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Fasciotomy

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Authors

Waroot Nimjareansuk, D.O.
Mary Grace Castro, D.O.

Summary

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Acute compartment syndrome of the leg status post fasciotomy
Status post fasciotomy for acute compartment syndrome of the deep leg compartment.[1]Ormiston RV, Marappa-Ganeshan R. Fasciotomy. In: StatPearls. StatPearls Publishing; 2021.

Introduction

  • Fasciotomy, the definitive treatment for acute compartment syndrome (ACS), is a procedure in which the fascia is cut to reduce pressure in a muscle compartment, thereby restoring perfusion.
  • ACS most frequently occurs in the lower leg and forearm, often in the setting of fractures and trauma. If not rapidly diagnosed and treated, ACS can lead to significant morbidity and mortality.
  • Patients with chronic exertional compartment syndrome (CECS), typically young endurance athletes, may also benefit from fasciotomy.
  • Unlike ACS, CECS is characterized by a reversible increase in compartment pressure during exercise and is not considered a surgical emergency. Fasciotomy may be indicated for symptom control and return to athletic activities.

Indications

  • Acute compartment syndrome (ACS)
    • Clinical evidence either impending or established
    • Compartment pressure measurements are an important objective measure
      • Compartment pressure greater than 30mmHg or
      • Delta pressure = diastolic pressure minus compartment pressure greater than 30
Diagnostic criteria for Acute Compartment Syndrome
Diagnostic criteria for Acute Compartment Syndrome.[2]Image courtesy of acepnow.com, “Tips for Quickly Diagnosing Compartment Syndrome”.

Measuring Compartment Pressure

  • Create a sterile field and anesthetize the area with local anesthetic.
  • Obtain Stryker Intra-compartmental monitor system.
  • Connect the 3 ml syringe prefilled with normal saline to the diaphragm chamber.
  • Connect the 18-gauge needle with side port to the diaphragm chamber.
  • Place the diaphragm chamber apparatus into the pressure monitor.
Measuring compartment pressures.
  • Angle the pressure monitor upward at 45 degrees and press the syringe to inject the saline into the chamber expressing all air bubbles.
  • Press the zero button while angling the pressure monitor at the same angle of intended insertion.
  • Insert the needle perpendicular to the skin into the compartment of interest and inject approximately 0.3 ml of saline into the compartment.
  • Read the compartment pressure on the monitor.

Lower Leg Anatomy

  • Anterior: supine, junction of the proximal and middle thirds of the tibia and 1 cm lateral to tibial margin, 1 to 3 cm deep
  • Lateral: supine, junction of the proximal and middle thirds of the fibula and anterior to the posterior margin of the fibula, 1 to 1.5 cm deep towards the fibula
  • Deep Posterior: supine, junction of the proximal and middle thirds of the tibia and posterior to the medial margin of the tibia, 2 to 4 cm deep towards posterior fibula
Anatomy of the lower leg
Anatomy of the lower leg (click to enlarge).
  • Superficial Posterior: prone, junction of the proximal and middle thirds of the leg, 3 to 5 cm off midline, 2 to 4 cm deep

Forearm Anatomy

  • Volar: supination, one third of the way down the arm and medial to the palmaris longus, 1 to 2 cm deep aiming towards the ulna
  • Dorsal: pronation one third of the way down the arm and 1 to 2 cm lateral to ulna, 1 to 2 cm deep
  • Mobile Wad: supination, one third of the way down the forearm and at lateral forearm, 1 to 1.5 cm deep
Anatomy of the forearm (click to enlarge).[3]Williams, David Tyndale and Hyung Tae Kim. “CHAPTER 51 Wrist and Forearm.” (2013).

Procedure

  • General
    • This decision is made in consultation with your trauma or orthopedic surgeon
    • The exception would be in austere environments where consultants may not be immediately available.
    • Place patient under general or regional anesthesia
      • For the thigh, consider Fascia Iliaca Block
      • For the leg, consider Sci-Pop block
      • For the arm, consider M/U/R block
    • Set up a sterile field by sterilizing the skin with betadine and sterile drapes
  • Materials
    • Sterile gloves
    • Sterile drapes
    • Skin antiseptic
    • Scalpel
    • Blunt-tipped dissecting scissors
    • Soft tissue retractors
    • Electrocautery
    • Wound vacuum-assisted closure or bulky dressing

Lower Leg

  • A lateral vertically oriented longitudinal incision is performed between the tibia and the fibular shaft.
  • Expose the anterior and lateral compartments by retracting the skin and subcutaneous tissue medially and laterally.
  • A longitudinal incision is made through the anterior compartment with the scalpel or electrocautery extending the incision proximally and distally. The same procedure is undertaken for the lateral compartment.
Illustration of lower leg fasciotomy
Illustration of lower leg fasciotomy including both the medial and lateral incisions with retraction.
  • A medial longitudinal incision is performed 1-2 cm medial to the tibia.
  • Expose the superficial and deep posterior compartments by retracting the skin anteriorly and posteriorly.
  • The saphenous vein and nerve should be retracted.
  • The gastrocnemius fascia is incised to decompress the superficial posterior compartment.
  • An incision is performed between the soleus muscle and the tibia to decompress the deep posterior compartment.
Skin marked for lower leg fasciotomy
Skin marked for lower leg fasciotomy with lower extremity landmarks labeled.[4]Anwer M, Banerjee N, Agarwal H, Kumar S. Compartment syndrome of the non-injured limb. BMJ Case Rep. 2020;13(4):e231657.
Video demonstration of dual incision fasciotomy of the lower leg. (Note: due to graphic content, it must be watched on youtube)

