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Fasciotomy

  • Author: Jennifer Wood, MD; Chief Editor: Thomas M DeBerardino, MD  more...
 
Updated: Sep 28, 2015
 

Overview

Introduction

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.[1] 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.[2]

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[2] ; however, if compartment syndrome is diagnosed and treated within 6 hours of onset, overall functional impairment is unlikely.[2]

Key considerations

Fascial compartments are defined by unforgiving connective-tissue septa and osseous structures. Without sufficient compliance of these structures, pressure increases within the closed system, causing microvascular compromise and subsequent muscle and nerve ischemia.[1]

Compartments that have the least baseline compliance are those that are most likely to develop compartment syndrome. This is the case for the anterior and deep posterior compartments of the leg. Although it most commonly (40%) occurs in the compartments at the level of the tibia and fibula,[2] compartment syndrome is seen anywhere muscle groups are enclosed as described above, including the buttocks and lumbar paraspinous muscles.[1, 3]

Diagnosis of compartment syndrome can be made by clinical examination or with more objective measures such as compartment pressures. Although absolute compartmental pressures are often used for fasciotomy decision making, the difference between the compartment pressure and diastolic pressure (Δ p), has been associated with an increased accuracy in diagnosing compartment syndrome and is particularly useful in the multitrauma patient. Multitrauma patients can become hypotensive and therefore create an environment in which the development of compartment syndrome can occur at lower pressures and confound diagnosis of compartment syndrome in these clinical scenarios.[4] A high clinical suspicion for compartment syndrome along with serial examinations without the use of compartment pressure measurements is still used in many settings today.

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 findings
  • Pain 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.[5]

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 (see the image below).[6]

Myonecrosis. Excised muscle from a patient with a Myonecrosis. Excised muscle from a patient with a femur fracture and compartment syndrome of the leg that was released more than 10 hours from onset. Patient went on to an above-the-knee amputation.

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 (see the image below).

Rhabdomyolysis: 31-year-old dehydrated and overwei Rhabdomyolysis: 31-year-old dehydrated and overweight female with sickle cell trait presented with bilateral thigh and leg compartment syndrome after military physical training (PT) test.

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).

Crush injury to the hand created pressures high en Crush injury to the hand created pressures high enough to result in muscle extrusion from the adductor compartment and tearing of the skin over the palm.
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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 gloves
  • Sterile drapes
  • Soft tissue retractors
  • Scalpel
  • Dissecting scissors
  • Electrocautery
  • Wound V.A.C. or bulky dressings
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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.

Fasciotomy. Fasciotomy.

Anterolateral incision

(1)  Make skin incision, approximately 15-20 cm long, as follows:

  • Center between tibial crest and fibula shaft
  • Proximal 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 compartments
  • Superficial 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 incision
  • Metzenbaum 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 incision
  • Metzenbaum 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.

Fasciotomy Fasciotomy

(1) Make a skin incision, approximately 15-20 cm in length, as follows:

  • Placed approximately 2 cm posterior to the posteromedial border of the tibia
  • Proximal 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 tibia
  • Identify 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 muscle
  • Extend 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 tibia
  • Release 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

See the image below.

Fasciotomy 10 hours from onset of compartment synd Fasciotomy 10 hours from onset of compartment syndrome secondary to femur fracture. Notice the blister denoted by arrow. Patient later had an above-knee amputation secondary to myonecrosis from prolonged ischemia.

Leg fasciotomy - Single-incision technique

Matsen et al made the one-incision technique popular.[4] 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]

Fasciotomy. Fasciotomy.

(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.

See the image below.

Compartment syndrome of the forearm of an anticoag Compartment syndrome of the forearm of an anticoagulated patient after the radial artery was punctured while obtaining an arterial blood gas.

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 eminences
  • Incise 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 ligament
  • Incise 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.

Forearm after compartment release. Median nerve de Forearm after compartment release. Median nerve denoted by star.

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.

Fasciotomy. Fasciotomy.

(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.

Locations for dorsal incisions over second and fou Locations for dorsal incisions over second and fourth metacarpals. Provides access to the dorsal and volar interosseous compartments and adductor compartment to the thumb.
Locations for thenar incision over radial aspect o Locations for thenar incision over radial aspect of the thumb metacarpal and mark for the hypothenar incision over ulnar aspect of the fifth metacarpal.

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 metacarpal
  • Identify 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 metacarpal
  • Identify 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.

See the images below.

Crush injury from Image 3: status post-compartment Crush injury from Image 3: status post-compartment release. Traumatic tear provided access to the thenar volar interosseous compartments.
Single dorsal incision was made to gain access to Single dorsal incision was made to gain access to the dorsal interosseous compartments, and hypothenar incision to gain access to the hypothenar compartment.

