Peggers’ Super Summary of Decompression Fasciotomies
Definition:
A persistent rise in pressure within a confined fibro-osseous
compartment that leads to partial or complete infarction and fibrosis
of it’s contents
LOWER LEG
Compartments
Compartment
Anterior
Indications:

Clinical suspicion

Delta P of 30mmHg
Lateral
Clinical assessment
SYMPTOMS

Severe pain unrelieved by analgesia

Pain is persistent and progressive
SIGNS

Shiny tense skin

Limb feels tense

Nerve sensory from the nerve that transverses that
compartment

Passive stretch exacerbates pain

Presence of pulse does not exclude compartment syndrome
INVESTIGATIONS

Pressure monitoring
o
Absolute value of 30mmhg for 8 hours or unknown
period
o
Delta P of 30mmHg

Blood tests
o
Ck suggests muscle necrosis (must also check
U&Es)
Anatomy:
FINGER

Mid-axial incision is dorsal to the n/v bundles
HAND

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10 compartments
Extensor tendons
Superficial radial nerve – 1st dorsal interossei region
Deep motor branches of the ulnar and median nerves
Palmar arch at Kaplan’s line
FOREARM
Forearm flexors

Superficial – proximately PT and then FCR, Palmaris longus
and FCU

Intermediate – FDS

Deep – FDP & FPL

Deep and distal - PQ
Forearm extensors by compartment

Proximately – supinator and brachioradialis

1st – abductor pollicis longus and EPB

2nd – ECRL (2nd MC base) ECRB (3rd MC Base)

3rd – EPL

4th – Extensor Digitorum & Extensor indicis

5th – Extensor digiti minimi

6th - ECU
Deep Posterior
Superficial
Posterior
Muscles
Tibialis anterior
Extensor hallucis &
digitorum longus
Peroneus tertius
Peroneus longus & brevis
Tibialis posterior
Flexor hallucis & digitorum
longus
Popliteus
Gastrocnemius
Soleus
Plantaris
Neurovascular structures
Anterior tibial vessels
Deep peroneal nerve
Superficial peroneal
nerve
Tibial nerve
Posterior tibial Artery
Sural cutaneous nerve
Principles of Operative Treatment:

REMOVE RINGS OF BRACELETS

General anaesthesia

Can use tourniquet for initial exposure BUT must deflate to
examine muscle

Incisions must be full length

Design incisions to avoid direct exposure of nerves and
tendons

Minimise cutaneous nerve damage and preserve cutaneous
veins

If EPIMYSIUM of muscles appear tight also incise this
Upper Limb Fasciotomy:
HAND OVERVIEW

10 compartments

4 dorsal interossei

3 palmar interossei

Adductor compartment (adductor pollicis of thumb)

Thenar

Hypothenar
HAND INCISIONS

Dorsal incision

Decompresses all interossei and the also the adductor
compartments

Incisions are made between the 2/3 metacarpals & 4/5
metacarpals

Retract the skin to release the 4 compartments between each
metacarpal, the 3 palmar interossei are also here and the
adductor pollicis is deep to index finger metacarpal (deep to
n/v bundles)

Tenotomy scissors are used on the ulnar boarder of the index
finger MC to access the adductor pollicis must feel the
posterior fascia of the PALMAR interossei give way to be in
the compartment

Tenotomy scissors are also used in each of the other
compartments to spit the fibres of the dorsal interossei to gain
access into the palmar compartment
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Peggers’ Super Summary of Decompression Fasciotomies
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Palmar incision
Decompresses both ulnar and median nerves
And also Thenar and Hypothenar muscles
Make a lazy S incision in the carpal tunnel then extend distally
as a zig-zag (Brunner) if required
Incise the fascia over then Thenar muscles
Release Guyon’s canal is much more superficial than you
think, superficial to the carpal tunnel
Continue into the Hypothenar muscles, preserving the deep
motor branches of the ulnar nerve and the ulnar artery as it
divides into superficial and deep palmar arches
Make a longitudinal midline incision on the extensor aspect of
the forearm

Examine the muscles systematically
LOWER LIMB

2 longitudinal incisions designed to release compression and
preserve medial perforators required for subsequent flap
closure

The medial incision is 2 cm posterior to the subcutaneous
medal boarder of the tibia

The lateral incision is halfway between the tibia and fibula

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
FINGER

Finger decompression occurs at the non dominant side of each
finger at the mid-axial



Bending the finger and placing a dot at each crease apex and
joining the dots up with the finger straight creates the mid-axial
line

This is dorsal to the n/v bundles

Continue inside dorsal to the near side n/v bundle and then
onto the volar side of the flexor tendons and then dorsally to
the far side n/v bundle

The non dominant side of the finger is the ulnar side for the
middle 3 fingers and radial side for thumb and little finger
FOREARM

Flexor Incision

The distal incision is a 5cm continuation of the carpal tunnel
and distal wrist crease along the ulnar side of the forearm

Continue in a straight line to the radial side of the antecubital
fossa

To extend into the upper arm use the antecubital flexors crease
to extend the incision into the radial side of the antecubital
fossa

The extension into the upper arm continues proximately over
the posteromedial aspects of the biceps brachii to decompress
the biceps compartment, brachial artery and branches of the
brachial plexus

Extensor incision
Medial expose the superficial posterior compartment exposing
the gastrocnemius
Retract gastrocnemius and expose the fascia of the deep
compartment, expose the muscles and explore the n/v bundle
Laterally expose the fascia of the anterior compartment and
examine the contents
Follow the under surface of the anterior compartment fascia
until the vertical septum is found and incise this to gain access
to the lateral compartment
Examine the lateral compartment
Wound Closure:

Closure of the wound occurs in stages via a bootlace approach

Split skin grafts are other option which provide coverage and
contracture and thus can be excised in stages.

8/10th dermatome is used, the graft is left for 5-7 days splinted
and the donor site for 14 days with mefix blue gauze mefix
(under surface mefix allowed to peel and trimmed as it does)

Mark donor site size inject LA infiltration with adrenaline into
donor site.

Decide on dermatome width and jelly both dermatome and
skin

Use assistant to hold skin taught

Start dermatome before hitting skin and continue until machine
has left skin
Post-operative rehabilitation:

Mobilise only once graft taken and stable circa 1-2 weeks

PT mobilisation for 6-12 to prevent adhesions and stiffness

Night splints for 4-6 weeks to prevent contractures
o
i.e. ankle at 900
o
Wrist at 20-300 of extension, MCPs at 60-700
flexion and IPs at 1800.
Outpatient follow up:
 Dressing clinic until wounds heeled
 Review at 6 weeks and 3 months
 Excision of skin graft if patient wishes at 9-12 months
 Tendon transfer for function consider plastics referral
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