Volkmann's ischemic contracture. Prevention and treatment

It may be concluded that treatment of patients with Volkmann's ischemic contracture is complicated and depends on a number of different variables. Optimal treatment of an established contracture requires a through examination of the extent of damage of the ischemia, followed by conservative therapy or operation. The most important measures concerning Volkmann's ischemic contracture, however, involve measures to prevent the contracture. It is poignant that very simple measures, such as monitoring high-risk injuries and immediate vascular repair or decompression if symptoms of a compartment syndrome are present, can prevent this disabling condition. The following summaries hopefully provide guidelines for prevention and treatment of Volkmann's ischemic contracture.     

曲美它嗪对大鼠心肌缺血挛缩的保护作用

目的　探讨曲美它嗪 (TMZ)对心肌缺血挛缩的保护作用。方法　大鼠分为A、B、C、D4组 ,A为对照组 ,微流量灌注 (0～ 1ml/min)制成心肌缺血模型 ,实验前口服曲美它嗪 (3mg/d× 7d) ,灌流液中加入 1× 10 -6mol/L的TMZ ,观察缺血后心脏发展压力的变化。结果　口服曲美它嗪、灌流液中添加曲美它嗪组与对照组相比 ,心肌缺血后发展压力有明显改善。缺血 30min时 ,A组 :(4 .49± 0 .6 0 )kPa(1kPa =0 .75mmHg) ;D组 :(1.39± 0 .75 )kPa ,差异有非常显著性 (P <0 .0 1)。再灌注 15min时 ,A组 :(4 .2 8± 0 .77)kPa ;D组 :(1.36± 0 .2 7)kPa ,差异有非常显著性 (P <0 .0 1)。缺血后发展压力恢复率在复灌后 5min内明显改善 ,A组 :(74.3± 8.4) % ,D组 :(98.6± 3.2 ) % ,差异有非常显著性 (P <0 .0 1)。结论　曲美它嗪对心肌缺血挛缩有明显的保护作用。     

The study of structural proteins in the ischemic contracture muscle

The purpose of this study was to make clear the changes of structural proteins in the ischemic contracture muscle. Ischemia experiments were conducted on the forelimb of canines. Contracture proteins (myosin, actin, alpha-actinin) were isolated and analysed by using SDS-polyacrylamide gel electrophoresis. In the muscle group after 7-hour-ischemia, the muscle structural proteins were changed remarkably, along the time course after the release of tourniquet. After 7 days, myosin heavy chain decreased to 1/2 to 1/3 the original value. It was especially myosin heavy chain that changed remarkably among muscle structural proteins. Actin showed changes after 10-hour-ischemia.     

Capsular contracture and silicone gel: Experimental study

Wistar rats were used to study the effects, if any, of membrane thickness and implant volume of a silicone gel prosthesis on the development of fibrous capsule contraction. A total of 30 miniprostheses with three different membrane thicknesses and two different volumes were implanted in the subcutaneous space of five animals. One hundred eighty days later the fibrous capsule was resected and histologically analyzed. Different grades of thickness were observed. The statistical analysis of the data indicates that the thickness of the prosthesis' membrane and the implant's volume did not impact significantly on the grade of fibrosis.This research was supported by Hospital de Cirurgia Plás-tica Cranio-Facial da SOBRAPAR (Brazilian Society for Research and Cranio Facial Rehabilitation) and conducted by UNICAMP (State University of Campinas)     

前臂屈肌群起点下移治疗前臂缺血性肌挛缩

目的：用前臂屈肌群起点下移法，治疗晚期前臂缺血性肌挛缩Ⅰ、Ⅱ级。方法：将前臂屈肌起始部切断后在骨膜下剥离，并向远侧推移至腕关节和手指能够伸直为止。此处即为屈肌新起点，与周围组织缝合固定。结果：临床应用１２例。疗效优者：腕背伸３０度以上１例；良者：腕掌屈１７０度～腕背伸３０度 ７例。优良率达 ６６．７％（８／１２）。结论：该术式对功能肌的损伤较轻，保留了指浅屈肌的功能，术后屈肌力量减弱较轻。术中可根据挛编程度调节松解幅度，病变轻使伸指幅度大，病变重使伸指幅度小，各指伸直幅度保持一致。晚期手术时机，一般在伤后１年为宜。     

前臂缺血性肌挛缩的康复治疗

叙述前臂缺血性肌挛缩康复治疗的方法、疗效及其与预后的关系。方法:对20例前臂缺血性肌挛缩进行局部创面处理后,以强化热疗法、低中频电疗、运动疗法、作业疗法、感觉训练和使用夹板支具等手段行康复治疗。治疗时间1个月～1年,平均为7.2个月。结果:20例中,疗效优者(S_4M_5)7例,良(S_3M_4)4例,可(S_2M_3)9例,优良率为55％。结论:前臂缺血性肌挛缩的预后主要和损伤程度、治疗时间及是否作康复治疗有密切的关系。及时有效的康复治疗可以促使缺血性肌挛缩的病理过程向好的方面转归,减少并发症的发生。     

Application of ultrasonic investigation in estimation of morphofunctional state of muscles in patients with ischemic contracture of foot

Results of ultrasonic investigation of the shin and foot muscles were analyzed in 14 patients with an ischemic contracture of foot (ICF). All the patients were operated on, clinical significance of ICF ultrasonic semiotics was estimated. Structural changes were demonstrated by diffuse strengthening of echogeneicity, striateness loss, ischemized muscles thickness reduction, origination of hypoechogenic (of hydrophilic nature) portions in places of necrosis of muscular tissues. Hyperechogeneicity is caused by fibrosis of an ischemized muscles, which during isometric contraction somewhat thickened, their echogeneicity did not change.     

