Fasciotomy

Article Author:
Rory Ormiston
Article Editor:
Raghavendra Marappa-Ganeshan
Updated:
7/31/2020 3:20:35 PM
PubMed Link:
Fasciotomy

Introduction

A fasciotomy is an emergency procedure used to treat acute compartment syndrome. Compartment syndrome is when the pressure builds up in a non-compliant osseofascial compartment and causes ischemia leading to muscle and nerve necrosis. It occurs most commonly in the volar compartment of the forearm, deep posterior, or anterior compartment of the leg. It can, however, happen in any closed space where there is muscle surrounded by substantial fascia, i.e., the hand, foot, thigh, or buttock.

Compartment syndrome categorizes as acute or chronic. Acute compartment syndrome often follows high energy trauma, fractures, circumferential burns, crush injuries, or even a tight plaster cast. Chronic compartment syndrome develops with muscular overuse and commonly occurs in the leg of runners or military personnel or the forearm of weightlifters and rowers. Occasionally acute exertional compartment syndrome can be seen after strenuous exertion.

Anatomy and Physiology

The lower leg is the most frequent site of compartment syndrome and associated fasciotomy. The lower leg anatomically divides into four compartments; anterior, lateral, superficial posterior, and deep posterior.

The anterior compartment of the leg contains:

  • Tibialis anterior
  • Extensor halluces longus
  • Extensor digitorum longus
  • Peroneus tertius
  • Deep fibular nerve
  • Anterior tibial artery

The lateral compartment contains:

  • Peroneus longus
  • Peroneus tertius
  • Superficial fibular nerve
  • Fibular artery

The superficial posterior compartment contains:

  • Gastrocnemius
  • Soleus
  • Planataris
  • Sural nerve

The deep posterior compartment contains:

  • Tibialis posterior
  • Flexor hallucis longus
  • Flexor digitorum longus
  • Popliteus
  • Tibial nerve
  • Posterior tibial artery

The forearm is the most common site of compartment syndrome in the upper limb. It subdivides into four compartments; superficial volar, deep volar, dorsal compartment, and the mobile wad of Henry. The volar compartments are most commonly affected.

The superficial volar compartment contains:

  • Flexor carpi ulnaris
  • Flexor carpi radialis
  • Pronator teres
  • Palmaris longus
  • Flexor digitorum superficialis ( often also described as being in an intermediate volar compartment)
  • Ulnar nerve
  • Ulnar artery

The deep volar compartment contains:

  • Flexor digitorum profundus
  • Flexor pollicis longus
  • Pronator quadratus
  • Median nerve 
  • Anterior interosseous artery
  • Anterior interosseous nerve

The dorsal compartment contains:

  • Extensor digitorum
  • Extensor digiti minimi
  • Extensor carpi ulnaris
  • Supinator
  • Extensor indicis
  • Extensor pollicis longus
  • Extensor pollicis brevis
  • Abductor pollicis longus
  • Posterior interosseous nerve
  • Posterior interosseus artery

The mobile wad of Henry contains:

  • Brachioradialis
  • Extensor carpi radialis longus
  • Extensor carpi radialis brevis
  • Radial nerve
  • Radial artery 

The median and ulnar nerves lie in the volar forearm between the flexor digitorum superficialis and profundus. The radial nerve lies deep to the mobile wad.

Indications

Classical features of compartment syndrome are those of ischemia, pain out of proportion to the injury, paraesthesia, pallor, paralysis, and pain on passive movement, especially stretch of the concerned compartment. Two-point discrimination can be useful for determining nerve ischemia. These signs and symptoms can be challenging to assess depending on the conscious level, sensory state, and ability to communicate. In these circumstances, monitoring of compartment pressures can be useful.[1][2][3]

Measuring compartment pressures is possible via multiple methods, none of which have robust supporting evidence. No universal agreement exists on indications for emergency fasciotomy. Some institutes operate if the difference between the compartment pressure and diastolic pressure is less than 20 mmHg. While some surgeons operate if a compartment pressure is greater than 30 mmHg with the correlation of clinical signs.[4][5]

Contraindications

There is no absolute contraindication to performing a fasciotomy. This section will explore the relative contraindications. Every decision to perform an emergency fasciotomy should be made by a senior team member and on a case-by-case basis in the context of the patient and the injury sustained.

The primary relative contraindication to performing a fasciotomy is delayed presentation; if the clinician suspects compartment syndrome of having been present for more than 12 hours, there is a potential risk of reperfusion injury.

