Introduction
Volkmann’s ischemic contracture is the outcome of prolonged muscle and nerve ischemia resulting most commonly from delayed or untreated acute compartment syndrome. Increased compartment pressures decrease capillary perfusion to the muscle ultimately leading to muscle necrosis and fibrosis, which clinically presents as contracture. Nerve dysfunction may also result from the initial trauma and/or subsequent scar formation as well as impaired nerve perfusion. The deep flexor compartment of the forearm and the median nerve are the most vulnerable ( Figs. 21.1 and 21.2 ).
Mild contractures with deep flexor involvement and no neurologic deficit that have failed nonoperative treatment respond well to soft tissue procedures such as a flexor origin or flexor pronator slide. This procedure relatively lengthens the forearm flexor muscles and is effective when good active finger flexion is present. Moderate contractures that involve both superficial and deep compartments and have neurologic dysfunction may also be treated with a flexor origin slide however its usually paired with complete median and ulnar nerve neurolysis and possible resection and grafting to restore protective sensation. Tendon transfers may be involved in the reconstruction as well, depending on the degree of neurologic injury. Severe contractions are best treated with free functional muscle transfers ( Figs. 21.3 and 21.4 ).
Therapy Considerations According to Type of Severity
Sustained ischemia results in irreversible changes to muscle whereby the necrotic muscle is replaced with fibrotic tissue. The maturation of fibrotic tissue occurs over 6 months to a year, resulting in progression of contracture severity over time. Nerve impairment occurs as fibrosis compresses the nerve and/or prevents gliding. The most vulnerable muscle group is the deep flexor compartment in the forearm.
Hand rehabilitation is directed toward maintenance of passive joint motion, preservation and strengthening of remaining muscle function, and correction of contracture through static progressive splinting of wrist, fingers, and thumb web space. Splinting is maintained until skeletal maturity ( Table 21.1 ).
| Type | Findings | Treatment Option | |
|---|---|---|---|
| Mild | Localized Volkmann’s contracture Deep flexor compartment FDP of long and ring finger Little or no nerve involvement | Therapy management:
| |
| Moderate | Nearly all FDP, FPL, and partial FDS Median nerve impairment Intrinsic minus posture Poor sensation along ulnar nerve | Therapy management:
| |
| Severe | All the flexor compartment Varied extensor compartment No intrinsic muscles Median, ulnar nerve impairment | Therapy management:
| |
Free Functional Muscle Transfer
Introduction
Functional deficits in the upper extremity that are not amenable to tendon, nerve, or rotational muscle transfers for reconstruction often require the use of a free functional muscle transfer as the most effective means to restore function. Common indications are Volkmann’s ischemic contracture, late reconstruction of brachial plexus injuries, traumatic muscle loss, oncologic resection, and congenital absence of motor function such as arthrogryposis. The gracilis has long been used as the workhorse of most upper extremity free muscle transfers due to its favorable neurovascular and musculotendinous anatomy. Other commonly used donor muscles include latissimus dorsi, medial gastrocnemius, pectoralis major, serratus anterior, tensor fascia lata, and rectus femoris.
Success of these procedures requires impeccable surgical technique paired with comprehensive therapy both preoperatively and postoperatively ( Figs. 21.5 and 21.6 ).
Before free functional muscle transfer, it is imperative that the patient has passive motion across the affected joint and that the soft tissue envelope is optimized for soft tissue gliding. This may mean that an antecedent surgery be performed for tenolysis, contracture release, and/or soft tissue coverage. At the time of muscle transfer surgical incisions are planned to maximize soft tissue coverage over the planned tenorrhaphy site. The transplanted muscle origin is spread to best match the width of the old origin and is secured to bone or periosteum using bone tunnels or nonabsorbable sutures. Marking and restoring the resting length of the gracilis during its harvest is of critical importance in ensuring its maximal function. Pulvertaft weave is the preferred method of distal tenorrhaphy. Vascular anastomosis should be performed first to minimize ischemic muscle changes, followed by venous anastomosis, and finally neurorrhaphy as close to the transplanted muscle as possible. Wound closure, dressings, and postoperative splinting are critical as to not compress the anastomoses. The operative extremity is immobilized with the elbow in flexion and hand in position of safety to protect the new muscle origin and insertion as well as the neurovascular anastomosis. Viability of the muscle flap is monitored for 48–72 hours via the skin flap using Doppler ultrasound and clinical exam.
In this part of the chapter, we will focus on the therapeutic management during the pre- and postoperative periods following free functional gracilis transfers (FFGT) for elbow flexion and digital flexion and extension ( Figs. 21.7–21.9 ).
Preoperative Assessment and Therapy
When nerve and muscle recovery has plateaued, preoperative assessment is critical to help the surgeon identify donor muscles and nerves, and guide targeted preoperative therapy. ( Box 21.1 ).