Volkmann's ischemic contracture due to soft tissue injury alone.

Fifteen upper extremities, in 14 patients in whom incipient or actual Volkmann's ischemic contracture was present, were seen in a 5 year period. Nine patients were stuporous due to drug overdose and had laid on the extremity; two had received a recent injury of main arterial trunks; two had sudden severe compression; one with chronic myelogenous leukemia had each arm involved at different times in a bizarre autoimmune response causing massive swelling. No patient had a fracture or dislocation. Pain and tenderness, loss of sensibility, resistant muscle contracture, and rock-hard muscle compartments were warning signs. Immediate fasciotomy was done. Useful function was restored when treatment was carried out in the early stages of the ischemia.     

Experimental study of neurotization of denervated muscles with nerve-to-vein transfer.

Neurotization of denervated muscles was attempted by means of coaptation of peripheral nerves to the veins draining these muscles. In Sprague-Dawley rats, the lateral gastrocnemius branch from the tibial nerve was severed and its proximal end was sutured to the distal stump of the lateral gastrocnemius vein. In all animals nerve-muscle communication was confirmed electrophysiologically 2 and 6 months after the operation. However, histological examination revealed that the regenerated nerve fibers were not within the vessel lumen, but ran through the scar tissue in close proximity to the outside of the vessel, to enter the muscle. Control animals, in which only nerve resection was done, did not display nerve reinnervation. These results suggest that, although nerve fibers did not regenerate into the vein, the vein works well as a guide for regenerating nerve fibers to denervated muscle.     

臀肌挛缩症的分级与治疗

目的 探讨非手术的物理疗法以及手术治疗重度臀肌挛缩症的适应证和方法，提出医院的分级，分析分级的必要性和意义。方法 根据制定的臀肌挛缩症的分级标准，将210名患者按病情轻重程度分为Ⅰ，Ⅱ，Ⅲ度，Ⅰ度采用非手术的物理疗法治疗；Ⅱ度及Ⅲ度患者全部采用经大转子内上方斜形小切口手术治疗。Ⅱ度患者手术彻底松解紧张纤维化的臀肌及挛缩增厚的阔筋膜；Ⅲ度患者手术松解必须深达髋关节囊，斜行切开关节囊后上方，行关节囊成形术。术后早期进行积极的并膝屈髋功能锻炼，防止粘连。结果 Ⅰ度患者23例，经理疗，按摩治疗，所有症状均有不同程度减轻，有效率为100%，优良率为39%；Ⅱ，Ⅲ度患者187例，全部行手术治疗，优良率达97%。结论 将臀肌挛缩症进行分级，更有利于准确的区别该病的轻重程度和选择相应的治疗方法。非手术疗法治疗臀肌挛缩症有一定的疗效。主要适用于Ⅰ度患者；手术治疗适用于Ⅱ，Ⅲ度患者，疗效满意。     

Functional results after treatment of Volkmann's ischemic contracture: a long-term followup study

The main objective of this retrospective study was to evaluate the long-term functional outcome in patients treated for Volkmann's ischemic contracture. In this study, functional outcome (measured as mobility, grip strength, and sensibility) and arm length difference after treatment of Volkmann's ischemic contracture were analyzed and discussed. Twenty-five patients treated between 1969 and 2001 were evaluated. The method of treatment was related to the severity of the infarction, ranging from conservative to free vascularized muscle transplantation. Although the study population was small, we could observe a wide range of functional outcome. Substantial improvement of function was obtained in patients who had free vascularized muscle transplantation. Unfortunately in one patient with an occlusion of the distal brachial artery and an insufficient flow through the collateral circulation of the radial artery, the gracilis muscle was lost. Tendon lengthening had unsatisfactory results because of recurrence of the contracture. Excision of fibrotic muscle tissue, neurolysis and tenolysis sometimes combined with a tendon transfer gave good hand function results in patients with sufficient remaining muscle tissue. In most of the patients in whom the contracture developed during childhood, a difference in forearm length was observed.     

Congenital Volkmann-Lesser ischemic contracture of the upper limb

Neonatal vascular compromise to limbs has been associated traditionally with perinatal injury of the brachial plexus, fracture of the clavicle or humerus, or iatrogenic causes. Congenital Volkmann's ischemic contracture is an exceptional etiology of ischemic limb in the newborn. Fewer than 10 cases had been described in the literature. The authors report a newborn presenting at birth with partial bluish discoloration of the right forearm. The clinical picture and laboratory studies lead to the diagnosis of congenital Volkmann-Lesser ischemic contracture.