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 anteriormedial 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 twoincision four-compartment 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 Campbells Operative Orthopaedics. Ed 10 th. Vol
3. Mosby. USA. 2003. P : 2449-57.
http://orthopaedi-dan.blogspot.com/2012/03/kompartemen-sindrom.html.