Reconstruction of a Chronic Volkmann Contracture following Forearm Revascularization with Burkhalter's Procedure and Fractional Flexor Tendon Lengthening after a Failed Stiles-Bunnell Transfer

Abstract

Volkmann ischemic contracture is a cause of limb dysfunction that can lead to varying amounts of limb deformity, stiffness, and paralysis. Several procedures have been used to improve limb function in these patients. An 11-year-old male patient sustained a domestic accident with a glass door, resulting in a severe soft tissue trauma to his proximal third of the right forearm with damage to flexor muscles and tendons, complete section of median and ulnar nerves, and radial and ulnar arteries. He was submitted to immediate repair of the radial artery and median and ulnar nerves. Ulnar artery was not repairable due to extensive soft tissue loss. Despite surgical treatment and successful revascularization, postoperatively he developed a postreperfusion syndrome, and in consequence an ischemic contracture. To improve his condition, simultaneous Burkhalter's procedure and fractional flexor tendon lengthening were used after a previous failed Stiles-Bunnell transfer. After 6 months, a good result was obtained, with restoration of a more anatomical hand rest position, improved arc of motion, and significant improvement of hand function with DASH (Disabilities of the Arm, Shoulder and Hand) score improving from 59 to 43 despite a slight reduction in grip strength. Opposition to the ring or little finger tip with the interphalangeal joint (IPJ) of the thumb extended was observed. The combination of fractional flexor tendon lengthening and Burkhalter's procedure is a reliable and simple procedure in cases of Volkmann's ischemic contracture and combined median and ulnar nerve palsy, without significant complications.

Introduction

Long-term sequelae of a raised compartment pressure were first described by Volkman in 1881. Volkmann's ischemic contracture is a cause of limb dysfunction that can lead to varying amounts of limb deformity, stiffness, and paralysis. 1

Several procedures, including tendon transfer procedures, have been used to improve limb function in these patients. Extensor indicis proprius (EIP) opponensplasty, a procedure popularized by Burkhalter et al, 2 has been described as a successful technique for restoring thumb opposition in patients with simultaneous median and ulnar nerve injuries. 3 4 5 The index finger has two extensor tendons on its extensor mechanism. EIP is therefore an expendable tendon, and its usage causes minimal morbidity to the donor site. 2 3

Here we report a case of reconstruction of a chronic Volkmann's ischemic contracture, with simultaneous Burkhalter's procedure and fractional flexor tendon lengthening (FFTL) after a failed Stiles-Bunnell transfer.

Case Report

An 11-year-old male patient sustained a domestic accident with a glass door, resulting in a severe soft tissue trauma to his right forearm. Surgical exploration revealed severe damage to flexor muscles and tendons of the forearm, complete section of median and ulnar nerves, and radial and ulnar arteries. The section level was at the proximal third, with near-total amputation of the forearm; ulnar artery injury was below the origin of interosseous trunk from the ulnar artery. He was submitted to immediate repair of the radial artery below brachial artery bifurcation and median and ulnar nerves. Ulnar artery was not repairable due to extensive soft tissue loss. For achieving adequate nerve coaptation, median nerve mobilization and anterior subcutaneous ulnar nerve transposition were performed, which may have contributed to some muscle motor nerve branches division. Warm ischemia time was 3.5 hours. Hemoglobin level was 5.1 g/dL immediately after patient arrival in the operating room, and red blood cell transfusion was given (two units). A previous attempt of revascularization was tried by vascular surgery without success, due to the small vessel size in this child patient; the surgery lasted approximately 4.5 hours. Skin decompression incisions were performed. Some muscle was left exposed for secondary coverage. Despite surgical treatment and successful revascularization, postoperatively, the patient developed a postreperfusion syndrome, and in consequence an ischemic contracture of the flexor compartment with severe hand and wrist dysfunction despite long periods of physical rehabilitation. Poor sensory results were seen with loss of protective sensation.

