Invited review article:: Surgery for Volkmann's ischaemic contracture

Volkmann's ischaemic contractures develop as a result of compartment syndrome and their clinical manifestation varies according to the location and involvement of muscles and the nerves in the fibrotic degeneration. Throughout our 30 years of hand surgery practice in a developing country, we had to treat many cases of Volkmann's contracture, mainly caused by inadequate initial treatments which nowadays are rarely seen. The earthquake in 1999 in Kocaeli caused mass casualties, and thousands of victims had to stay under the ruins for many hours before salvage. In many crushed extremities, acute compartment syndromes developed. It was an unusual experience for doctors who had to perform hundreds of emergency fasciotomies during the first days. We were involved in treatment of sub-acute cases and late complications and resultant contractures. Clinical diagnosis with presumption of a compartment syndrome and immediate fasciotomy as primary treatment is still valid. Timely secondary closures of soft tissue, if necessary with skin grafts or even with free-flaps, is important to overcome complications. In the early mid-term, after the first 6 to 12 hours, a second look may sometimes be necessary if the vessels and nerves are injured and early excision of irreversibly ischaemic muscles is called for. In established Volkmann's contractures, muscle shifting operations as well as lengthening tenotomies and tendon transfers are useful if there is sufficient functioning muscle tissue available. Neurolysis or nerve reconstruction is always necessary. In severe cases, free functioning muscle transfers provide new opportunities.