FASCIOTOMY IN THE EXTREMITIES
Compartment syndrome is characterized by excessive pressure of the neurovascular bundles
and soft tissues occupying a closed space. Excessive pressure result in critical ischemia to muscles, veins,
arteries, and nerves. Although this can happen in any closed space including the skull and the abdomen,
focus will remain on compartment syndrome in the extremities. In 1881,Richard von Volkmann
published an article describing contractures of the forearm flexor compartment (felt to be associated
with tight bandages following supracondylar fracture) leading to arterial insufficiency and poor venous
return. A variety of different compartment syndromes have been described in the upper and lower
extremities. Compartment syndrome has been documented in the shoulder, arm, forearm, hand,
buttock, thigh, leg, and foot.
Compartment syndrome develops as a result of a reduction of venous outflow. This can be
correlated with local tissue edema directly compressing on venous outflow channels or direct injury to
vessels as well. Reperfusion injury after vascular injury also causes tissue edema leading to the
development of compartment syndrome. In the case of a fracture, a bleeding long bone and the
development of a space occupying hematoma can exacerbate this situation.
Acute compartment syndrome usually follows trauma. The treatment is to decompress the
compartment as soon as is feasible. This may simply involve removing circumferential dressings or
pneumatic trousers or bivalving casts. More often, surgery is necessary. In order to eliminate a
compartment syndrome, all compartments within an anatomical region should be decompressed. For
example, in the lower leg, a four-compartment fasciotomy is typically necessary even if only one of the
compartments has elevated pressures. After completion of the fasciotomy, many surgeons will staple
vessel loops interwoven on the skin to synch the skin closed over the subsequent days as pressures and
swelling decrease.
ARM
The arm or brachium is divided into an anterior and posterior compartment. Compartment
syndromes of this region are rare. A single longitudinal incision along the length of posterior-medial
aspect of the biceps brachii will allow for access into both compartments with adequate decompression.
The basilic vein and medial brachial cutaneous nerves should be identified and preserved if possible.
FOREARM
Compartment syndrome of the forearm is usually associated with a fracture, often involving a
crushing injury or a gunshot wound to the forearm. It may also be seen associated with infection,
infiltration of fluid, or attempted closure of a tight surgical wound after internal fixation. The forearm is
composed of three fascial compartments: superficial flexor, deep flexor, and extensor. In order to
completely decompress the forearm, two incisions should be made. A longitudinal incision is first made
over the dorsal aspect of the forearm. This dorsal incision should begin at the lateral epicondyleof the
humerus and extend to the wrist. The skin and the subcutaneous tissues are opened exposing the fascia.
The fascia is then incised longitudinally as well for the length of the incision. This will provide access to
the extensor compartment and the mobile wad.
The volar incision is carried out slightly differently. Proximally, it starts on the brachial side of
the antecubital crease. The crease should be crossed slightly obliquely. An S-shaped incision is continued
passing laterally around the common flexor tendon then extending down the volar forearm. The skin
incision should extend onto the hand on the medial aspect of the thenar eminence. Attention should be
paid to preservation of the palmar branch of the median nerve. Once the skin and subcutaneous tissues
are incised, the fascia overlying the superficial compartment is opened. A space can be created between
the superficial radial nerve and brachioradialis laterally and the flexor carpi radialis and radial artery
medially. This will expose and decompress the deep compartment. Completion of the fasciotomy
includes a carpal tunnel release by incising the transcarpal ligament as well as division of the bicipital
fascia (lacertus fibrosus) proximally.
BUTTOCK
Compartment syndrome of the gluteal region is relatively rare. most commonly, it is associated
with immobility although it has been described from trauma as well as vascular causes. Three separate
nondistensible gluteal compartment exist, ie, (1) the gluteus maximus compartment,enveloped by its
own fascia, (2) the gluteus medius-minimus compartment, surrounded by the gluteal fascia and a deep
ileal boundary, and (3) the tensor fascia lata, enveloped by the gluteal fascia and the lateral fibrous
covering of the hip. Ultimately, it is the nondistensible gluteal fascia and aponeurosis anchored to the
sacrum, coccyx, ilium, and iliotibial tract that confine these three compartments. The inferior gluteal
artery and nerve travel out from beneath the inferior border of the pyriformis muscle and over the
superior gemellus into the gluteus maximus. The sciatic nerve, posterior femoral cutaneous nerve,
pudendal nerve, and nerve to the obturator internus and superior gemellus muscles also arise from
beneath the inferior edge of the pyriformis. This location predisposes to compression and loss of
function,particularly of the very large sciatic nerve.
A single “question mark” incision over the posterior margin of the iliotibial tract is usually
adequate for complete decompression. this incision is made from the posterior superior iliac spine,
approximately 10 cm superolaterally along the iliac crest, then continuing over the greater trochanter to
the level of the inferior gluteal fold. The incision is extended medially beneath the buttocks to the
midline of the upper thigh and down a few centimeters over the midposterior thigh. The superolateral
edge of the gluteus maximus is separated from the iliotibial tract, enabling exposure of the underlying
muscles while protecting the neurovascular bundles. In particular, the gluteus maximus must be
reflected carefully to avoid the superior gluteal artery. Furthermore, the gluteus maximus is reflected
medially to expose the gluteus medius.
