Fasciotomy is a clinical procedure indicated once the clinical diagnosis of compartment syndrome is made. This article focuses on the treatment of acute compartment syndrome.
Compartment syndrome results from the combination of increased interstitial tissue pressure and the noncompliant nature of the fascia and osseous structures that make up a fascial compartment.
Severe complications following compartment syndrome were first described in 1881 by Richard Van Volkmann after he noted that interruption of the blood supply to the flexors in the forearm secondary to supracondylar fractures resulted in paralysis and contracture of the affected muscle group.
A fasciotomy consists of one or more fascial incisions and remains the only effective way to treat acute compartment syndrome.
The importance of timely evaluation and clinical suspicion is based on the sequelae of compartment syndrome. Nerve conduction can be negatively affected after 2 hours of ischemia; however, if compartment syndrome is diagnosed and treated within 6 hours of onset, overall functional impairment is unlikely.
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| Fasciotomy |
Indications
Indications for surgical intervention in acute compartment syndrome in the alert patient are generally based on clinical impression. Four signs and symptoms are commonly referred to as the four Ps, as follows:
Pain that is out of proportion to clinical findingsPain with passive stretch of involved muscles
Pain with palpation of involved compartment
Pressure increase within the compartment as measured
Certainly, all of these signs do not need to be and are often not present in the setting of acute compartment syndrome. A pulseless extremity more likely reflects large vessel injury as a very late finding in compartment syndrome and may not develop at all despite protracted elevated pressures.
In a patient who cannot express pain or paresthesias, serial clinical examinations along with monitoring of compartment pressure can play a more important role in the diagnosis.
The pressure point at which fasciotomy should be considered is not a specific value, although a compartment pressure of 30 mm Hg is a commonly cited value. Masquelet notes that whenever diastolic pressure minus tissue pressure (Δ p) is less than 30 mm Hg, fasciotomy is indicated.
Contraindications
Fasciotomy is contraindicated when diagnosis of compartment syndrome is made late. Fasciotomy 3-4 days after onset of compartment syndrome can lead to infection and kidney failure in a setting of devascularized and necrotic muscle.
Etiology
Many factors play a role in the development of compartment syndrome, including vascular injuries, soft tissue trauma, and systemic hypotension in the patient with a traumatized extremity.
Most commonly, acute compartment syndrome is secondary to trauma such as fracture, arterial injury, physical compression, or burn. However, postoperative hematoma, tight-fitting casts, and infiltration of fluids through an intravenous catheter, as well as a multitude of other issues, have also been described in association with compartment syndrome.
Pathophysiology
Interstitial pressures increase within a compartment, and, as it reaches and exceeds venous pressure, venous outflow is halted, causing further increase in intracompartmental pressures. This results in a shunting of blood flow away from the injury and toward areas of lower vascular resistance. In this environment, muscle cells are unable to adapt to the decreased oxygen tension that is secondary to the increased tissue pressures.
This cycle propagates itself and cell death–induced metabolic changes contribute to the hypoxia, further increasing pressure. Knowing the pressure at which this cycle is initiated has been the goal of many studies, and although no incontrovertible value has been identified, compartmental pressures measuring 30 mm Hg or more are understood to often require surgical intervention (see the image below).
Preparation
Anesthesia
Anesthesia decision making differs based on the situation in which the compartment syndrome and fasciotomy occur. General anesthesia is often performed when the situation allows.
Equipment
See the list below:
Sterile glovesSterile drapes
Soft tissue retractors
Scalpel
Dissecting scissors
Electrocautery
Wound V.A.C. or bulky dressings
Technique
Overview
Any time a procedure is indicated for a patient, step one is always obtain informed consent. Areas involved in the procedure need to be sterilely prepared and draped as well.
Leg fasciotomy - Double-incision technique
Positioning
The patient is positioned supine, with a bump under the affected hip.
Approach
Two longitudinal 15- to 20-cm incisions are made.
The anterolateral incision is used to decompress the anterior and lateral compartments.
The posteromedial incision is used to decompress the superficial posterior and deep posterior compartments.
An anterolateral incision is demonstrated in the image below.
Anterolateral incision
(1) Make skin incision, approximately 15-20 cm long, as follows:
Center between tibial crest and fibula shaftProximal landmark for incision is approximately 3 cm distal to the level of the tibial tuberosity
Distal landmark is the lateral malleolus
(2) Perform subcutaneous dissection to expose the fascia overlying the anterior and lateral compartments.
(3) Identify the intermuscular septum between the anterior and lateral compartments.
