Fasciotomy for Acute Compartment Syndrome

The definitive surgical therapy for compartment syndrome (CS) is emergent fasciotomy (compartment release). The goal of decompression is restoration of muscle perfusion within 6 hours. Following fasciotomy, fracture reduction or stabilization and vascular repair can be performed, if needed. ^{[1, 2]}

Delay in performing fasciotomy can negatively affect the outcome. In a retrospective study of 34 such cases, Ebraheim et al concluded that bedside fasciotomy under local anesthesia could be safe and effective treatment for patients with delayed presentation or an anticipated delay for undergoing surgery in the operating room under general or regional anesthesia. ^[3]

A study by Han et al indicated that in patients who develop compartment syndrome of the foot following blunt trauma, shorter intervals between injury and fasciotomy lead to better outcomes in quality of life scores, American Orthopaedic Foot and Ankle Society scale scores, and visual analog scale pain scores, as well as with regard to the ability to wear shoes comfortably, walk without assistance, and return to work. The study, which included 14 patients, also found that the likelihood of a good outcome was greater in patients who were younger, had no bony injury, had no concomitant injuries, and had sustained a low-velocity crush injury. ^[4]

However, a study by Kanj et al found that decompressive fasciotomy was effective in treating pediatric patients with acute compartment syndrome of the upper extremity even when there was a long delay between injury and surgery. Among patients in the study (average age 9.3 y), fasciotomy was performed an average of 32.8 hours after injury, but despite the length of time to treatment, 17 of 22 patients had excellent outcomes and five had fair outcomes. ^[5]

In contrast, a literature review by Oliver indicated that in patients with forearm compartment syndrome, unfavorable outcomes are significantly more likely to occur in those who undergo fasciotomy than in individuals who are treated conservatively (relative risk = 4.82). ^[6]

For additional information on this topic, see the Medscape Reference article Acute Compartment Syndrome.

Have the anesthesiologist administer an anti-staphylococcal antibiotic (eg, cefazolin or a broad-spectrum cephalosporin). Prepare and drape the thigh in standard surgical fashion. ^[7]

Make a lateral incision beginning just distal to the intertrochanteric line and extending to the lateral epicondyle. Use subcutaneous dissection to expose the iliotibial band, and then make a straight incision through the iliotibial band in line with its fibers. ^{[8, 9, 10, 11, 12]}

Carefully reflect the vastus lateralis off the lateral intermuscular septum, making sure to coagulate all perforating vessels as they are encountered. Make a 1- to 2-cm incision in the lateral intermuscular septum, and using Metzenbaum scissors, extend the septum proximally and distally along the length of the incision.

After the anterior and posterior compartments have been released, measure the pressure of the medial compartment. If the pressure is elevated, make a separate medial incision to release the adductor compartment. Before closing, ensure that meticulous hemostasis has been obtained.

Pack the wound open and apply a large, bulky dressing. In 1-3 days, the patient is returned to the operating suite, at which time any additional necrotic muscle is debrided. This process may need to be repeated several times. If possible, the skin is loosely approximated during the final operation.

Single- and double-incision techniques have been described. The double-incision technique is safer and more effective and should be used in general. ^{[11, 12, 13, 14]} To minimize soft tissue injury, especially in the setting of fracture/compartment syndrome, some surgeons prefer a single-incision approach. Regardless of the approach used, adequate exposure of the entire anterior compartment and, in particular, the peroneal nerve is paramount.

The image below displays a single-incision fasciotomy.

Anterolateral and posteromedial fasciotomies are shown in the images below.

Double-incision fasciotomy

The anterior and lateral compartments are approached through a single incision. Make an approximately 15-cm incision over the anterior intermuscular septum, centered halfway between the fibular shaft and the crest of the tibia. The incision must be large enough to provide adequate visualization. In an elective decompression, a 4- to 5-cm incision may be adequate.

Use subcutaneous dissection for wide exposure of the fascial compartments. Make a transverse incision to expose the lateral intermuscular septum and to identify the superficial peroneal nerve just deep to the septum.

Make a small nick in the anterior intermuscular septum midway between the septum and tibial crest. Using Metzenbaum scissors or a fasciotome, release the anterior compartment proximally (aim for the patella) and distally (aim for the center of the ankle) in line with the tibialis anterior.

Then, perform a longitudinal fasciotomy of the lateral compartment in line with the fibular shaft. Direct the scissors toward the lateral malleolus to stay posterior to the superficial peroneal nerve.

Make a second longitudinal incision 2 cm posterior to the posterior medial margin of the tibia. Use wide subcutaneous dissection to allow identification of the fascial planes.

Retract the saphenous vein and nerve anteriorly. Make a transverse incision to identify the septum between the deep and superficial posterior compartments. Release the fascia over the superficial posterior compartment. Release the fascia over the gastrocsoleus complex along the length of the compartment.