THIGH
The thigh is divided into three anatomical compartment: anterior, adductor, and posterior.
Within the anterior compartment are the rectus femoris, vastus lateralis, vastus medialis, and vastus
intermedius muscles. The femoral neurovascular bundle traverses the anterior compartment until it
passed through the adductor canal and eventually the adductor hiatus to enter the popliteal space. The
adductor compartment contains the adductor magnus, adductor longus, adductor brevis, pectineus, and
gracilis muscles. It also contains the anterior and posterior division of the obturator nerve as well as the
femoral neurovascular bundle. The posterior compartment contains the biceps femoris,
semimembranosus, and semitendinosus muscles as well as the sciatic nerve.
There are two main intermuscular septa, medial and lateral. In order to reduce pressures in the
thigh, all three compartments need to opened. This can be done with two generous longitudinalskin
incisions. The anterior and posterior compartments can be reached through an anterior-lateral incision.
The incision should be carried down through the iliotibial band. This exposes the anterior compartment.
The fascia over the vastus lateralis should be divided. Next the intermuscular septum is divided, opening
the posterior compartment. The adductor compartment should be addressed through a longitudinal
incision over the anterior-medial thigh.
LEG
A compartment syndrome of the lower leg is the one that surgeons are likely to encounter most
frequently. Anatomically, the leg is divided into four fascial compartments: anterior, lateral, superficial
posterior, and deep posterior. The three neurovascular bundles reside in the anterior (one) and deep
posterior compartments (two neurovascular bundles). Other than the tibia and fibula, the stiff
interosseous membrane, the anterior intermuscular septum dividing the anterior from the lateral
compartment, and the transverse intermuscular septum dividing the superficial from the deep posterior
compartment bind the compartment. As with any anatomical region, the goal is to fully release all
compartments within the anatomic space.
There are three main techniques to accomplish that goal in the lower leg. They include a
fibulectomy, a single lateral incision technique, and a two-incision technique. While a fibulectomy would
clearly open all four compartments by dividing the interosseous membrane and intermuscular septa, it
causes significant morbidity without added benefit. Currently it is only of historical interest and rarely
performed at this time. The leg can also be decompressed using a single skin incision with a technique
popularized by Matsen et al (1980), called the perifibular fasciotomy. The skin incision extends distally
from the fibular head to the ankle along the contour of the fibula.
The most popular technique for decompression of the lower leg is a two-incision fourcompartment fasciotomy. The lateral incision extends from the fibular head to the ankle. It is centered
over the border of the anterior and lateral compartments. The skin and subcutaneous tissues are
separated from the overlying fascia. Care must be taken to identify and preserve the superficial peroneal
nerve. Next, a fasciotomy of the fascia overlying the anterior compartment 1 cm anterior to the
intermuscular septum is performed followed by a fasciotomy 1 cm posterior to the intermuscular
septum on the fascia overlying the lateral compartment. The fasciotomies should be generous,extending
the length of the skin incision. A medial incision is fashioned approximately 2 cm posterior to the
posterior-medial border of the tibia. The greater saphenous vein along with the saphenous nerve should
be identified and preserved. A fasciotomy should be performed along the full length of the
compartment. The soleal bridge should be removed from the posterior tibia for adequate exposure to
the deep posterior compartment.
FOOT/HAND
Both the hand and the foot are rare locations for compartment syndrome and they are treated
very similarly. Diagnostically,pain on passive strechis a much more reliable sign of compartment
syndrome in the hand than it is in the foot. The most common compartment involved in compartment
syndrome of the hands or feet are the interossei. Dorsal longitudinal incision can be made over the
interossei to decompress these compartments. In the foot the medial, central, and lateral compartment
must also be opened. This can be accomplished with a medial incision to expose the deep flexor
muscles.
POST OPERATIVE CARE
After completion of a fasciotomy, careful follow-up is required. The surgeon should consider
return to the OR at 48 hours to debride any devitalized tissue. Additionally, it is usually at this point that
the skin can begin to be reapproximated. At the time Operation, many surgeons will place vessel loops
interlaced througt skin staples at the skin edge. Over subsequent days, an attempt is made to close the
wound. For those wounds that untimately do not close, a split thickness skin graft should be used.
REFERENCE
Gracias VH, Reilly PM, McKenney MG, Velmahos GC, et al. Acute Care Surgery A Guide for General
Surgeon. The Extremities 2009; 17:189-199.
Azar F. Compartment Syndrome in Campbell’s Operative Orthopaedics. Ed 10th. Vol 3. Mosby. USA.
2003. P : 2449-57.
http://orthopaedi-dan.blogspot.com/2012/03/kompartemen-sindrom.html.