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Fasciotomy

Overview

Introduction

Fasciotomy is a clinical procedure indicated once the clinical diagnosis of compartment syndrome is made. This article focuses on the treatment of acute compartment syndrome.

Compartment syndrome results from the combination of increased interstitial tissue pressure and the noncompliant nature of the fascia and osseous structures that make up a fascial compartment.
Severe complications following compartment syndrome were first described in 1881 by Richard Van Volkmann after he noted that interruption of the blood supply to the flexors in the forearm secondary to supracondylar fractures resulted in paralysis and contracture of the affected muscle group.

A fasciotomy consists of one or more fascial incisions and remains the only effective way to treat acute compartment syndrome.

The importance of timely evaluation and clinical suspicion is based on the sequelae of compartment syndrome. Nerve conduction can be negatively affected after 2 hours of ischemia
; however, if compartment syndrome is diagnosed and treated within 6 hours of onset, overall functional impairment is unlikely.

Key considerations

Fascial compartments are defined by unforgiving connective-tissue septa and osseous structures. Without sufficient compliance of these structures, pressure increases within the closed system, causing microvascular compromise and subsequent muscle and nerve ischemia.

Compartments that have the least baseline compliance are those that are most likely to develop compartment syndrome. This is the case for the anterior and deep posterior compartments of the leg. Although it most commonly (40%) occurs in the compartments at the level of the tibia and fibula,
compartment syndrome is seen anywhere muscle groups are enclosed as described above, including the buttocks and lumbar paraspinous muscles.

Diagnosis of compartment syndrome can be made by clinical examination or with more objective measures such as compartment pressures. Although absolute compartmental pressures are often used for fasciotomy decision making, the difference between the compartment pressure and diastolic pressure (Δ p), has been associated with an increased accuracy in diagnosing compartment syndrome and is particularly useful in the multitrauma patient. Multitrauma patients can become hypotensive and therefore create an environment in which the development of compartment syndrome can occur at lower pressures and confound diagnosis of compartment syndrome in these clinical scenarios.
A high clinical suspicion for compartment syndrome along with serial examinations without the use of compartment pressure measurements is still used in many settings today.

Indications

Indications for surgical intervention in acute compartment syndrome in the alert patient are generally based on clinical impression.
Four signs and symptoms are commonly referred to as the four Ps, as follows:

Pain that is out of proportion to clinical findings

Pain with passive stretch of involved muscles

Pain with palpation of involved compartment

Pressure increase within the compartment as measured

Certainly, all of these signs do not need to be and are often not present in the setting of acute compartment syndrome. A pulseless extremity more likely reflects large vessel injury as a very late finding in compartment syndrome and may not develop at all despite protracted elevated pressures.

In a patient who cannot express pain or paresthesias, serial clinical examinations along with monitoring of compartment pressure can play a more important role in the diagnosis.

The pressure point at which fasciotomy should be considered is not a specific value, although a compartment pressure of 30 mm Hg is a commonly cited value. Masquelet notes that whenever diastolic pressure minus tissue pressure (Δ p) is less than 30 mm Hg, fasciotomy is indicated.

Contraindications

Fasciotomy is contraindicated when diagnosis of compartment syndrome is made late. Fasciotomy 3-4 days after onset of compartment syndrome can lead to infection and kidney failure in a setting of devascularized and necrotic muscle (see the image below).

Myonecrosis. Excised muscle from a patient with a

Myonecrosis. Excised muscle from a patient with a femur fracture and compartment syndrome of the leg that was released more than 10 hours from onset. Patient went on to an above-the-knee amputation.

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Etiology

Many factors play a role in the development of compartment syndrome, including vascular injuries, soft tissue trauma, and systemic hypotension in the patient with a traumatized extremity.

Most commonly, acute compartment syndrome is secondary to trauma such as fracture, arterial injury, physical compression, or burn.
However, postoperative hematoma, tight-fitting casts, and infiltration of fluids through an intravenous catheter, as well as a multitude of other issues, have also been described in association with compartment syndrome (see the image below).

Rhabdomyolysis: 31-year-old dehydrated and overwei

Rhabdomyolysis: 31-year-old dehydrated and overweight female with sickle cell trait presented with bilateral thigh and leg compartment syndrome after military physical training (PT) test.

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Pathophysiology

Interstitial pressures increase within a compartment, and, as it reaches and exceeds venous pressure, venous outflow is halted, causing further increase in intracompartmental pressures. This results in a shunting of blood flow away from the injury and toward areas of lower vascular resistance. In this environment, muscle cells are unable to adapt to the decreased oxygen tension that is secondary to the increased tissue pressures.

This cycle propagates itself and cell death–induced metabolic changes contribute to the hypoxia, further increasing pressure. Knowing the pressure at which this cycle is initiated has been the goal of many studies, and although no incontrovertible value has been identified, compartmental pressures measuring 30 mm Hg or more are understood to often require surgical intervention (see the image below).

Crush injury to the hand created pressures high en

Crush injury to the hand created pressures high enough to result in muscle extrusion from the adductor compartment and tearing of the skin over the palm.

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