Please tell me about Volkmann's ischaemic contracture and myositis ossificans.?

Question

Can you explain what these conditions are? I read that Supracondylar fracture can cause the above conditions. Please tell me how and also other causes for the above to occur.

Answer 1

VOLKMANN'S ISCHAEMIC CONTRACTURE

Definition : Volmann's ischamic contracture (VIC) is a contracture developing in a group os muscles caused by ischemia due to compression or spasm of arteries.

Etiology : It is seen in the forearm and hand and less commonly in the leg and foot. Ischemia contracture of the forearm and hand is a tragic complication still common in India. This crippling deformity is mostly due to tight bandaging with crude splints applied by traditional bone setters in the treatment of elbow and forearm injuries. It is also seen in hospital practice due to the careless application of tight plaster bandages. It can occur in grossly displaced supracondylar fractures, where the sharp anterior edge of the upper fragment irritates or demages the brachial artery.

Pathology : The condition is due to contusion, spasm or thrombosis of the brachial artery at the elbow, or the radial and ulnar arteries in the upper half of the forearm. It is also due to edema and increased pressure in ther anterior osteofascial compartment of the forearm. There is an area of ischemic necrosis of the pronator and flexor muscles in the forearm, followed by fibrosis and later contractures of these muscles. These may also be associated ischaemic paralysis of the median and ulnar nerves. In the later stages there are secondary capsular contractures of the wrist and the finger joints.

Clinical features

Clinically this can be described in two stages.

1. Acute Volkmann's Ischaemia
2. Chronic Volkmanns's Ischaemic Contracture.

Acute Volkmann's Ischaemia

The patient who has been manipulated and plastered for supracondylar fracture elbow may present the next day with acute unbearable pain and swelling in the fingers and hand. Thee will be pallor of the skin and edema and inability to move the fingers. Capillary filling in the nail bed and redial pulse are absent. There may also be paraesthesia and paresis due to ischemia of median and ulnar nerve. Passive extension of the fingers causes severe pain.

Treatment : This is an emergency, threatening the life of the limb and must be tackled with speed and vigour to prevent permanent damage.

At this stage of all constricting bandages and plaster should be removed immediately and fixion at the elbow lessened. If the fracture at the elbow has not been reduced, immediate manipulation must be done to reduce the fracture and relieve the pressure on the blood vessels.

If the pulse does not reappear after this, the artery is surgically explored and decompressed. Incision of the skin and deep fascia (fasciotomy) releases the tension in the cubital fossa and forearm and restores the pulse in the vessel. If the vessel is found damaged it should be repaired.

Chronic Volkman's Ischaemic Contracture

This is the established contractures of the forearm muscle in varying grades of severity. The deformity is typical. The forearm is wasted , the wrist is fixed, the metacarpophalageal joints remain extended, interphalangeal joints are flexed. On passively extending the wrist, the finger flexion gets worse but on full flexion of the wrist, fingers can be fully extended passively. This is the Volkmann's sign. There will also be varying degrees of paresis of the median and ulnar nerves.

Treatment : This disabling condition is difficult to treat and only salvaging procedures are often possible. In minimal deormities, prologed physiotherphy and splinting with elastic traction to the fingers will correct the deformity and improve function.

In cases where conservative treatment has failed, the deformity can be improved by surgery. The soft tissue procedures used are the sliding of the origin of the common flexor muscles or lengthening the flexor tendons. The bony procedures used are shortening the forearm bones or excisionn of the carpal bones improving the appearance and function of the hand.

Ischemic contracture to leg

Volkmann's inchemic contracture also occurs in the muscles of the leg and foot. In closed fractures of the proximal end of the tibial shafts, the haematoma confined under the tense osteofascial compartment compresses the tibial arteries, causing progressive ischemia and later contracture. If untreated it leads to equins contracture and clawing of the toes.

MYOSITIS OSSIFICANS

Definition

Mysositis ossificans is a condition wherein there is new bone formation in soft tissues around joints following trauma.