Electrophysiologic studies 10 months after injury revealed lesion of the ulnar and median nerves, with complete loss of evoked motor and sensory potential and partial radial nerve injury: less severe lesion of the right radial nerve with decreased amplitude of motor potential (~50%) and sensory potential; voluntary traces in the common extensor tendons were practically normal.

A first attempt to improve hand position and function was made using a Stiles-Bunnell procedure, to improve metacarpophalangeal (MP) flexion and interphalangeal (IP) extension, but it failed to improve claw deformity and intrinsic minus deformity correction, and the patient maintained severe hand dysfunction ( Fig. 1 ).

Fig. 1.

Patient hand before surgical intervention.

The patient was then submitted by the same surgeon who has revascularized his forearm, to tenolysis and lengthening tenotomy of the superficial and deep flexor compartment of the forearm, associated with Burkhalter's procedure to improve hand position in neutral stance, and to partially restore thumb opposition.

Severe fibrosis and muscle retraction were present both in superficial and deep volar compartments of the forearm. Nerves were totally degenerated with a cord-like appearance. In the superficial compartment, flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) lengthening was performed at the musculotendinous junction by making two incisions in their tendinous fibers. The proximal incision was transverse, and the distal one was oblique. The palmaris longus and flexor digitorum muscles were lengthened by only one transverse incision in each ( Fig. 2 ).

Fig. 2.

Schematic illustration of superficial and deep compartment lengthening tenotomies.

In the deep compartment, the flexor pollicis longus and flexor digitorum profundus muscles were lengthened by making two incisions in their tendinous parts, as described previously for FCR and FCU ( Fig. 3 ).

Fig. 3.

Intraoperative view of FCU tendon lengthening. FCU, flexor carpi ulnaris.

Burkhalter's procedure was performed as described by the authors. 2 EIP tendon was dissected and tunneled subcutaneously to the ulnar aspect of the wrist. The substance of the FCU tendon was pierced with a number 15 scalpel blade, and the EIP tendon was brought through this tendon split incision, acting as an ulnar pulley for the transfer. Another subcutaneous tunnel was then created from this pulley to the insertion site of the abductor pollicis brevis tendon ( Fig. 4 ).

Fig. 4.

Schematic illustration of Burkhalter's procedure (left). Intraoperative view before implantation to insertion site of the abductor pollicis brevis tendon (right). APB, abductor pollicis brevis; EIP, extensor indicis proprius; FCU, flexor carpi ulnaris.

After the procedure, the patient was immobilized with dorsal and palmar splints with elbow on a brachial suspension at 90-degree flexion for 6 weeks. After splint removal, hand position was significantly better and thumb opposition partially restored ( Fig. 5 ), despite a slight reduction in grip strength. At this point, the patient started a physical rehabilitation program.

Fig. 5.

Hand in rest position and thumb opposition at 6 weeks follow-up.

After 6 months, a good or excellent result was obtained ( Fig. 6 ), with restoration of a more anatomical hand rest position and significant improvement of hand function with DASH (Disabilities of the Arm, Shoulder and Hand) score improving from 59 to 43 (10.1 is the mean DASH score in a large general population survey). Results of opponensplasty were recorded using the criteria of Sundararaj and Mani ( Table 1 ), and classified as excellent: opposition to the ring or little finger tip with the interphalangeal joint (IPJ) of the thumb extended was observed, with the wrist in 10 degrees of extension to eliminate any element of wrist tenodesis that might aid opposition.

Fig. 6.

Hand performance in different tasks: ( A ) pinch; ( B ) thumb opposition with finger flexion; ( C ) grip.

Table 1. Results of opponensplasty using the criteria of Sundararaj and Mani.

