Fasciotomy: An Inpatient Physical Therapy Program Utilizing Negative Pressure Wound
Therapy for Epithelialization
Mallory Joy Jensen
Introduction
Acute limb compartment syndrome is characterized by raised pressure in an unyielding
osteofascial compartment. Sustained elevation of tissue pressure reduces capillary
perfusion below a level necessary for tissue viability, and irreversible muscle and nerve
damage may occur within hours. Causes include trauma, revascularization procedures,
burns, and exercise. Regardless of the cause, the increased intracompartmental pressure
must be promptly decompressed by surgical fasciotomy. Despite the problems associated
with long skin incisions, open fasciotomy by incision of the skin and fascia is the most
reliable method for adequate compartment decompression (1).
Fasciotomies performed for compartment syndrome and ischemic vascular disease often
require closure in 2 to 4 weeks by skin graft. This leaves the patient with an unsightly
scar and a limb with reduced strength. The use of vacuum-assisted closure (VAC) has
been found to quickly reduce the edema and permit earlier closure with an adjacent skin.
A study conducted by Weidland supported these findings. Within his study he followed
three trauma patients that had compartment syndromes which were treated with a surgical
fasciotomy as well as the use of the VAC to close the fasciotomy wounds with adjacent
skin. The patients within Weidland’s study experienced closure of their fasciotomy
wounds in 3 to 18 days. It was concluded that the use of the VAC accelerated the
reduction of edema in a synergistic fashion, permitting early closure of fasciotomy
wound (2).
Fasciotomy wounds can also be a major contributor to a patient’s length of stay within
the hospital, as well as a difficult reconstructive challenge. Once the compartment
pressure has been relieved and stabilized, the wound is closed as quickly and early as
possible to avoid later complications. Skin grafting can lead to morbidity and scarring at
both the donor and fasciotomy site. Primary closure results in a more functional and
esthetic outcome with less morbidity for the patient, but can often be difficult to achieve
secondary to edema, skin retraction, and skin edge necrosis. Zannis et al. compared
primary closure times of 804 fasciotomy wounds that were treated with either VAC
dressings, normal saline wet-to-dry dressings or a combination of both. The findings of
this study indicated that there was a statistically significant higher rate of primary closure
using the VAC versus traditional wet-to-dry dressings. In addition, the time to primary
closure of wounds or time to skin grafting was found to be shorter when the VAC was
employed. The VAC was also found to decrease hospitalization time, allow for earlier
rehabilitation, and ultimately lead to increased patient satisfaction. (3)
The Journal of Surgery and Orthopedics reviewed the records of 34 patients who had
compartment syndrome of the leg that were treated with the standard two-incision release
of all four compartments and the application of VAC therapy until the time of definitive
wound closure or coverage. The main parameter of interest within this study was the time
to "definitive closure" (delayed primary closure with sutures or skin graft coverage) of
the wounds. Of the 68 wounds in 34 patients managed with VAC therapy, the average
time to definitive closure for both the lateral and the medial wounds was 6.7 days, while
the average time to definitive closure in 70 wounds of 34 control patients, was 16.1 days.
This difference in time to wound closure between the VAC group and the non-VAC
group was statistically significant. It further supported the supposition that vacuumassisted wound management was effective in hastening the resolution of wound edema,
through enhanced local blood flow, promoting the granulation of tissue, and thwarting
bacterial colonization, which may account for its utility in the management of fasciotomy
wounds in the setting of compartment syndrome of the leg (4).
The purpose of this case study was to show the effectiveness of Negative Pressure
Wound Therapy in promoting the healing time for a patient with a compartment
syndrome and surgical fasciotomy, which in turn allowed the patient to progress faster
within her inpatient physical therapy program.
Case Description
Patient
The patient was a 29-year-old Caucasian female with a past history of anemia,
depression, and bipolar disorder, as well as a MRSA soft tissue infection or abscess,
which was treated with Bactrim and Augmentin. One week later, the patient experienced
an abscess on her buttock and was prescribed double strength Bactrim and Augmentin.
The following day, the patient was seen in the ER with a rash on her calf and flu-like
symptoms. She also complained of generalized body aches, muscle cramps and was
hyperventilating. The patient was advised to follow up with a primary care physician and
was then prescribed a non-narcotic pain medication because of her past history of
narcotic abuse. During the course of care with her primary care physician the patient’s
creatinine increased from 1 to 9.8, she stopped urinating, experienced fatigue and
weakness, retained fluid and gained 8 pounds in a couple of days. The patient also
developed severe edema and pain in her right leg and a culture of an abscess on this leg
came back positive for MRSA, which was treated with antibiotics. The patient’s edema
was secondary due to acute renal failure.
