What is Volkmann's contracture a complication of?

Volkmann's Contracture: Complication of Supracondylar Humeral Fracture

Volkmann's contracture is primarily a complication of supracondylar humeral fracture (option d), resulting from compartment syndrome and ischemia in the forearm.

Pathophysiology and Mechanism

Volkmann's contracture develops through the following sequence:

1. Initial injury: Supracondylar humeral fracture damages or compresses the brachial artery
2. Vascular compromise: Leads to forearm ischemia and compartment syndrome
3. Tissue damage: Prolonged ischemia causes muscle necrosis and fibrosis
4. Contracture development: Results in permanent flexion deformity of wrist and fingers

The supracondylar region is particularly vulnerable because:

• The brachial artery passes close to the fracture site
• Displacement of bone fragments can directly damage or compress the artery
• Swelling in a confined anatomical space increases compartment pressure

Evidence and Epidemiology

Multiple studies confirm the association between supracondylar fractures and Volkmann's contracture:

• Supracondylar fractures represent 3-15% of all pediatric fractures and are the most common fractures requiring surgical intervention in children 1
• Absence of palpable pulse in type-III supracondylar fractures occurs in up to 20% of cases 1
• Risk factors include older children, male patients, "floating elbow" injuries, and pre-existing neurovascular injury 1
• Improper treatment of supracondylar fractures, particularly excessive flexion during immobilization, significantly increases risk 2

Prevention and Management

Early recognition and intervention are critical to prevent Volkmann's contracture:

• Careful neurovascular assessment of the affected limb is essential
• Avoid excessive elbow flexion during immobilization
• Closed reduction with percutaneous pinning is the recommended treatment for displaced fractures 1
• Immediate fasciotomy is indicated for impending compartment syndrome 3
• For established contractures, treatment options include neurolysis, infarct excision, flexor pronator slide, and tendon transfers 3

Differential Diagnosis

While Volkmann's contracture is primarily associated with supracondylar humeral fractures, it's important to distinguish from other options:

• Humeral head fractures (option a): Rarely associated with Volkmann's contracture due to distance from critical neurovascular structures
• Femoral neck fractures (option b): May cause avascular necrosis but not Volkmann's contracture
• Posterior knee dislocations (option c): Associated with popliteal artery injury but not Volkmann's contracture
• Colles' fractures (option e): Can cause complications but rarely Volkmann's contracture

Conclusion

The clear association between supracondylar humeral fractures and Volkmann's contracture is well-established in the medical literature. The anatomical relationship between the fracture site and the brachial artery, combined with the confined space of the antecubital fossa, creates the perfect conditions for compartment syndrome and subsequent ischemic contracture if not properly managed.