Vascular: Fasciotomy

General Considerations

General Principles

  • Skin & Fascial Incisions Should Extend the Entire Length of the Compartment
  • All Compartments at Risk Should Be Opened
  • Skin Incision Should Not Be Closed at the Initial Operation

Skin Closure

  • Leave Open with Delayed Closure at 3-7 Days
  • Delayed Primary Closure or Split-Thickness Skin Graft
  • Issues of Early Wound Closure:
    • Recurrent Compartment Syndrome from Continued Swelling
    • Unable to Assess Nonviable Muscle/Tissue Which Can Lead to Infection
      • Muscle Necrosis Occurs from the Inside-Out & May Require Further Debridement
    • Skin Necrosis
  • Delayed Closure Management
    • Open with Wet-to-Dry Dressings
    • Negative Pressure Wound Therapy
    • “Shoelace Technique” (Gradual Suture Approximation) – Staples Along Edges with Vessel Loop Threaded in Crisscross Fashion and Tightened Every 48 Hours
    • Dynamic Dermatotraction & Static Tension Devices – Less Popular

WVAC Closure 1

“Shoelace” Closure 2

Upper Extremity Fasciotomies

Upper Arm Fasciotomy

  • Single Incision from Deltoid Insertion to Lateral Epicondyle
  • Incise Anterior Fascia to Release Anterior Compartment
  • Incise Posterior Fascia to Release Posterior Compartment

Forearm Fasciotomy

  • Volar (“Henry”) Incision:
    • Start Proximal Over Medial Epicondyle
    • ‘S’ Curve Laterally Over Antecubital Fossa & Extended Medially Over Forearm
    • Finish Over the Palmar Crease
    • Release Volar Compartment & Lateral/Mobile Wad
  • Dorsal Incision:
    • Single Vertical Incision
    • Release Dorsal Compartment

Hand Fasciotomy

  • Two Longitudinal Dorsal Incisions Over 2nd/4th Metacarpals
  • Longitudinal Incision Over Medial Aspect of 5th Metacarpal
  • Longitudinal Incision Over Lateral Aspect of 1st Metacarpal
  • Tailor Fasciotomies to Symptoms
  • All Should Also Have Carpal Tunnel Release

Forearm Fasciotomy Incision 3

Hand Fasciotomy Incisions 4

Lower Extremity Fasciotomies

Buttock Fasciotomy

  • Longitudinal Incision – Not Standardized
  • Release All Three Muscle Compartments

Thigh Fasciotomy

  • Release Anterior & Posterior Compartments
    • Can Use Single Lateral Skin Incision or Two Separate Anterior/Posterior Incisions
  • Can Include Medial/Adductor Incision
    • Can Omit – Rarely Develops Compartment Syndrome

Calf Fasciotomy

  • Double-Incision Fasciotomy
    • Most Common Approach – Easier to Access Deep Posterior Compartment
    • Anterolateral Incision:
      • 15-20 cm Vertical Incision Midway Between Tibia & Fibula
      • Incise Anterior Fascia Just Anterior to the Intermuscular Septum
      • Incise Lateral Fascia Just Posterior to the Intermuscular Septum
        • Protect Superficial Peroneal Nerve (Around Neck of Fibula)
          • Most Common Injured Nerve – 10-12 cm Superior to the Lateral Malleolus
    • Posteromedial Incision:
      • 15-20 cm Vertical Incision 1-2 cm Posterior to Posterior Border of Tibia
      • Retract Saphenous Neurovascular Bundle Anteriorly
      • Incise Superficial Posterior Fascia Just Under the Skin Incision
      • Detach the Soleus from the Tibia to Access/Incise the Deep Posterior Fascia
  • Single-Incision Fasciotomy
    • Skin Incision: 15-18 cm Lateral Incision Just Anterior to Fibula
    • Anterior Compartment: Directly Incised
    • Lateral Compartment: Directly Incised
    • Superficial Posterior Compartment: Raise a Small Posterior Flap to Access
    • Deep Posterior Compartment: Reflect the Soleus from Fibula Through the Posterior Flap

Buttock Fasciotomy 5

Thigh Fasciotomy 6

Foot Fasciotomy

  • Dual Dorsal Incisions:
  • Medial Incision – Along Medial Margin of Second Metatarsal
    • Releases 1st/2nd Interosseous, Medial & Deep Central
  • Lateral Incision – Along Lateral Margin of Fourth Metatarsal
    • Releases 3rd/4th Interosseous, Lateral, Superficial Central & Middle Central
  • Consider Adding a Medial Incision to Release the Calcaneal Compartment

Foot Fasciotomy Incisions 7

Foot Fasciotomy Depth 3

References

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  2. Pomert T. Wikimedia Commons. (License: CC BY-SA-4.0)
  3. Raza H, Mahapatra A. Acute compartment syndrome in orthopedics: causes, diagnosis, and management. Adv Orthop. 2015;2015:543412. (License: CC BY-3.0)
  4. Gallagher E, Ruiter T. Spontaneous Arterial Hemorrhage of the Hand Resulting in Compartment Syndrome. Eplasty. 2015 Jul 31;15:ic44.(License: CC BY-2.0)
  5. Diaz Dilernia F, Zaidenberg EE, Gamsie S, Taype Zamboni DE, Carabelli GS, Barla JD, Sancineto CF. Gluteal Compartment Syndrome Secondary to Pelvic Trauma. Case Rep Orthop. 2016;2016:2780295. (License: CC BY-4.0)
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