From the Guidelines
The most likely cause of Volkmann's contracture following a supracondylar fracture in a pediatric patient is compartment syndrome due to vascular compromise, particularly of the brachial artery. This occurs when the fracture fragments compress or damage the brachial artery, leading to decreased blood flow to the forearm muscles. As ischemia develops, muscle tissue swells within the confined fascial compartments, further increasing pressure and worsening the ischemia. Without prompt intervention, this cycle leads to muscle necrosis and subsequent fibrosis, resulting in the characteristic flexion contracture of the wrist and fingers. Early warning signs include pain out of proportion to the injury, pain with passive finger extension, paresthesias, pallor, and diminished or absent pulses. Immediate treatment is essential and involves fracture reduction to relieve arterial compression, removal of constrictive dressings, and in severe cases, fasciotomy to decompress the compartments. The condition is more common in children due to their smaller vessels and the higher incidence of displaced supracondylar fractures with significant swelling. Prevention through careful monitoring of neurovascular status and maintaining the elbow in less than 90 degrees of flexion after reduction is crucial in pediatric fracture management, as emphasized by the American Academy of Orthopaedic Surgeons in their Appropriate Use Criteria document for Management of Pediatric Supracondylar Humerus Fractures With Vascular Injury 1.
Key Points
- Compartment syndrome due to vascular compromise is the primary cause of Volkmann's contracture in pediatric patients with supracondylar fractures.
- Early recognition and treatment are critical to prevent long-term morbidity and mortality.
- The American Academy of Orthopaedic Surgeons provides guidelines for the management of pediatric supracondylar humerus fractures with vascular injury, emphasizing the importance of prompt intervention and careful monitoring of neurovascular status.
Treatment Options
- Fracture reduction to relieve arterial compression
- Removal of constrictive dressings
- Fasciotomy to decompress the compartments in severe cases
- Maintenance of the elbow in less than 90 degrees of flexion after reduction to prevent further compromise of the brachial artery.
From the Research
Causes of Volkmann's Contracture
The most likely cause of Volkmann's contracture from a supracondylar fracture in a pediatric patient is:
- Compartment syndrome, which can be caused by a supracondylar fracture of the humerus 2, 3, 4, 5
- Arterial injury, which can occur concurrently with a supracondylar fracture 2, 3
- Improper treatment, such as reduction of the fracture and fixation with a bandage or cast with the elbow in flexion 2
Risk Factors
Risk factors for compartment syndrome and Volkmann's contracture in pediatric patients with supracondylar fractures include:
- Older children 4
- Male patients 4
- Floating elbow injuries 4, 5
- Neurovascular injury 4
- Medial comminution, which can lead to varus malunion 4
- Elbow flexion beyond 90° in supracondylar humerus fractures 5
Prevention
Prevention of Volkmann's contracture can be achieved through: