Selective Fascicular Coaptation of Free Functioning Gracilis Transfer for Restoration of Independent Thumb and Finger Flexion Following Volkmann Ischemic Contracture

Abstract

Children are prone to developing moderate to severe Volkmann ischemic contracture following a supracondylar fracture of the humerus or its treatment. Given the variable extent of forearm muscle damage, tendon transfers and tenodeses are often unavailable. To address these contractures, intensive hand therapy and a free functioning muscle transfer are required. Despite functional improvement following free muscle transplantation, reconstructed patients with severe Volkmann ischemic contracture tend to have persistent difficulty with fine motor activities owing to the losses of intrinsic muscle function and independence of thumb and finger flexion. The authors demonstrate how selective coaptation of separate fascicular territories of the gracilis nerve branches to the branches of the anterior interosseous nerve that innervate flexor pollicis longus and flexor digitorum profundus may be performed to establish a degree of independent thumb and finger flexion with a single free gracilis transfer. This technical refinement as well as its long-term outcomes in a series of three patients is presented.

Functional Free Muscle Transfer for Upper Extremity Reconstruction

“…First performed at the Sixth People's Hospital in Shanghai in 1973, the lateral portion of the pectoralis major was used to reconstruct the flexor muscles of the forearm for a patient with Volkmann ischemic contracture. 29 Krimmer et al used the gracilis muscle in 15 patients with a primary indication of Volkmann contracture. All patients achieved less than 2-cm pulp to palm grip.…”

Redefining the Anatomic Boundaries for Safe Dissection of the Skin Paddle in a Gracilis Myofasciocutaneous Free Flap: An Indocyanine Green Cadaveric Injection Study

“…In 1978, Manktelow and McKee 15 described the free gracilis muscle to replace the long flexor musculature of the finger, and later went on to describe its use in replacing forearm musculature, facial reanimation, and anterior lower leg to treat foot drop. 16–18…”

Localized type Volkmann's contracture treated with tendon transfer and tension-reduced early mobilization

“…Up to now, a variety of therapeutic techniques for Volkmann's contracture, such as splinting, [1,2] excision of the affected muscle, [1,3,4] muscle sliding, [1,5–8] tendon lengthening, [2,9,10] and free muscle transplantation, [3,11,12] have been reported. Tsuge classified the disease into 3 groups according to severity, mild (localized), moderate, and severe type.…”