The patient was a smoker, and has smoked a half pack of cigarettes a day for 10 years. In
addition, the patient denies alcohol use, but has had a narcotic seeking behavior in the
past. She was single and prior to her hospitalization lived with her son and parents in a
two story house with four stairs dividing each level.
Examination
The following examination was performed by the physical therapist upon admission to
the hospital.
AROM
Strength
Right lower extremity (RLE) not tested,
Left lower extremity (LLE) within
functional limits.
RLE not tested.
LLE within functional limits.
Sensation
Bed Mobility/ Transfers
Balance
Cognition
Pain
Stair Mobility
Gait
Integumentary
Patient reports decreased sensation on the
lateral aspect of her right foot.
Patient required contact guard assist (CGA)
for supine to sit, and out of bed/into bed
and sit to stand transfers.
Sitting: Good
Standing: Fair
Oriented 3: Cooperative, resistant, anxious.
5/10
Not tested
Patient able to ambulate 10 feet with
forward wheeled walker (FWW) and nonweight bearing (NWB) on RLE
Deferred to nursing and wound care staff
Interventions
After the initial examination, the patient and physical therapist discussed therapy and
patient goals. The following Discharge goals were set and agreed upon by both the
therapist and patient.
Discharge Goals: To be met in 14 days
1. Bed mobility, Independent
2. Functional transfers demonstrated independently
3. Patient will ambulate 150 feet independent with a forward wheeled walker (FWW)
4. Patient and family will be independent with written home exercise program.
5. Patient will ascend and descend 4 stairs with CGA and use of handrail.
The patient’s physical therapy sessions were once daily for 30-45 minutes during her 14
day stay at the hospital. The initial plan of treatment set by the physical therapist
consisted of gait training, transfer training, therapeutic exercises, stair training, and
patient/family education for appropriate interventions for compartment syndrome
resulting in a fasciotomy.
Gait Training
Initially gait training was performed with a FWW, with the patient non weight-bearing on
her right lower extremity secondary to the fasciotomy and the negative pressure wound
vac in place. Patient was allowed standing and seated rest breaks as needed. Gait training
began at 10 feet with a FWW and minimal assistance (Min A). Patient demonstrated an
antalgic, narrow base of support, decreased step height, and decreased step length. Verbal
cues were required for vertical posture, appropriate lower extremity/upper extremity
(LE/UE) placement, safe utilization of assistive device, neurological facilitation, and
muscular facilitation sequencing.
The patient progressed to weight bearing as tolerated (WBAT) on the RLEs with a FWW
and performed tandem/anterior posterior weight shifting to facilitate weight bearing on
right lower extremity. Ambulation progressed from 10 feet with multiple rest breaks to
200 feet without a break.
Transfer Training
Transfer training involved: supine-to-sit; sit-to-stand; and chair-to wheelchair (w/c)
transfers. The patient initially required minimum assist for transfers, and education on
proper hand placement and sequencing to complete tasks. Safe transfers were discussed
initially to remain non-weight-bearing on the involved right lower extremity. The training
was progressed once the patient was allowed to begin weight bearing through her right
lower extremity for sit-to-stand and stand-pivot transfers. The patient was discharged
with a wheelchair for transfers once the patient was full weight bearing on the right lower
extremity.
Therapeutic Exercise
Exercises were demonstrated to the patient initially and supported with verbal cues and
precautions for her incision on the RLE. The following table outlines the progression of
therapeutic exercises that were performed, how many repetitions and how often.
Day 1: Bilateral Day 2: Bilateral Day 3: Bilateral Day 4: Bilateral Day 5: Bilateral
supine exercise supine exercise supine exercise seated exercises seated exercises
L ankle pumps L ankle pumps L ankle pumps B heel raises 1
B heel raises 3
1 x10
1 x 20
1 x 20
x 20
x 10
Gluteal sets 1 x Gluteal sets 2 x Gluteal sets 2 x Gluteal sets 1 x Gluteal sets 2 x
10
10
10
10
15
Heel slides1 x Heel slides 2 x Heel slides 2 x LAQ 1 x 10
LAQ 2 x 15
10
10
10
Quad sets 1 x
Quad sets 2 x
Quad sets 3 x
Triceps push up Triceps push up
10
10
10
2 x 10
2 x 15
Supine hip
Supine hip
Supine hip
Shoulder
Shoulder
Abd/ADD 1 x
Abd/ADD 2 x
Abd/ADD 2 x
flexion 2 x 10
flexion 2 x 15
10
10
10
Seated
Seated
marching hip
marching hip
flexion 2 x 10
flexion 2. 15
Stair Training
The patient was instructed to ascend stairs with the un-operated lower extremity (LLE)
and to descend stairs with the operated lower extremity (RLE). The following sequence
was used for stair training:
1. Ascend/descend 4” stairs with bilateral handrails
2. Ascend/descend 6” stairs with bilateral handrails
3. Ascend/descend 6” stairs with one handrail and one wall.
4. Ascend/descend 6” stairs with one hand rail and one hand held support from family.
Patient/Family Education
The patient was educated on gait safety, stair safety, and transfers safety. A handout
outlining a home exercise program was given to the patient and demonstrating her
understanding of each exercise. The patient was also educated on home safety, including
wheelchair and forward wheeled walker safety and mobility.
