture, Volckman needs to follow the rules of dressing or dressing after the surgery. The method of immobilization used must be designed in such a way that limb blood circulation is not disturbed.
After an injury, such as an elbow, and the observation of painful sensations over a long period of time, you must contact a doctor to have an X-ray diffraction pattern and prevent the development of a post-traumatic contracture.
Nerve damage occurs in 7% of cases, with the general involvement of the radial, medial and elbow nerves. The majority of violations are observed in the background of an injury. Fortunately, neuropraxia can be eliminated with the help of conservative management.
In case of timely treatment, the lost contraceptive functions return after 7-12 weeks, after which restoration of sensations takes place, which can last for more than 6 months.
It is reported that 10% of children with supracondylar fractures temporarily lose their radial impulse. Such a violation is most often caused by edema, and not by the trauma of the brachial artery. Removal of edema usually helps to return arterial blood circulation.
Video: Folkman ischemic contracture. Volkmann's ischemic contracture. 1 (6) Diagnostics.