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.

Location for thigh incision beginning just distal Location for thigh incision beginning just distal to the intertrochanteric line.

Lateral incision

(1) Make longitudinal skin incision along lateral thigh, as follows:

  • Centered over the lateral aspect of the femur
  • Extends 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

See the images below.

Location of medial foot incision from just below t Location of medial foot incision from just below the medial malleolus to the proximal aspect of the first metatarsal.
Location of dorsal incisions: one between the seco Location of dorsal incisions: one between the second and third metatarsals and one between third and fourth metatarsals.

(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.

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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.

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Medications and Medical Devices

Negative-pressure wound therapy (wound V.A.C.) may be used instead of a bulky dressing.

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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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Contributor Information and Disclosures
Author

Jennifer Wood, MD Limb Lengthening and Reconstruction Fellow, Rubin Institute of Advanced Orthopaedics, Sinai Hospital Baltimore

Jennifer Wood, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, South Carolina Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

John J Walsh, IV, MD Professor and Chairman, Department of Orthopedic Surgery, University of South Carolina School of Medicine

John J Walsh, IV, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Christian Medical and Dental Associations, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Renee Genova, MD University of South Carolina School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Thomas M DeBerardino, MD Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; Ivy Sports Medicine; MTF; Aesculap; The Foundry, Cotera; ABMT<br/>Received research grant from: Histogenics; Cotera; Arthrex.

References
  1. Campbell WC, Canale ST, Beaty JH. Campbell's Operative Orthopaedics. Philadelphia, Pa: Mosby/Elsevier; 2008. 2737-743.

  2. Tintinalli JE, Stapczynski JS. Tintinalli's Emergency Medicine: a Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011. Chapter 8.

  3. Winkes MB, Hoogeveen AR, Scheltinga MR. Is surgery effective for deep posterior compartment syndrome of the leg? A systematic review. Br J Sports Med. 2013 Sep 24. [Medline].

  4. Browner BD. Skeletal Trauma. Philadelphia, Pa: Saunders Elsevier; 2009. Chapters 12,13, 48.

  5. Masquelet AC. Acute compartment syndrome of the leg: pressure measurement and fasciotomy. Orthop Traumatol Surg Res. 2010 Dec. 96 (8):913-7. [Medline].

  6. Arató E, Kürthy M, Sínay L, Kasza G, Menyhei G, Masoud S, et al. Pathology and diagnostic options of lower limb compartment syndrome. Clin Hemorheol Microcirc. 2009. 41 (1):1-8. [Medline].

  7. Doherty GM. Current Diagnosis & Treatment: Surgery. New York, NY: Lange Medical /McGraw-Hill; 2010.

  8. Leversedge FJ, Moore TJ, Peterson BC, Seiler JG 3rd. Compartment syndrome of the upper extremity. J Hand Surg Am. 2011 Mar. 36 (3):544-59; quiz 560. [Medline].

 
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Myonecrosis. Excised muscle from a patient with a femur fracture and compartment syndrome of the leg that was released more than 10 hours from onset. Patient went on to an above-the-knee amputation.
Rhabdomyolysis: 31-year-old dehydrated and overweight female with sickle cell trait presented with bilateral thigh and leg compartment syndrome after military physical training (PT) test.
Crush injury to the hand created pressures high enough to result in muscle extrusion from the adductor compartment and tearing of the skin over the palm.
Fasciotomy.
Fasciotomy
Fasciotomy 10 hours from onset of compartment syndrome secondary to femur fracture. Notice the blister denoted by arrow. Patient later had an above-knee amputation secondary to myonecrosis from prolonged ischemia.
Fasciotomy.
Compartment syndrome of the forearm of an anticoagulated patient after the radial artery was punctured while obtaining an arterial blood gas.
Forearm after compartment release. Median nerve denoted by star.
Fasciotomy.
Locations for dorsal incisions over second and fourth metacarpals. Provides access to the dorsal and volar interosseous compartments and adductor compartment to the thumb.
Locations for thenar incision over radial aspect of the thumb metacarpal and mark for the hypothenar incision over ulnar aspect of the fifth metacarpal.
Crush injury from Image 3: status post-compartment release. Traumatic tear provided access to the thenar volar interosseous compartments.
Single dorsal incision was made to gain access to the dorsal interosseous compartments, and hypothenar incision to gain access to the hypothenar compartment.
Location for thigh incision beginning just distal to the intertrochanteric line.
Location of medial foot incision from just below the medial malleolus to the proximal aspect of the first metatarsal.
Location of dorsal incisions: one between the second and third metatarsals and one between third and fourth metatarsals.
 
 
 
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