Fasciotomy

For acute compartment syndrome treatment (TABLE 53.1)

Common locations for compartment syndrome include the calf, the anterior thigh, and the forearm

Once the diagnosis is made, early fasciotomy is advocated to reduce the risk of limb loss or dysfunction, rhabdomyolysis, lactic acidosis, and infection

Muscle death typically begins within 4 to 6 hours of vascular compromise; irreversible damage is usually achieved by 12 hours

Early consultation should be obtained with general, vascular, and/or orthopedic surgery

CONTRAINDICATIONS

Although there are no absolute contraindications to fasciotomy in the acute setting, relative contraindications may include:

A nonviable extremity

Acute compartment syndrome associated with snake bites

RISKS/CONSENT ISSUES

Pain

Bleeding

Infection

Iatrogenic injury to nerve, muscle, and vascular structures

Continued muscle damage, despite intervention

General Basic Steps

Conscious sedation and analgesia

Sterilization

Fasciotomy

Verification

TABLE 53.1.

EXTERNAL AND INTERNAL CAUSES OF COMPARTMENT SYNDROME

External causes

Internal causes

Constrictive cast or dressing

Tight fascial closure

Prolonged limb compression during unconsciousness, paralysis, or surgery

Edema, inflammation, or hemorrhage within a fascial compartment following trauma, closed or open fractures, burns, frostbite, electrocution, rhabdomyolysis, infection, or envenomation

Venous obstruction or ligation

Edema following revascularization or reperfusion

Iatrogenic extravasation of fluids from intravenous catheter or arterial line

Adapted from Moore EE. Trauma. 5th ed. New York, NY: McGraw Hill; 2005:903; table 41-1.

LANDMARKS

The forearm—there are two compartments

The volar compartment of the arm is accessed through a volar–ulnar incision beginning 3 cm below the medial epicondyle and running down the volar–ulnar aspect of the arm, ending 5 cm proximal to the ulnar styloid. This incision allows for soft-tissue coverage of the flexor tendons and ulnar and median nerves (FIGURES 53.1 and 53.2).

The dorsal compartment of the arm is accessed through a dorsal incision from 2 cm below the lateral epicondyle, cutting longitudinally to the midline of the dorsum of the wrist

The lower leg—there are four compartments accessible by two approaches

Double-incision fasciotomy; two approximately 8-cm incisions are made

Lateral incision 1 cm anterior to the fibula

Begin 2 cm below the fibular head and continue two-thirds of the length of the leg—this avoids peroneal nerve where it exits the fascia

Make two corresponding fascial incisions; one into the anterior compartment and one into the lateral compartment (FIGURE 53.3)

Medial incision 2 cm posterior to the tibia; stay posterior incising over the gastrocnemius

Begin 2 cm below the tibial tuberosity and continue two-thirds the length of the leg—this course avoids the saphenous vein and nerve

Make two corresponding fascial incisions; one into the superficial posterior compartment and other into the deep posterior compartment

The perifibular approach has been shown to be less efficacious, requires more exposure, may require fibulectomy, and has generally fallen out of favor

FIGURE 53.1 Volar release in the forearm. The upper illustration shows the incision that is used. The lower left picture depicts the relevant incisional anatomy. The lower right picture depicts the cross-sectional anatomy.

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