PSEUDO–VOLKMANN’S CONTRACTURE: A RARE COMPLICATION FOLLOWING BOTH BONE FOREARM SHAFT FRACTURE FIXATION

Introduction: Several complications have been attributed to the operative management such as infection, compartment syndrome, non-union, malunion, refracture, synostosis, and nerve injuries. Here we describe a rare complication termed as Pseudo–Volkmann’s contracture (PVC) following the fixation of both bone forearm fractures. Contrary to Volkmann’s contracture, wherein ischemia is the cause for contracture, PVC results from mechanical entrapment of the flexor group, resulting in contractures. Case Scenario: A 21-year-old male presented with complaints of inability to extend the left thumb for two years. He had a history of trauma two years back and sustained both bone fractures of the left forearm. He was further managed by open reduction and internal fixation with dynamic compression plating. The patient noticed he was unable to extend his left thumb from postoperative day 1. The fracture showed good clinical union, intraoperatively. The flexor pollicis longus (FPL) musculo-tendinous junction was entrapped under the plate at the fracture site and adhered to the periosteum. Muscles showed good signs of viability, without any indication of previous ischemia. A linear bone trough was noted along the radial margin, entrapping the FPL. Implant removal with fractional tendon release, myo-tenolysis of FPL, and median nerve neurolysis. The adherent tissue of the FPL was released in a subperiosteal fashion. Following the release of adhesions around the FPL, complete passive movements of the thumb were noted. Results: Sollerman hand function test score improved from 10 at the presentation to 80 at the six-month follow-up. Three years of follow-up showed excellent clinical outcomes with no deficits. Discussion: PVC, despite being a rare phenomenon, is now gaining traction due to higher reporting of the condition [Deeney VF, Kaye JJ, Geary SP, Cole WG. Pseudo–Volkmann’s contracture due to tethering of flexor digitorum profundus to fractures of the ulna in children. J Pediatr Orthop 18 (4): 437–440, 1998; Geissler J, Westberg J, Stevanovic M. Pseudo–Volkmann contracture: A case report and review of the current literature. J Am Acad Orthop Surg Glob Res Rev 2 (11): e031, 2018, doi:10.5435/JAAOSGlobal-D-18-00031; Shaw B, Murphy K. Flexor tendon entrapment in ulnar shaft fractures. Clin Orthop Relat Res 330: 181–184, 1996; Song DJ, Kennebrew GJ Jr, Jex JW. Isolated ring finger flexor digitorum profundus entrapment after closed reduction and intramedullary fixation of both-bone forearm fracture. Orthopedics 35 (8): e1283–e1285, 2012, doi:10.3928/01477447-20120725-36]. Clinically both active and passive extensions of the thumb are lost with the wrist in extension. However, the same are present with the wrist in flexion. This presentation greatly overlaps that of Volkmann’s contracture but can be differentiated with an extensive history, the lack of ischaemic clinical findings, and intraoperative assessment of the viable muscular tissue [Geissler J, Westberg J, Stevanovic M. Pseudo–Volkmann contracture: A case report and review of the current literature. J Am Acad Orthop Surg Glob Res Rev 2 (11): e031, 2018, doi:10.5435/JAAOSGlobal-D-18-00031]. Often, the identification of digital contractures is delayed 4–6 weeks following the onset. Established contactures do not respond well to physical therapy [Prabhu RKR, Swaminathan N, Harvey LA. Passive movements for the treatment and prevention of contractures. Cochrane Database Syst Rev 12: CD009331, 2013, doi:10.1002/14651858.CD009331.pub2]. Early diagnosis in the postoperative period warrants an attempt at manipulation. Further, if manipulation does not provide an adequate range of movements, surgical exploration, and release have to be undertaken. Fractional tendon release and myotenolysis are only needed in chronic established cases. Occasionally, in chronic cases, lengthening might be needed to gain complete motion. Conclusion: PVC is a rare complication following both bone forearm fracture fixation with very limited reported literature, especially in the adult population. The clinical picture may overlap with Volkmann’s contracture and must be differentiated to properly manage the condition. Prompt diagnosis and treatment of PVC can result in excellent clinical outcomes.