Outcomes
The following table outlines the patient’s status at time of discharge (Note: strength and
activity tolerance were not formally assessed; the patient’s ability to perform exercises or
do functional activities were used in place of these). The patient was discharged to home
with home health and instructions to use her FWW for ambulation, transfers and standing
activities until cleared by her Physician and home health physical therapist.
AROM
Strength
Sensation
Bed Mobility/Transfers
Balance
Cognition
Pain
Stair Mobility
Gait
Integumentary
Within functional limits
Patient can perform 30 repetitions of the
following bilateral seated exercises: heel
raises, gluteal sets. LAQ, triceps pushups,
shoulder flexion, and hip flexion
Intact at this time, no deficits
Patient is independent in all transfers,
including those from low surfaces, with
and without rails.
Sitting dynamic: Good
Standing dynamic: Good Patient is fully awake and oriented
4/10 during activity
Ascend/descend five 6” stairs with one
handrail and hand held support from family
Patient can ambulate independently 200
feet with FWW.
Deferred to nursing and wound care staff
Discussion
Despite the problems associated with long skin incisions, open fasciotomy by incision of
the skin and fascia is the most reliable method for compartment decompression (1).
Fasciotomies performed for compartment syndrome and ischemic vascular disease often
requires closure in 2 to 4 weeks by skin graft, which leaves the patient with an unsightly
scar and limb with reduced strength. The use of vacuum-assisted closure (VAC) has been
found to be effective in quickly reduce the edema and permit earlier closure with adjacent
skin (2). Pictures 1 and 2 show the surgical fasciotomy on the medial and lateral sides of
the right calf, while Pictures 3 and 4 show the patient’s right calf after ten days of
negative pressure wound therapy and surgical closure with staples. According to the
study done by Wake Forest University School of Medicine it required a total of 16.1 days
for surgical closure without utilizing negative pressure wound therapy (4), as shown
within this case study it required only 10 days to accomplish definitive closure of
traditional medial and lateral compartment syndrome release utilizing a negative
pressure wound therapy VAC. The negative pressure wound therapy maintained exudate
levels within the tissue around the fasciotomy, isolated the wound from potential
infectious diseases, and promoted blood flow in preparation for granulation of new tissue
before surgical closure. As shown in the outcome, the treatment plan facilitated the
patient to become independent with bed mobility, all functional transfers, ability to
ambulate 200 feet, ascend and descend 5 stairs with use of handrail. The patient
accomplished all goals upon discharge.
Figure 1
Figure 3
Figure 2
Figure 4
Conclusion
There are multiple reliable resources that show the effectiveness of Negative Pressure
Wound Therapy and how it is conducive to progressing healing fast and therefore shorter
hospital stays are required. As health care professionals we can intervene with the
appropriate interventions to progress a patient with a compartment syndrome within an
inpatient physical therapy program.
References
1. Michael F Pearse - consultant orthopedic surgeon, Lorraine Harry - research fellow,
Jagdeep Nanchahal - senior lecturer in plastic and reconstructive surgery. “Acute
Compartment Syndrome of the Leg” 14 September 2008. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124092/
2. Weiland DE. (Mar 2007). “Fasciotomy closure using simultaneous vacuum-assisted
closure and hyperbaric oxygen.” 73(3): 261-6. PMID: 17375783 [PubMed –
indexed for MEDLINE] Retrieved from http://www.ncbi. nlm.nih.gov/pubmed/
17375783
3. Zannis J, Angobaldo J, Marks M, DeFranzo A, David L, Molnar J, Argenta L.
(Apr 2009). “Comparison of fasciotomy wound closures using traditional dressing
changes and the vacuum-assisted closure device.” 62(4): 407-9. Department of
Plastic and Reconstructive Surgery, Wake Forest University School of Medicine,
Winston-Salem, NC, USA. Retrieved from http://www.ncbi.nlm.nih. gov/pubmed/
19325346.
4. Yang CC, Chang DS, Webb LX. (Spring 2006). “Vacuum-assisted closure for
fasciotomy wounds following compartment syndrome of the leg.” J Surg Orthop
Adv. 15(1):19-23. Department of Orthopaedic Surgery, Wake Forest University
School of Medicine, Winston-Salem, NC 27157, USA. Retrieved from http://
www.ncbi.nlm.nih.gov/pubmed/16603108