The name is a misnomer as it is not an inflammation of the muscles. It is better referred to as post traumatic ossification. This condition is quite different from the Myositis ossificans progressiva (described elsewhere) which is generalised.

Etiopathology

This complication is very common following injuries around the elbow. Myositis ossificans can occur after reduction of the dislocation of the elbow or supracondylar fracture. Sometimes, it occurs even after minim al injuries like crack supracondylar fracture or crack fracture of the neck of the radius. In all these cases, the invariable cause is massage to the elbow and vigorous passive stretching to resore movements of the elbow, given by the bone setters or by well meaning relations of the patient.

It also occurs around hip joints following head injuries and traumatic paraplegia.

The exact mechanism of this type of new bone formation is unclear. Following trauma, there is hemorrhage around the periosteum, capsular ligaments as well as muscles surrounding the joint. In some cases, in the reactionary stage, there is formation of new bone around these tissues. This is called myositis ossiicans.

Clinnical features

In the early active stage, there is slight warmth with limitation of movements due to muscle spasm In the later consolidating stage a firm lumb is palpable is front of the elbow. In the final stages a bony hard lumb is flt surrounding the elbow with total loss of movement.

Radiological features

In the early active stage a fussy ill defined radio opacity (cotton wool appearance) is seen in front of the elbow. In the later mature stage the radiograph shows a dense irregular radio opaque mass.

Treatment

The best treatment is preventive. In all cases of elbow injuries, strict instructions must be given not to give massage or passive stretching to the joint after removal of the plaster. Even in crack fractures of the lower end of the humerus or neck of the radius, it is a wise precaution to apply a plaster slab for a short time to prevent the elbow being massaged.

In the active stage, the range or movement is recorded and the elbow is rested in a plaster slab for about 4 weeks. When the plaster is removed it will be found that movement has improved and that the shadow is smaller but denser. Immobilisation may be continued for another 3 weeks for maximum increase of range of movements. The radiograph may then show a dense well defined homogenous calcified mass. Thereafter, active exercise are encouraged.

When the condition is well established and non progressive, surgical excision of the myositic mass may be done to restore mobility. Some cases may benefit by arthroplasty (excision or replacement ) of the elbow joint.

FAT EMBOLISM

Fat embolism syndrome is a serious post traumatic complication causing sudden respiratory distress. It occurs within the first few days after major polytrauma or fracture of the pelvis or femur. It can also occur after fracture manipulation or intramedullary fixation operation.

Pathogenesis

Free fat globules of microscopic sizes from the bone marrow, excape into the blood stream and cause embolic phenomena in the lungs, brain and skin.

Clinical features

The condition occurs usually in young adults and is of sudden onset, presenting with acute pulmonary or cerebral symptoms. The early symptoms are shortness of breath, followed by restlessness and confusion. The clinical signs are pyrexia, tachycardia and tachypnoea with dyspnoea and cyanosis. Characteristic petechial rashes develop in the chest, axillae, foot, neck and conjunctiva. Disorientation and coma follow in more severe case which may end fatally.

Investigations

There is arterial hypoxemia due to pulmonary insufficiency and PA 02 values fall below
60 mm Hg. Thrombocytopenia also occurs. Urine may show sudanophilic granules. Fundoscopy reveals fat emboli in retinal vessels. Chest X ray shows snow storm appearance.

Treatment

The only specific treatment off fat embolism is directed at improving the hypoxemia due to respiratory distress. Oxygen is administered by nasal tubing or face mask ventilator. Accurate monitoring of blood gases, fluid and electrolyte balance is essential. The use of massive steriod therapy has been found to be helpful. Mild or moderate cases recover in a week or ten days. Massive fat embolism is most often fatal.

NON-UNION

Non-union is defined as failure of the fracture to unite by bony continuity. It is a difficult and challenging morbidity and needs surgical intervention active rehabilitation.

