Richard von Volkmann: Volkmann's ischaemic contracture.
In the German surgical journal Zentralblatt fur Chirurgie of 1881,
Richard von Volkmann wrote; 'The paralyses and contractures that
follow tightly applied bandages, chiefly in the forearm and hand, and
less often in the lower extremity, are to be viewed as ischemic. They
arise from the arterial supply being interrupted for too long'. The
article then goes on to state; 'contractures of a similar nature
also appear after ligatures, avulsions and contusions of large
KEYWORDS Ischaemic contracture / Richard von Volkmann
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: Oct, 2012 Source Volume: 22 Source Issue: 10|
Classically, this condition complicates supracondylar fractures of
the lower end of the humerus in children, where the lower part of the
brachial artery is stretched over the proximal end of the fracture. I
used to teach, years ago, that the patient presents with 'four
p's' - Pain, Pallor, Pulselessness and Paralysis. I then
became examiner at the Royal College of Surgeons in Dublin, where my
Irish colleague added a fifth 'p' - Perishing with cold. I
remain indebted to him!
In most cases, if the fracture is gently reduced and the elbow not flexed too much, the pulse returns and all is well. In more severe injuries, the muscles are deprived of their blood supply, become ischaemic, and are replaced by fibrous scar tissue, contraction of which results in a crippling 'claw hand' deformity. A similar condition can occur in the lower limb. Many years ago, when I was Resident Surgical Officer at the old Sheffield Royal Infirmary, I followed up 343 adults one to five years after they had sustained a fracture of the shaft of the tibia. Nine of these patients showed clinical features of Volkmann's contracture, with clawed contractures of the toes and flexion deformities of the ankles.
Modern advances in fracture treatment, avoidance of over-tight splintage, the availability of vascular tree visualisation with arteriography and the Doppler probe and surgical reconstruction or replacement of damaged arteries have made this condition less common, but sadly it still occurs. The nursing and surgical staff need to be on their toes when there is a possibility that this complication might occur.
Richard von Volkmann was born in Leipzig, Germany in 1830. His father was a distinguished professor of Anatomy and Physiology. Richard studied Medicine in Berlin, and received his medical doctorate in 1854 at the age of 24. He trained in surgery at the University of Halle, Saxony, where he was appointed deputy to the professor. In 1867 he was promoted to Director and Professor at the Halle University Surgical Clinic, and it was at Halle that, apart from his war service, he was to spend the rest of his career. Those early days at Halle were before the teachings of Joseph Lister and the technique of antiseptic surgery had been heard of; indeed, Lister's papers on this subject were first published in 'The Lancet' in 1867, the year of Volkmann's promotion. When Volkmann took over as head of the department, 'Hospital Gangrene' was so common in the surgical wards at Halle that it was said that 'No one dared to touch a knife in the surgical clinic'. The newly appointed professor served as an Army surgeon during the both the war with Austria and the Franco-Prussian war of 1870-1. In both, the morbidity and mortality of gunshot wounds from overwhelming sepsis, as well as tetanus and gas gangrene, were frightful.
Volkmann was one of Lister's first disciples, read his publications avidly and did much to spread the principles of 'Listerism' to continental Europe, which, indeed, was in advance of practice in the United Kingdom. Sir George Makins, surgeon at St. Thomas's Hospital, who visited Volkmann in 1879, left a vivid account of Volkmann's method. The operating theatre had terrazzo paving; very important as this allowed efficient drainage. In addition to Lister's carbolic spray, producing an aerosol over the wound and the operating team, the wounds were irrigated very freely with 1 in 20 carbolic solution, which was poured over the wound from gardeners' watering cans with long spouts. The surgeon and his assistants all wore long rubber boots to protect themselves from the flood. The slogan of the clinic was 'If dirt be unavoidable, it must be antiseptic dirt'.
Volkmann was an elegant, bold and original operative surgeon. Visitors from all over Europe flocked to his clinic and, through him, the principles of antiseptic surgery were propounded and propagated. He drew attention to the fact that skin carcinomas could result from exposure to irritating substances and published an important study of skin cancer in paraffin workers. He was particularly interested in the surgery of bone and joints and in cancer surgery, performing a successful excision of carcinoma of the rectum in 1878. Readers of this paper may well be familiar with 'Volkmann's spoon', a useful instrument for scraping out a deep cavity, for example, a breaking down tuberculous lymph node in the neck.
The honour of 'Von' added to his name, (the equivalent of a knighthood in the United Kingdom) was given to him in 1885 by the Emperor Wilhelm I. Volkmann was a striking personality, of medium height, rather stout and with magnificent long Dunreary whiskers - you can easily spot him in photographs of surgical groups. Unlike the average surgeon, he was a man of culture who published books of poetry under a pseudonym--Richard Leander.
He died of spinal disease in 1889 in hospital in Jena at the comparatively early age of 59.
by Professor Harold Ellis
Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE1 1UL.
About the author
Professor Harold Ellis
Emeritus Professor of Surgery, University of London; Department of Anatomy, Guy's Hospital, London
No competing interests declared
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Provenance and Peer review: Commissioned; Peer reviewed; Accepted for publication January 2012.
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