- •
Full or nearly full PROM across joint for the planned transfer
- •
Functional motor and sensory functioning above and below transfer site
- •
Adequate antagonist muscle power
Full passive range of motion of the affected joint as well as full passive and active range of motion of neighboring joints is considered crucial for successful surgical outcome. Serial splinting may be effective in resolving joint contractures in addition to an extensive stretching program.
Decreased sensation in the involved upper extremity may lead to poor postoperative functional outcomes. Assessment of protective sensation, light touch, and two-point discrimination provides valuable information of specific areas of nerve injury. However, sensory exams can be difficult to perform and may be unreliable in young children.
Assessing the strength and motor function of antagonistic muscle will predict and prepare for future concerns regarding muscle imbalance between the antagonistic and transplanted muscle.
The child and caregiver’s commitment to comply with the preoperative home program (i.e., stretching and splinting) will help to gauge their readiness to commit to the long and complex rehabilitative journey ahead.
Postoperative Assessment and Therapy
Therapeutic management following FFGT is limited in the literature and does not exist for children. Some authors have contributed brief guidelines, but it is up to the therapist to gather relevant information about the procedure and work together with the surgeon to design a course of postoperative care. Therapists unfamiliar with this procedure would benefit from the mentorship of a colleague who has gained successful experience with these cases ( Box 21.2 ).
- 1.
What pre-op evaluation criteria will lead to successful outcomes?
- 2.
Which protocol is preferred by the referring surgeon?
- 3.
What splints will be needed during the immobilization period and over the long term?
- 4.
What strategies support muscle transfer until reinnervation? How is reinnervation monitored?
- 5.
During the activation phase, what synergistic pairing is required and how long must it be employed?
- 6.
What activity sequence is best during the strength and function phase in order to reach full recovery?
- 7.
What are the expected outcomes and the timelines to achieve them?
Standard Assesment and Outcome Measures
The British Medical Research Council (MRC) grading system is a well-accepted scale that is used to grade muscles individually ( Box 21.3 ).
British Medical Research Council (MRC) grading system
- •
0 No contraction
- •
1 Flicker/trace contraction
- •
2 Active movement with gravity eliminated
- •
3 Active movement against gravity
- •
4 Active movement against resistance
- •
5 Normal strength
The Active Movement Scale (AMS) designed for infants with brachial plexus birth palsy is an accepted scale to measure motion in infants and younger children ( Box 21.4 ).
Active Movement Scale
Gravity eliminated
- •
0 no contraction
- •
1 contraction, no motion
- •
2 <50% motion
- •
3 >50% motion
- •
4 full motion
- •
Against Gravity
- •
5 <50% motion
- •
6 >50% motion
- •
7 full motion
- •
Surface electromyography (sEMG) is an effective measure of determining muscle reinnervation.
It is also helpful in giving visual or auditory feedback to induce synergist pairing, gain muscle control, and determine when pairing is no longer needed. Placement of sensors should be standardized during each use.
Splinting Requirements: Immobilization Phase
FFGT to restore elbow flexion: The upper extremity is held in a sling with 90 degrees–100 degrees of elbow flexion. An additional strap may be needed to maintain shoulder adduction, in cases when intercostal or phrenic nerve transfers are used. Great care is taken, as even a brief period of shoulder abduction in the post-op period can lead to rupture of the nerve repair. Postoperative immobilization is 4–8 weeks depending on surgeon’s preference.
FFGT to restore finger flexion or extension: Please refer to Table 21.2 for specific postoperative positioning ( Fig. 21.10 ).
| Elbow Flexion | Finger Extension | Finger Flexion | |
| Donor muscle options | Gracilis a Latissimus dorsi Tensor fasciae latae Medial gastrocnemius | Gracilis a Latissimus dorsi Tensor fasciae latae | Gracilis a Latissimus dorsi Tensor fasciae latae |
| New origin | Distal half of clavicle (gracilis) Coracoid (latissimus) | Lateral epicondyle, common extensor fascia | Medial epicondyle of humerus, flexor-pronator fascia |
| New insertion | Distal biceps tendon Bone at radial tuberosity Bone at ulna-level of tuberosity | Tendons of EDC, EPL | Tendons of FDP at distal forearm |
| Recipient nerve (options) | Musculocutaneous Spinal accessory (terminal branch) Intercostal Medial pectoral (not preferred because of size) | Posterior interosseous Motor branch to pronator teres | Anterior interosseous Median motor fascicles |
| Position for restoration of resting length | Full elbow extension | Elbow, wrist, and fingers in full extension | Full elbow extension, wrist flexion at 20–30 a , finger MCP 90 a flex |
| Postoperative Position | Immobilization at 90 a elbow flexion for 8 weeks. | Immobilization with elbow at 90 a flexion, wrist at 30 a ext., full MCP ext., IP joints left free for 6 weeks. | Immobilization with elbow at 90 a flex, wrist at 30 a flex, MCP at 90 a flex. Thumb in palmar abduction, IP flex. |
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