One study has demonstrated that fasciotomies performed within 6 hours resulted in almost complete limb function recovery, between 6 and 12 hours normal functional recovery rate was 68%. However, fasciotomies performed after 12 hours resulted in only 8% regaining normal limb function.[6]

Conversely, another more recent study has shown that there is no difference in limb salvage rate when comparing early (<12 hours) to late (>12 hours) fasciotomy. It did demonstrate the infection rate is significantly higher in patients whose fasciotomies were delayed.[7] 

In a 2008 study, a cohort of 336 combat patients received 643 fasciotomies (upper and lower limb included). Patients who underwent a delayed fasciotomy had twice the amputation rate and three times the mortality.[8]

These considerations of irreversible nerve and muscle damage and high risk of infection change the risk-benefit analysis in missed compartment syndrome and negate the necessity for emergency surgery.[9][7]

Equipment

  • Skin preparation with an antiseptic solution
  • Skin scalpel
  • Inside scalpel
  • Forceps
  • A simple hand-held retractor (Langenbeck)
  • Diathermy
  • Dressing

Personnel

The procedure can be carried out by any medical professional with the appropriate training. Often this is a surgical resident or attending. They will need direct assistance from a scrub nurse and anesthetist and will need the support of a full theatre team.

Preparation

A theatre brief is necessary at the start of the theatre session. Before the procedure begins, the surgical team should complete the WHO theater checklist.

For a fasciotomy of the leg, the patient is positioned supine. The leg should be prepped and draped to above the knee.

For a forearm fasciotomy, the patient should be positioned supine with the arm abducted to 90 on a table extension. The patient should then be prepped and draped to above the elbow.

Technique

Single-incision fasciotomy of the leg (Davey, Rorabeck and Fowler technique)

  • Make a 10 cm skin incision beginning at the lateral malleolus and extending proximally along the fibula.
  • Develop the subcutaneous plane anteriorly to expose the fascial layer– beware of damage to the superficial peroneal nerve at this stage.
  • Make a longitudinal incision in the anterior and lateral fascial compartments.
  • Develop the subcutaneous plane posteriorly and perform a longitudinal incision into the superficial posterior compartment.
  • Identify the soleus in the superficial posterior compartment begin to develop the plane between the distal third of the soleus and the lateral compartment.
  • Remove the soleus and the deeper flexor hallucis longus from the posterior fibula. Be aware the peroneal neurovascular bundle will be immediately medial to the fibula.
  • Retract the peroneal vessels posteriorly to expose the fascial attachment of the tibialis posterior to the fibula, make a longitudinal incision.
  • Apply appropriate wound dressing.

Double incision fasciotomy of the leg (Mubarak and Harges technique)

Anterolateral Incision

  • Make a 20 cm anterior skin incision centered between the crest of the tibia and the fibula.
  • Identify the anterior intramuscular septum, make a longitudinal incision either side into the anterior and lateral compartments.

Posteromedial Incision

  • Make a second skin incision starting 2 cm proximal and 2 cm superior to the medial malleolus of the tibia extending proximally in line with the tibia longitudinally.
  • Carefully use blunt dissection to identify the fascial layer, the long saphenous vein, and the saphenous nerve; retract these anteriorly.
  • Make an incision along the length of the posterior fascial compartment.
  • Make another fascial incision over the flexor digitorum longus muscle immediately posterior and medial to the tibia to release the posterior compartment.

Forearm fasciotomy

Volar incision

  • Make a large skin incision starting just radial to the flexor carpi ulnaris and extending proximally to the medial epicondyle.
  • Extend the incision distally to the wrist crease, cross the wrist crease diagonally towards the hypothenar eminence, and into the palm to facilitate a carpal tunnel release.
  • Make a longitudinal incision into the superficial fascial compartment.
  • Retract the flexor carpi ulnaris, the ulnar neurovascular bundle medially.
  • Retract the flexor digitorum superficialis medially.
  • This exposes the deep fascial compartment; make a fascial incision onto the flexor digitorum profundus.
  • Extend both fascial incisions to the transverse carpal ligament.

Dorsal incision

  • Make a skin 10cm incision between the extensor digitorum communis and extensor carpi radialis brevis starting 2cm distal to the lateral epicondyle.
  • This incision will allow you to release the fascia over the mobile wad immediately.
  • Develop the subcutaneous plane posteriorly to expose the extensor retinaculum and release the fascia to decompress the posterior compartment.

Follow up

Fasciotomy wound management begins with an inspection at 48 hours. If the compartments are soft, this closure is achievable by primary wound closure, secondary wound healing, or as needed in approximately 50% of wounds split-thickness skin grafting. Delayed primary closure is also feasible using a vessel loop shoelace stitch. A negative pressure wound management device is another option.

