Free Functional Gracilis Muscle Transfer for Severe Pediatric Volkmann Ischemic Contracture After Traditional...

Volkmann ischemic contracture is a severe and largely preventable complication of untreated or delayed compartment syndrome. In children, it is most commonly associated with supracondylar humerus fractures, especially when external compression from casts or splints is not promptly recognized. We report the case of a six-and-a-half-year-old right-handed girl who developed severe left upper-limb dysfunction after a closed supracondylar humerus fracture treated in a rural setting with tight traditional splint immobilization, locally known as "Jbira." No fasciotomy was performed during the acute phase. She presented 18 months after the injury with elbow stiffness, fixed forearm pronation, wrist stiffness, proximal interphalangeal joint deformities, loss of active digital flexion, and paresthesia involving the thumb and index finger. The condition was classified as severe Volkmann ischemic contracture. A staged reconstruction was performed. The first stage included release of fibrotic forearm tissue, excision of nonfunctional flexor fibrosis, ulnar nerve neurolysis and transposition, median nerve reconstruction with a sural nerve graft, passive joint mobilization, and radial derotational osteotomy. One year later, because active finger flexion remained insufficient, a free functional innervated gracilis muscle transfer was performed. At 12-month follow-up after the gracilis transfer, the patient achieved Medical Research Council grade M3 active finger flexion, partial fist formation, and functional grasp sufficient to hold a glass and a bottle. This case supports staged free functional gracilis transfer as a useful salvage option in severe pediatric Volkmann ischemic contracture.