Volkmann ischaemic contracture !

Volkmann contracture is a permanent bending of the wrist and fingers after forearm muscles die from lack of blood, often after an elbow fracture.

Updated 2026-10-29

Structures involved

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Why it happens

What it is

Permanent flexion deformity of the wrist and fingers caused by death and scarring of forearm muscles after untreated or late-treated ischaemia, classically following a supracondylar humerus fracture or acute compartment syndrome of the forearm.

Who gets it

Now uncommon where compartment syndrome is recognised and treated early, but it still occurs after missed injuries, especially in children with elbow fractures and in adults after crush injuries.

Causes

Acute compartment syndrome of the forearm that was not decompressed in time
Supracondylar humerus fracture in children with brachial artery injury or swelling
Forearm fractures, crush injuries, burns and tight casts or bandages
Prolonged limb compression (for example during intoxication), reperfusion after vascular repair and intravenous infiltration

Risk factors

Displaced supracondylar fracture in a child
High-energy forearm trauma or crush injury
Circumferential casts or dressings
Delayed recognition of compartment syndrome, for example in sedated or non-verbal patients

Pathophysiology

Raised pressure inside a closed fascial compartment, or loss of arterial inflow, starves muscle and nerve of oxygen. After several hours the muscle dies; it is then replaced by fibrous scar that shortens. The deep flexors (flexor digitorum profundus and flexor pollicis longus) are the most vulnerable, and the median and ulnar nerves may be caught in the scar.

Classification

Tsuge mild: localised, mainly the flexor digitorum profundus of two or three fingers, little or no nerve deficit
Tsuge moderate: all deep flexors and some superficial flexors, with sensory and motor nerve deficits
Tsuge severe: flexors and extensors involved, with marked nerve damage

Symptoms and signs

Flexed wrist and fingers that cannot be fully straightened
Fingers extend more when the wrist is flexed (Volkmann sign), showing shortening of the flexor muscles
Wasted, firm forearm and weak grip
Numbness and weakness in the median and ulnar nerve territories
Clawing of the hand in severe cases

Diagnosis

Clinical: History of an injury followed by a fixed flexion deformity; the Volkmann sign; examination of each muscle and nerve to grade severity.
Tests: Nerve conduction studies and electromyography map nerve damage. In the acute phase, compartment pressure can be measured when examination is unreliable.
Imaging: MRI shows the extent of muscle necrosis and fibrosis; X-rays check old fractures and growth disturbance.

Differential diagnosis

Dupuytren contracture
Ulnar or combined nerve palsy (claw hand)
Spastic contracture from cerebral palsy or stroke
Post-traumatic joint contracture
Arthrogryposis or congenital camptodactyly

Goal of treatment

In the acute phase, prevent the contracture by restoring blood flow and decompressing the compartment; once established, release the contracture, protect nerves and restore as much hand function as possible.

Treatment

Acute: Prevention: urgent fasciotomy for forearm compartment syndrome and restoration of arterial flow after a supracondylar fracture, removing tight casts and dressings.
Rehabilitation: Mild contracture: stretching, serial or dynamic splinting and hand therapy.
Surgical: Moderate contracture: excision of necrotic muscle, release of nerves and a flexor-pronator muscle slide or tendon lengthening.
Surgical: Severe contracture: tendon transfers, or a free functioning muscle transfer with nerve repair, after scar release.

Complications

Permanent loss of grip and fine hand function
Chronic nerve pain and sensory loss
Limb-length and growth disturbance in children
Recurrence of the deformity after release

Prognosis

Depends on severity and the time from injury. Mild cases can regain good function with therapy and limited surgery; severe cases keep major disability despite reconstruction. Prevention through early recognition of compartment syndrome is far more effective than treatment.

Prevention

Repeated neurovascular checks after elbow and forearm fractures
Avoiding tight casts and forced elbow flexion in swollen limbs
Early fasciotomy for compartment syndrome

Test yourself

Think of the answer, then tap the question to see it.

Which fracture is classically associated with Volkmann ischaemic contracture?

A displaced supracondylar fracture of the humerus in a child, through brachial artery injury or forearm compartment syndrome.

Which forearm muscles are most vulnerable in Volkmann contracture?

The deep flexors: flexor digitorum profundus and flexor pollicis longus.

What is the Volkmann sign?

The fingers can be extended more when the wrist is flexed, showing shortening of the flexor muscles.

What is the most effective way to prevent Volkmann contracture?

Early recognition of compartment syndrome and urgent fasciotomy, with restoration of arterial flow after injury.

Which nerves are often involved in Volkmann contracture?

The median and ulnar nerves, which can be compressed or damaged by ischaemia and scar.

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Educational information, not medical advice. For any symptom, see a health professional.

Sources: Volkmann Contracture (StatPearls (NCBI Bookshelf), 2023).

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