Volkmann’s hand requires early debridement, neurolysis regardless of reconstruction status
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Wide exposure prior to thorough debridement is essential when treating Volkmann’s contracture, regardless of what the next steps to treat the patient might be, a presenter said at the American Society for Surgery of the Hand Annual Meeting.
In a presentation about his experiences managing patients with Volkmann’s ischemic hand contracture during overseas medical mission trips, Scott N. Oishi, MD, of UT Southwestern Medical Center and Scottish Rite for Children in Dallas, stressed the importance of a complete debridement and neurolysis in patients with Volkmann’s hand, which is an ischemic condition.
“To me, the most important thing about treating a Volkmann’s is complete debridement and neurolysis and initially treating with nerve graft, if needed, but through a wide exposure. So, extensile exposure from the medial epicondyle all the way up to the wrist, and even into the carpal tunnel, if you need to,” he said.
Such a wide exposure facilitates view of all the structures in the hand and allows surgeons to assess whatever might not be alive due to the ischemia that arises from compartment syndrome, Oishi said.
Furthermore, the ability to perform a complete evaluation through an extensive exposure is critical because, he said, the soft tissue death that usually occurs with Volkmann’s contracture is in the deep compartment and may not be observed in the superficial compartment.
“It is a complete evaluation exposure that is absolutely important to the correct treatment,” Oishi said.
“After that’s performed, range of motion exercises and time to regain passive range of motion and sensation, I think, is important before you do any kind of reconstructive procedure,” he said, noting reconstruction often involves a tendon transfer.
Severe cases, in which patients present with intrinsic paralysis, loss of finger sensation and a lack of active finger flexion, are those for which a reconstructive procedure is typically indicated, according to Oishi.
“So in mild cases, I think it’s different. We can go in and debride,” he said.
Common precursors to Volkmann’s contracture of the hand include supracondylar fracture of the humerus, distal radius fracture, soft tissue injuries “and also some fascial extravasation of blood or fluids because that increased compartment pressure, as we know, can lead to muscle ischemic death followed by the contractures,” Oishi said.
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Oishi SN. Common challenging cases in global hand surgery. Presented at: American Society for Surgery of the Hand Annual Meeting; Oct. 1-3, 2020 (virtual meeting).
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