(4) Make a small transverse fascial incision, centered over the intermuscular septum, as follows:
Incision extends over the anterior and lateral compartmentsSuperficial peroneal nerve in lateral compartment must be identified and protected
(5) Release the anterior compartment, as follows:
Incise fascia overlying the anterior compartment by longitudinally extending the transverse fascial incisionMetzenbaum scissors are typically used for incising the fascia
Proximally, aim for the lateral border of the patella
Distally, aim for the center of the ankle joint
(6) Release the lateral compartment, as follows:
Incise the fascia overlying the lateral compartment, in line with the fibular shaft, by longitudinally extending the transverse fascial incisionMetzenbaum scissors are typically used for incising fascia
Proximally, terminate the incision approximately 5 cm distal to the fibular head to minimize the risk of injury to the common peroneal nerve
Distally, direct the scissors toward the lateral malleolus to minimize the risk of injury to the superficial peroneal nerve
Posteromedial incision
A posteromedial incision is demonstrated in the image below.
(1) Make a skin incision, approximately 15-20 cm in length, as follows:
Placed approximately 2 cm posterior to the posteromedial border of the tibiaProximal landmark for incision is approximately 3 cm distal to the level of the tibial tuberosity
Distal landmark is the medial malleolus
(2) Perform subcutaneous dissection to expose the fascia overlying the superficial and deep posterior compartments, as follows:
Anterior dissection exposes the posteromedial border of the tibiaIdentify and protect the saphenous vein and nerve
(3) Release the superficial posterior compartment, as follows:
Incise the fascia approximately 2 cm posterior to the skin incision, overlying the gastrocnemius muscleExtend the fascial incision longitudinally, the entire length of the gastrocnemius-soleus complex
(4) Release the deep posterior compartment, as follows:
Dissect the superficial posterior compartment off the posteromedial border of the tibiaRelease the fascia overlying the soleus and proximally release the soleus bridge
Incise the fascia longitudinally the entire length of the flexor digitorum longus (FDL) muscle
Incise the fascia longitudinally the entire length of the tibialis posterior muscle if warranted
Metzenbaum scissors are typically used for incising fascia
Protect the posterior tibial neurovascular bundle, located between the FDL and the flexor hallucis longus
Leg fasciotomy - Single-incision technique
Matsen et al made the one-incision technique popular. [6] This technique is popular given that only a single longitudinal incision is used (see the image below); however, note that it may be challenging to determine if all four compartments are truly decompressed, especially in a severely injured extremity. For the most part, the double-incision technique should be used because it is the safer and more effective technique.
(1) Begin the lateral incision at the head of the fibula and extend it distally along the path of the fibula to the ankle, followed by subcutaneous dissection.
(2) Identify the intermuscular septum between the anterior and lateral compartments, being mindful to protect the superficial peroneal nerve in this territory.
(3) Beginning 1 cm anterior to the intermuscular septum, release the anterior compartment.
(4) Beginning 1 cm posterior to the septum, release the lateral compartment.
(5) Identify the superficial posterior compartment and perform a fasciotomy of the superficial posterior compartment over the gastrocnemius-soleus complex.
(6) Retract the lateral compartment anteriorly and the superficial peroneal compartment posteriorly to expose the deep posterior compartment.
(7) Identify the interosseous membrane at the posterior aspect of the fibula and release the deep posterior compartment from this tissue.
Forearm fasciotomy
Positioning
The patient is positioned supine.
Approach
Two incisions are used if both volar and dorsal compartment releases are required.
The volar incision is used to decompress the volar and mobile wad compartments.
The dorsal incision is used to decompress the dorsal compartment.
Volar incision
The S-type incision includes carpal tunnel release.
The distal landmark is the distal extent of the carpal tunnel.
The proximal landmark is the ulnar side of the elbow flexion crease.
The S-shaped forearm incision begins and ends along the ulnar border of forearm and is located along the radial border of mid forearm.
(1) Make a skin incision, as follows:
Begins approximately 3 cm distal to the wrist flexion crease, centered between the thenar and hypothenar eminencesIncise proximally and longitudinally, to the distal aspect of the wrist flexion crease
Angle the incision obliquely across the wrist flexion crease, to the ulnar aspect of the distal forearm
Continue proximally with a curvilinear S-shaped incision the length of the forearm
The S shape begins distally, along the ulnar aspect of the distal forearm; curves radially, to the radial aspect of the mid forearm; curves back towards the ulnar aspect of the forearm, ending at the distal aspect of the elbow flexion crease
(2) Perform subcutaneous dissection to expose the fascia overlying the mobile wad and superficial forearm muscles.
(3) Proximally, identify and divide the lacertus fibrosis; protect the underlying brachial artery and median nerve.
(4) Longitudinally incise the fascia overlying the flexor carpi ulnaris.
(5) Expose the deep compartment of the forearm by the retracting flexor carpi ulnaris ulnarly and the flexor digitorum superficialis laterally.
(6) Longitudinally incise the fascia overlying the deep muscles of the forearm.
(7) Identify and release the fascia overlying the mobile wad; this includes the brachioradialis and wrist extensors.
(8) Distally, perform a carpal tunnel release, as follows:
Incise the palmar fascia to expose the transverse carpal ligamentIncise the transverse carpal ligament along the ulnar side
Identify and protect the median nerve (slight wrist flexion typically facilitates this)
Visualize and incise the antebrachial fascia
Suture a skin flap loosely over the median nerve (if median nerve is exposed)
(9) Assess dorsal compartments to determine if a fasciotomy needed.