Note: Testing of opposition should be performed with the wrist in 10 degrees of extension to eliminate any element of wrist tenodesis that might aid opposition.
Excellent	Opposition to the ring or little finger tip with the interphalangeal joint (IPJ) of the thumb extended
Good	Opposition to the index or middle finger tip with the IPJ of the thumb extended
Fair	The IPJ of the thumb flexes for opposition
Poor	No opposition

Discussion

Morbidity and mortality after revascularization of acute ischemic limbs remain high, despite many surgical improvements during the past decades. To a large extent, this is related to reperfusion itself after complete, acute, prolonged ischemia that results in postreperfusion syndrome. 6 This is usually a consequence of massive edema, a marked decrease in oxygen consumption, glucose consumption, tissue ATP, total adenine nucleotides, muscle pH, and total calcium, as well as a massive increase in plasma creatine kinase concentration and potassium, together with the development of muscle rigidity.

In 1872, Volkmann 1 described a rapidly progressive posttraumatic muscle contracture and was the first to differentiate between the paralysis of muscles due to nerve injury and that due to a traumatic lesion of the muscles. At first, he regarded this syndrome as an “inflammatory myositis,” but in later papers, he stated that these contractures were invariably caused by a stoppage of arterial blood due to tight bandages and splints. Since then, a great number of cases of Volkmann's ischemic paralysis have been reported; however, the term Volkmann's ischemic paralysis continues to strike fear into any physician dealing with injuries to the upper extremity. 7

Some authors 8 emphasized that a nonrecognized forearm compartment syndrome, which has been mistreated, could cause Volkmann's ischemic paralysis. Prevention, prompt recognition, and treatment of an acute compartment syndrome reduce the overall morbidity associated with this condition. However, prolonged ischemia can result in irreversible changes in the muscles, nerves, and vascular endothelium, leading to permanent disability of the hand and wrist.

Several classification systems have been described. Seddon 9 was the first to introduce the concept of the ellipsoid infarct involving the muscles of the proximal forearm and described a spectrum of contracture from mild to severe. The most popular classification was described by Tsuge, 10 who classified contracture into mild, moderate, and severe types, according to the extent of the muscle involvement ( Table 2 ).

Table 2. Tsuge classification of Volkmann's ischemic contracture.

Type	Affected muscles	Neurologic	Finger position
Mild	Flexor digitorum profundus	No or minimal loss of sensibility	Contracture of two or three fingers
Moderate	Flexor digitorum profundus, flexor pollicis longus, and parts of superficial flexor muscles	Loss of sensibility in (parts of) the hands	All fingers, the thumb, and often the wrist are affected
Severe	All flexor muscles and parts of the extensor muscles	Serious loss of sensibility or motor function	Claw hand

Various treatments have been proposed including excision of the infarcted muscle, excision of scarred fibrotic nerves without distal function, followed by nerve grafting to try to establish some protective sensation, fractional or Z-lengthening of the affected muscles, muscle sliding operations (flexor origin muscle slide), neurolysis, tendon transfers, and functional free muscle transfers, as well as combinations of the above procedures. 10 11 12 13 14 15 The most marked ischemia usually occurs in the deeply situated muscles such as the flexor pollicis longus and flexor digitorum profundus, as well as in the pronator teres and flexor digitorum superficialis muscles, and mild ischemia occurs in the superficially located wrist flexors. Excision of the flexor digitorum superficialis muscles tendons may be performed not at the time of the primary surgery, but at the time of tendon transfer, allowing tenolysis of the profundus tendons and less adhesions will occur than if the superficialis had been excised initially. 10 However, in the severe type, degeneration of all flexor muscles and also varying degrees of degeneration of the extensor muscles are present. In our patient, the neurologic signs were severe, and in consequence of rhabdomyolysis, the median and ulnar nerves were surrounded by the scarred portion of the muscles, and so neurolysis would be less effective.