Make another fascial incision over the flexor digitorum longus (FDL) muscle, and release the entire deep posterior compartment. As the surgical dissection is carried proximally, note the origin of the soleus from the proximal third of the tibia. Detach the soleal bridge, and retract to expose the FDL and tibialis posterior.

After release of the posterior compartment, identify the tibialis posterior muscle compartment. ^[15] If increased tension is evident in this compartment, release it over the extent of the muscle body.

Antibiotic beads may be used if a comminuted open fracture is present, particularly if bone loss occurs. Vessiloops or rubber bands may be used on the skin to prevent excessive skin retraction. Pack the wound open and apply a posterior plaster splint with the ankle held at 90°. Return the patient to the operating room for debridement in 1-3 days if necessary or for skin closure.

Postoperative details

Monitor the patient's hemodynamic status and maintain adequate blood pressure and volume status. If rhabdomyolysis occurs, continue hydration, monitor urine output and kidney function, and watch potassium status closely.

Daily redress wounds that are left open, and undertake subsequent operative debridements as needed. Prophylactic antibiotics may be of benefit.

Follow-up

The postoperative wound check is at 3-5 days. Suture removal occurs at 10-14 days (if the wounds are closed). Patients may need skin grafting or traction dermoplasty if the skin defect is large.

A retrospective study by Blair et al indicated that in patients with tibial plateau or shaft fractures treated with surgery, four-compartment fasciotomies increase the risk of infection and nonunion. The investigators reported that in those patients with acute compartment syndrome requiring four-compartment fasciotomy, nonunion and deep infection both occurred in 20% of the group, compared with 5% and 4%, respectively, of patients without compartment syndrome. ^[16]

In a retrospective study of patients with tibial plateau fracture who underwent emergent four-compartment fasciotomy for acute compartment syndrome, DeKeyser et al found that the chance of surgical site infection (SSI) requiring surgical débridement was significantly higher for double-incision fasciotomies than for single-incision procedures. The SSI rate for single-incision fasciotomies was 18.1%, versus 41.3% for the dual-incision operations, with a minimum 3-month follow-up after plate and screw fixation. ^[17]

A retrospective study by MacKenzie et al indicated that in patients with fracture of the tibial diaphysis who undergo urgent fasciotomy for acute compartment syndrome, short- and long-term outcomes are similar to those of controls without the syndrome. With regard to short-term outcomes, the two study groups did not differ significantly in terms of overall rates of infection (17% vs 9.2%, respectively), deep infection (4.9% vs 3.8%, respectively), and nonunion (4.9% vs 7.0%, respectively). Long-term results were also comparable, as measured using the EQ-5D three-level (EQ-5D-3L) questionnaire, the Oxford Knee Score, and the Manchester-Oxford Foot Questionnaire. However, the patients with acute compartment syndrome did experience less satisfaction in the long-term, despite fasciotomy. ^[18]

Postoperative rehabilitation

The rehabilitation protocol depends most on the underlying mechanism of injury. For stable tibial shaft fractures treated with closed reduction and casting, the following guidelines apply:

• 0-3 weeks: Begin quadriceps sets, hamstring sets, gluteal sets, and straight-leg raises before hospital discharge; early weightbearing is performed as tolerated; ice, elevation, and anti-inflammatory drugs are recommended

• 3-5 weeks: Increase weightbearing; begin range-of-motion (ROM) exercises on the knee (0-140°), and start open-chain exercises with Thera-Band (The Hygienic Corporation) or ankle weights; begin closed-chain exercises if patient is bearing weight

• 6-8 weeks: Ambulate, bearing full weight; continue open- and closed-chain exercises

• 3-4 months: Discontinue cast or patellar tendon bearing (PTB); begin ankle stretching, ROM exercises, and strengthening

Postoperative motor deficits resulting from compartment syndrome are treated initially with appropriate orthotic devices (eg, a footdrop brace when the anterior compartment of the leg is affected). If function does not return in about 1 year, tendon transfer and other forms of reconstructive surgery may be considered.

Volkmann contracture is the residual limb deformity that continues over weeks to months following untreated acute compartment syndrome or ischemia from persistent arterial insufficiency. Approximately 1-10% of all cases of compartment syndrome result in Volkmann contracture. ^[19]

The fasciotomy technique is a matter of surgical choice. The goal is salvage of a functional extremity. In no way should the adequacy of decompression be compromised due to concern over cosmesis. It is essential to decompress all tight compartments, and the skin must be considered a potentially significant limiting structure. ^{[20, 21]}

Decompression fasciotomy of the forearm is performed through a volar approach, a dorsal approach, or both. In the forearm, unlike the fascial compartments of the leg, the volar compartment, dorsal compartment, and mobile wad compartment (containing the brachioradialis and radial wrist extensors) are interconnected. Thus, fasciotomies of all 3 compartments may be unnecessary.