Delayed union of a fracture is one where healing has not occurred at the expected time of union for the type and site of the fracture.

Etiology

The causes of delayed and non-unionn are as follows.

1. Soft tissue interposition between the fragments.
2. Segmental fractures with impaired blood supply to the middle fragment.
3. Comminuted fractures.
4. Open fractures.
5. Infected fractures.
6. Pathological fractures.
7. Inadequate immobilisation and
8. Insecure fixation and premature weight bearing.

Pathology : There are two types of non-union.

The hypertrophic type where the fracture ends are hypertrophic, sclerosed and vascular. There is a fibrous union and this has a biological capacity to unite. The second is the atrophic type where the fragments are inert and a avascular. The ends of the fragments are tapering, osteoporotic and very mobile with sometimes a false joint with even a synovial lining.

Clinical features

It occurs in long bones like humerus, forearm or tibia. It occurs in intra capsular fracture of neck of femur and in fracture scaphoid. The characteristic sign is abnormal mobility or yielding at the fracture site without pain.

Radiologically there is sclerosis of fracture surfaced and closure of the medullary canal in the hypertrophic type. There is osteoporosis and tapering of fracture ends in the atrophic type.

Treatment

Established non-union is long bones has to be treated by operation. The fracture site freshened by excision of the scar tissue and the bones ends fixed by rigid internal fixation and supplemented by cancellous bone grafts to promote osteogenesis.

Bone tissue has been shown to have natural Bioelectrical properties. Application of electrical current, constant or pulsed has been shown to stimulate osteogensis at the negative electrode. In recent years this technique has been used in cases of non-union, in conjunction with good reduction and immobilisation to promote union of the fracture.

MALUNION

This means that the fracture has anatomically malunited with angulation, rotation or overriding of the fragments. This is due to failure to reduce the fragments into proper alignment or failure to hold them in position till union.

Clinical features

The patient presents with a deformity at the fracture site. It commonly occurs at the shaft of long bones e.g. forearm, femur, tibia or at the end of bones e.g. supra conbdylar fracture humerus, Colles' fracture. Radiology will show the degree of angulation, rotation or overriding of the fragments.

If the deformity is minimal and the function of the limb is satisfactory the malunion can be accepted. In young children, malunion tends to correct itself by the remodelling at the fracture site. If the deformity is gross or functional disability is marked, malunion is surgically treated by osteotomy, realignment and internal fixation.

CROSS UNION

This complication can occur in fractures of the shafts of the radius and ulna and in fractures of the tibia and fibula. The proximal fragment of one bone unites with the distal fragment of the other bone.

Answer 2

Volkmann's Contracture

Answer 3

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RE:
Please tell me about Volkmann's ischaemic contracture and myositis ossificans.?
Can you explain what these conditions are? I read that Supracondylar fracture can cause the above conditions. Please tell me how and also other causes for the above to occur.

Answer 4

Volkman's is a compartmental condition occuring in arms or legs due to loss of circulation due to swelling with muscle death and contracture.
Myositis ossifans is a simple formation of bone in previously injured muscle and not disabling.

Answer 5

Volkman`s ischemic contracture following ill corrected supracondylar fracture of humerus is caused by compression of Brachial artery. The fore arm gets atrophied thin and functionless. Myositis ossificans is abnormal calcification in muscles and tendons mostly precipitated by massage of fractured or sprained areas by quacks and massage gadgets.

Answer 6

During application of POP there are chances of compression of brachial artery which leads to volkman contracture, and myositis ossificans is excessive formation of spongy bone at the supracondylar fracture site..

Causes may be excesisve heat application, extra vasation to fracture site

regards

aroun

Answer 7

Diseases of the musculoskeletal system and connective tissue. YES, THESE ARE FORMED DUE TO FRACTURES.

Answer 8

yes it can be caused after supracondylar fracture, do you have one dear? If es then pl do not worry too much incidence is quite low