FFTL has been successfully applied to patients with severe MP flexion contracture in rheumatoid hands. 16 For severe wrist and finger contracture in cerebral palsy, Zancolli et al 17 also advocate lengthening multiple flexor tendons via circumferential release of the muscle fascia. Le Viet 18 broadened the application to include Volkmann's contracture and recommended intramuscular transverse tenotomy at the musculotendinous junction. This technique has some advantages: there are no sutures in the tendon itself, it allows early reeducation, active flexion is preserved immediately, and there is good tendon healing. It is possible to lengthen selectively the superficial flexors or the deep flexors, or both. However, there must be no adherence in the carpal tunnel or digital sheath, and active flexion must be preserved.

Because of the extent of muscle degeneration, and even if the deformity can be improved using flexor tendon lengthening or muscle sliding, the grip strength is expected to be markedly decreased and in particular the power of flexion of the distal IPJ. In a review of 19 patients, performed by Shama and Swamy, 19 most patients (14 cases) were able to achieve grip strengths in the good range (within ≥ 75% of the normal limb). However, preoperatively, most patients like in this report, are unable to perform the test due to the deformity, and poor grip was already present.

Our patient who had a severe type of contracture reported improved arc of motion and functional outcomes, despite a slight reduction in grip strength. There was no loss of motion and he regained basic hand functions that had been lost before, such as using a knife, opening a door, carrying a heavy bag, or preparing a meal. He had a modified Stiles-Bunnell procedure before, where the middle finger superficialis tendon was divided distally in the finger and retrieved into the palm, split into four slips, and inserted on the lateral band. This procedure was unsuccessful because of median nerve lesion, despite some digital flexion was observed before the surgery, suggesting proximal flexor muscle innervation.

When the patient has a severe injury with acute ischemia and damage to the median and ulnar nerves, intrinsic-minus deformity due to nerve paralysis or flexion contracture of the finger may occur and the patient develops a Volkmann-like contracture. In severe and old cases, in which there are severe joint contractures, irreversible nerve damage, without regeneration capacity, is present. If a motor is not available because of degeneration or marked atrophy of the extensors, flexor tenodesis and intermetacarpal fusion with the thumb in opposition should be considered. If a suitable donor is available like in our patient, tendon transfers can be performed. He had a modified Stiles-Bunnell procedure before, where the middle finger superficialis tendon was divided distally in the finger and retrieved into the palm and split into four slips. Each slip was then passed along the path of the lumbrical, volar to the deep transverse metacarpal ligament, and back into the finger, where it was inserted on the lateral band. This procedure was unsuccessful because of median nerve lesion, despite some digital flexion was observed before the surgery, suggesting proximal flexor muscle innervation.

The most devastating loss of movement following high or low median nerve injury is the loss of thumb opposition, which is a complex movement that involves palmar abduction, pronation, and flexion of the thumb metacarpal and proximal phalanx. This can be restored with an opponensplasty, and the ideal insertion for an opposition transfer is the APB insertion to re-create the combination of movements that result in thumb opposition. The angle of pull should be from the location of the pisiform, because this approximates the normal direction APB pull, and a pulley is often necessary to create the proper line of pull (the transverse carpal ligament, the palmar fascia edge, a loop of the FCU tendon, and the FCU tendon itself have all been used as pulleys). The EIP opponensplasty is available in cases of both low and high median nerve injury, and although the EIP is a weak motor, it is sufficiently strong to move the thumb into opposition. We harvested the EIP tendon with an extension from the extensor expansion (extensor hood) to lengthen the tendon, since the patient had combined median and ulnar nerve palsy and had an “intrinsic minus” thumb. In these cases, there is need to have a “long” EIP tendon to reach for the dual insertion required for stabilization of the MP joint of the thumb.

Conclusion

Several procedures including tendon transfer procedures have been used to improve limb function in Volkmann's ischemic contracture. To the best of the authors’ knowledge, the combination of fractional flexor tendon lengthening and Burkhalter's procedure has not been reported before. It is a reliable and simple procedure in cases of Volkmann's contracture and combined median and ulnar nerve palsy, without significant complications.