Superficial fasciotomy is usually adequate to decompress the entire forearm. ^[22] The flexor digitorum profundus and flexor pollicis longus muscles (deep volar compartment) are among the most severely affected muscles, due to their deep location adjacent to the radius and ulna. Prefasciotomy and postfasciotomy pressures often are obtained from all compartments of the volar forearm, and if deep compartment pressures remain high after superficial fasciotomy, an additional release is indicated.

Forearm fasciotomy requires decompression from the wrist to mid arm, including the lacertus fibrosus fascia, the fascial compartments over the flexor carpi ulnaris, and the edge of the flexor superficialis muscles. With median nerve involvement, in addition to carpal tunnel release, the surgeon must explore the nerve in the proximal forearm.

The median nerve is decompressed throughout its course, including high-risk areas that are deep to the bicipital aponeurosis (lacertus fibrosus); between the humeral and ulnar heads of the pronator teres, the proximal arch, and deep fascial surface of the flexor digitorum superficialis; and the carpal tunnel. ^[23]

Preoperative prophylactic antibiotics against Staphylococcus aureus are generally recommended. After standard surgical preparation and draping, no tourniquet should be used.

Volar Henry approach for superficial and deep flexors

Make a volar curvilinear incision medial to the biceps tendon, crossing the elbow flexion crease at an angle. Carry the incision distally into the palm to allow for a carpal tunnel release (similar to the McConnell combined exposure of the median and ulnar nerves), but avoid crossing the wrist flexion crease at a right angle.

Divide the lacertus fibrosis proximally. Expose the brachial artery, and determine whether there is a normal flow. Release the superficial volar compartment throughout its length under direct vision. Identify the flexor carpi ulnaris, and retract it with its underlying ulnar neurovascular bundle medially.

Retract the flexor digitorum superficialis and median nerve laterally to expose the flexor digitorum profundus in the deep compartment. If its overlying fascia is tight, incise it longitudinally.

Continue the dissection distally by incising the transverse carpal ligament along the ulnar border of the palmaris longus tendon and median nerve. Inspect and examine the median nerve to ensure that it is not injured or entrapped. In the distal forearm, if the median nerve is exposed, suture the distal forearm skin flap loosely over the nerve. Leave the rest of the incision open.

If an associated fracture is present, reduce and stabilize the fracture and obtain hemostasis.

Check the dorsal compartments. The volar fasciotomy should decompress the dorsal musculature sufficiently. If not, release them also.

Apply a sterile moist dressing and a long arm splint. The elbow should not be left flexed beyond 90°.

The volar ulna approach (similar to the Henry approach) is used to release the flexor carpi ulnaris and flexor digitorum superficialis. Watch the proximal edge of the flexor digitorum superficialis, and decompress the ulnar nerve at the wrist.

Dorsal approach

Pronate the arm. Begin the incision distal to the lateral epicondyle between the extensor digitorum communis (EDC) and the extensor carpi radialis brevis (ECRB), extending approximately 10 cm distally toward the midline of the wrist.

Gently undermine the subcutaneous tissue, and release the fascia overlying the mobile wad of Henry and the extensor retinaculum (EDC and ECRB). Do not close the skin at this time, but anticipate secondary closure later. Apply a sterile, moist dressing and a long arm splint. The elbow should not be left flexed beyond 90°.

In the surgical treatment of hand compartment syndrome, anatomically, 10 separate osteofascial compartments can typically be released with a carpal tunnel release and 1 or 2 dorsal incisions. The transverse carpal ligament also requires release.

In the digits, 2 dorsal longitudinal incisions are usually made. Schnall et al, however, reported the use of an alternative approach for fasciotomy in cases of pyogenic flexor tenosynovitis ^[24] ; this approach involved irrigation of the tendon sheath and leaving the lateral incision open, which allowed early active mobilization of the finger.

Make 2 longitudinal dorsal hand incisions over the second and fourth metacarpals. Retract the extensor tendons to provide access to the dorsal and volar compartments. Open the dorsal and volar compartments by longitudinal releases. (The images below depict volar release.)

The dorsal incisions are generally left open but may be closed primarily. Closure that is delayed primarily, with or without skin grafting, is required for the volar incision.

Postoperative details and follow-up

The postoperative details depend on the etiology of the compartment syndrome and on the overall clinical condition of the patient. Elevate the affected extremity for 24-48 hours after surgery. If necrotic muscle develops, excise it. Tendinous attachments are retained if possible.

Delayed primary closure of the skin can usually be accomplished at 5 days. If closure is not possible within 5 days, a split-thickness skin graft should be applied instead. The rehabilitation protocol is dependent upon the underlying mechanism of injury and the stability of the fracture reduction.

Standard suture removal and postoperative wound checks are indicated. Patients may require skin grafting if the skin defect is large.