Complications

Due to muscle necrosis, rhabdomyolysis, and acute renal failure are common; treatment is with intravenous fluids and dialysis.[9]

Incomplete fasciotomies can create a need for a revision fasciotomy either for extension of fascial opening or opening a missed compartment. Compartments are most commonly missed when the anatomy is highly distorted, such as in cases of high energy trauma or patients with previous surgery and scarring. In these patients, the associated mortality increased by four times.[8]

Also, patients who underwent a delayed fasciotomy had twice the amputation rate and three times the mortality. It bears mention that in some cases, even with timely fasciotomies, the affected limb may not regain normal functionality and may result in an amputation.

Wound complications can include[10][11]:

  • Need for skin grafting
  • Scaring
  • Tendon tethering
  • Muscle herniation
  • Recurrent ulceration
  • Swollen limbs
  • Discolored wounds
  • Pruritus
  • Dry, scaly skin
  • Altered sensation

Clinical Significance

Early recognition and subsequently early treatment of compartment syndrome with fasciotomies causes a significant decrease in the risk of poor functional outcome, need for amputation, and death.

Additionally, the medico-legal burden of delayed fasciotomies is high; time from onset of the symptoms to fasciotomy directly linked to an increasing pay-out amount in medical negligence claims. Fasciotomy performed early was associated with a successful defense of any medico-legal action.[12]

Enhancing Healthcare Team Outcomes

Early recognition of compartment syndrome is best detected by those professionals who have regular contact with the patients in the ward. These ward staff typically junior doctors, nursing, and health care assistants have the most contact time with patients and are in the best position to detect increasing severity in symptoms. These are the members of staff who need the most training in recognizing compartment syndrome and who need to exercise the high index of suspicion and early escalation to a senior doctor who can initiate early aggressive treatment with fasciotomy. Therefore it is the responsibility of the senior doctors and the department management to ensure the ward staff has adequate training to recognize the symptoms, are familiar with pressure measuring equipment, and feel able to escalate appropriately. This will provide the best method of early detection, to facilitate early treatment and provide the best patient outcomes.



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References

[1] Schmidt AH, Acute compartment syndrome. Injury. 2017 Jun;     [PubMed PMID: 28449851]
[2] Schmidt AH, Acute Compartment Syndrome. The Orthopedic clinics of North America. 2016 Jul;     [PubMed PMID: 27241376]
[3] McQueen MM,Court-Brown CM, Early diagnosis of compartment syndrome: continuous pressure measurement or not? Injury. 2010 Apr;     [PubMed PMID: 19853852]
[4] Whitesides TE,Haney TC,Morimoto K,Harada H, Tissue pressure measurements as a determinant for the need of fasciotomy. Clinical orthopaedics and related research. 1975 Nov-Dec;     [PubMed PMID: 1192674]
[5] White TO,Howell GE,Will EM,Court-Brown CM,McQueen MM, Elevated intramuscular compartment pressures do not influence outcome after tibial fracture. The Journal of trauma. 2003 Dec;     [PubMed PMID: 14676660]
[6] Sheridan GW,Matsen FA 3rd, Fasciotomy in the treatment of the acute compartment syndrome. The Journal of bone and joint surgery. American volume. 1976 Jan;     [PubMed PMID: 1249096]
[7] Williams AB,Luchette FA,Papaconstantinou HT,Lim E,Hurst JM,Johannigman JA,Davis K Jr, The effect of early versus late fasciotomy in the management of extremity trauma. Surgery. 1997 Oct;     [PubMed PMID: 9347868]
[8] Ritenour AE,Dorlac WC,Fang R,Woods T,Jenkins DH,Flaherty SF,Wade CE,Holcomb JB, Complications after fasciotomy revision and delayed compartment release in combat patients. The Journal of trauma. 2008 Feb;     [PubMed PMID: 18376159]
[9] Donaldson J,Haddad B,Khan WS, The pathophysiology, diagnosis and current management of acute compartment syndrome. The open orthopaedics journal. 2014;     [PubMed PMID: 25067973]
[10] Velmahos GC,Theodorou D,Demetriades D,Chan L,Berne TV,Asensio J,Cornwell EE 3rd,Belzberg H,Stewart BM, Complications and nonclosure rates of fasciotomy for trauma and related risk factors. World journal of surgery. 1997 Mar-Apr;     [PubMed PMID: 9015166]
[11] Fitzgerald AM,Gaston P,Wilson Y,Quaba A,McQueen MM, Long-term sequelae of fasciotomy wounds. British journal of plastic surgery. 2000 Dec;     [PubMed PMID: 11090326]
[12] Bhattacharyya T,Vrahas MS, The medical-legal aspects of compartment syndrome. The Journal of bone and joint surgery. American volume. 2004 Apr;     [PubMed PMID: 15069156]