Thigh

  • A large, single lateral incision is made distal to the intertrochanteric line extending to the femoral lateral epicondyle. The anterior compartment is decompressed by incising the iliotibial band and the vastus lateralis fascia.
  • The vastus lateralis muscle is reflected medially and the lateral intermuscular septum is incised to decompress the posterior compartment.
Demonstration of lateral incision.[5]Benjamin ER, Bardes J. Lower Extremity Fasciotomies. In: Atlas of Surgical Techniques in Trauma. Cambridge University Press; 2019:400-412.
  • For the medial compartment, a second incision can be made over the adductor muscles. However, the compartment pressures should be measured first given that acute compartment syndrome occurs at a much lesser rate in this compartment.
Markings for medial thigh fasciotomy
Skin markings for medial incision.[6]Benjamin ER, Bardes J. Lower Extremity Fasciotomies. In: Atlas of Surgical Techniques in Trauma. Cambridge University Press; 2019:400-412.
Video demonstration of fasciotomy of the thigh. (Note: due to graphic content, it must be watched on youtube)

Foot

  • Two dorsal longitudinal incisions are made – one medial to the second metatarsal bone and the second lateral to the fourth metatarsal bone.
  • All four sub-compartments of the interosseous compartment are incised between the metatarsal bones.
  • The calcaneal compartment is decompressed with a direct incision through the previous dorsal incisions underneath the metatarsals.
Skin markings for faciotomy of the foot
Markings for incision for fasciotomy of the foot.[7]Image courtesy of https://surgeryreference.aofoundation.org/, “Compartment Syndrome”.
  • The lateral compartment is incised through the lateral dorsal incision.
  • The medial compartment is decompressed by dissecting the medial side of the second metatarsal bone or by making an incision posterior to the first metatarsal along the medial side of the foot.
Fasciotomy of the foot
Foot status post 5 incision fasciotomy.[8]Barshes NR, Pisimisis G, Kougias P. Compartment syndrome of the foot associated with a delayed presentation of acute limb ischemia. J Vasc Surg. 2016;63(3):819-822.
Video illustration of foot compartment syndrome with discussion of fasciotomy courtesy of Dr Ebraheim.

Forearm

  • An S-shaped volar incision is made just proximal to the medial condyle extending to the proximal one-third of the radial forearm and then further extending along the volar midline to the carpal tunnel and mid palm. The volar incision can be used to decompress the superficial volar, deep volar, and mobile wad compartments.
  • A dorsal incision is made distal to the lateral epicondyle to Lister’s tubercle to decompress the dorsal compartment.
S shaped marking for forearm fasciotomy
Skin marked for the S-shaped incision of the volar forearm. Additional markings are noted on the thenar and hypothenar eminence.[9]Image courtesy of orthobullets.com, “Hand & Forearm Compartment Syndrome”.
Status post volar forearm fasciotomy.[10]Badge R, Hemmady M. Forearm compartment syndrome following thrombolytic therapy for massive pulmonary embolism: A case report and review of literature. Case Rep Orthop. 2011;2011:678525.
Video demonstrating forearm fasciotomy on a cadaver. (Note: due to graphic content, it must be watched on youtube)

Hand

  • The dorsal approach decompresses the palmar and dorsal interosseous subcompartments.
  • A dorsal incision is made at the second metacarpal bone with dissection along both sides of the metacarpal.
  • Incisions can be made through the fascia of the first and second dorsal interosseous and the first palmar interosseous.
  • A second dorsal incision is made at the fourth metacarpal bone with dissection along sides of the metacarpal.
Hand fasciotomy skin marked
Hand marked for fasciotomy incisions. Note the fingers are marked for release too if needed.[11]Egro FM, Jaring MRF, Khan AZ. Compartment syndrome of the hand: beware of innocuous radius fractures. Eplasty. 2014;14:e6.
  • Incisions can be made through the fascia of the third and fourth dorsal interosseous and the fascia of the second and third palmar interosseous.
  • The thenar compartment can be decompressed by a longitudinal incision at the radial first metacarpal bone.
  • The hypothenar compartment can be decompressed by a longitudinal incision at the ulnar fifth metacarpal bone.
Status post hand fasciotomy
Following a snake bite (A,B), this patient received a dual incisional dorsally (C, D) and had a good recovery (E).[12]Kim YH, Choi J-H, Kim J, Chung YK. Fasciotomy in compartment syndrome from snakebite. Arch Plast Surg. 2019;46(1):69-74.
Description of compartment syndrome of the hand, including fasciotomy, courtesy of Dr Ebraheim.

Additional Considerations

  • Post procedure care
    • Dress wounds with saline-soaked gauze
    • Monitor for hyperkalemia secondary to rhabdomyolysis
    • Monitor for acute kidney injury secondary to myoglobinuria
  • Complications
    • Incomplete fasciotomy
    • Neurovascular injury
    • Bleeding
    • Wound complications
    • Hyperkalemia secondary to rhabdomyolysis
    • Acute kidney injury secondary to myoglobinuria
  • Absolute contraindications
    • Nonviable extremity
  • Relative contraindications
    • Delayed presentation (compartment syndrome more than 12 hours)

Pearls and Pitfalls

  • It is vital to make generous skin and fascial incisions to avoid an incomplete fasciotomy and recurrent compartment syndrome.
  • Delaying fasciotomy for acute compartment syndrome leads to poorer outcomes and increased complications.

References

References[+]