See the image below.
Dorsal incision
The dorsal approach for release of dorsal compartments is demonstrated in the image below.
The proximal landmark for incision is approximately 2 cm distal to the lateral epicondyle.
The distal landmark is the middle of the wrist.
(1) Make an approximately 10 cm longitudinal skin incision.
(2) Perform subcutaneous dissection to expose the fascia overlying the dorsal compartment.
(3) Longitudinally incise the fascia overlying the extensor digitorum communis muscle.
(4) Identify and dissect the interval between the extensor digitorum communis and the extensor carpi radialis muscles to access the deep fascia.
(5) Incise the deep fascia longitudinally over the deep dorsal compartment muscles.
Hand fasciotomy
Positioning
The patient is positioned supine.
Approach
Four incisions are used, two dorsal and two volar, as shown in the images below.
Volar incisions are used to decompress the thenar and hypothenar compartments.
Dorsal incisions are used to decompress the interosseus compartments and the thumb adductor compartment.
Volar incisions
(1) Two separate longitudinal incisions are made, over the thenar and hypothenar compartments.
(2) Thenar compartment release is as follows:
Make a longitudinal skin incision along the radial border of the thumb metacarpalIdentify and release fascia overlying the thenar muscles
(3) Hypothenar compartment release is as follows:
Make a longitudinal skin incision along the ulnar border of the small finger metacarpalIdentify and release the fascia overlying hypothenar muscles
Dorsal incisions
(1) Two separate longitudinal skin incisions are made, centered over the second and fourth metacarpals.
(2) Dissection proceeds along the radial and ulnar borders of the both the second and fourth metacarpals to the level of the dorsal interossei fascia.
(3) Incise the fascia of all four dorsal interosseus muscles.
(4) Continue blunt dissection along the ulnar side of the second metacarpal to decompress the first volar interosseus and adductor pollicis muscles.
(5) Continue blunt dissection along the radial side of the fourth and fifth metacarpals to decompress the second and third volar interosseus muscles, respectively.
Thigh fasciotomy
Positioning
The patient is positioned supine.
Approach
Typically, only one incision is used, located over the lateral thigh, as shown in the image below.
The lateral incision is used to decompress the anterior and posterior compartments.
A second incision, located over the medial thigh, is used if medial compartment release is required.
Lateral incision
(1) Make longitudinal skin incision along lateral thigh, as follows:
Centered over the lateral aspect of the femurExtends from the midline of the greater trochanter to the lateral epicondyle
(2) Perform subcutaneous dissection to expose the iliotibial band.
(3) Longitudinally incise the iliotibial band along the entire length of the skin incision.
(4) Identify and longitudinally incise the fascia overlying the vastus lateralis.
(5) Dissect the vastus lateralis off the lateral intermuscular septum and coagulate all perforators.
(6) Make a 1- to 2-cm incision in the lateral intermuscular septum, and longitudinally extend it, typically using Metzenbaum scissors, along the entire length of skin incision.
The anterior and posterior compartments have now been released.
Medial incision
(1) Make an approximately 20 cm longitudinal skin incision along the anteromedial thigh, centered over the adductor muscles.
(2) Perform subcutaneous dissection to expose the fascia overlying the medial compartment.
(3) Longitudinally incise the fascia along the entire length of the skin incision.
(4) Incise and release the medial intermuscular septum, if warranted.
Foot fasciotomy
(1) Make a medial foot incision extending from just below the medial malleolus to the proximal aspect of the first metatarsal.
(2) Release the fascia overlying the abductor hallucis and flexor digitorum brevis.
(3) Incise and release the medial intermuscular septum longitudinally.
(4) Bluntly dissect and release the central, lateral, and intrinsic compartments.
(5) Make two longitudinal dorsal incisions, one between the second and third metatarsal and the other between the third and fourth metatarsals.
(6) Divide the superficial fascia and elevate the interosseous muscles off the metatarsals to further decompress the compartments.
(7) Leave the wound open. Apply a large, bulky dressing or wound vacuum-assisted closure device.
Post-Procedure
Elevate the affected extremity for 24-48 hours after surgery.
If necrotic muscle develops, return to the operating room for excision of necrotic muscle.
Perform dressing changes at the bedside or in the operating room, as deemed appropriate per the clinical situation.
Perform delayed primary skin closure when swelling subsides. If delayed primary skin closure cannot be performed within 5 days, perform split-thickness skin grafting.
Overall, the rehabilitation protocol is dependent upon the underlying injury that caused the compartment syndrome and need for fasciotomy.
Perform standard suture or staple removal and postoperative wound checks.
Medications and Medical Devices
Negative-pressure wound therapy (wound V.A.C.) may be used instead of a bulky dressing.
Pearls
Many techniques have been described to facilitate primary closure of fasciotomy sites, including placing vascular loops in a zigzagged fashion across the fasciotomy site. This may help to slowly close the wound by gradually tensioning the incision with the vessel loops.
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