Lower extremity fasciotomy techniques
- J Gregory Modrall, MD
J Gregory Modrall, MD
- Professor of Surgery
- University of Texas Southwestern Medical Center
- Section Editors
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Sciences Center - Dallas Campus
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
Extremity fasciotomy is the only recognized treatment for acute compartment syndrome. The leg is the most frequently affected site in the lower extremity requiring fasciotomy [1,2]. Although less common, acute compartment syndrome can occur in the thigh, buttock, and foot [3-7]. In addition, patients who suffer from chronic compartment lower extremity syndromes may also benefit from fasciotomy.
For acute compartment syndrome, failure to recognize and decompress the muscular compartments in a timely fashion can compromise the extremity or the patient’s life. The indications for and techniques of lower extremity fasciotomy for emergent fasciotomy of the leg, thigh, buttock and foot will be reviewed here. Alternative techniques for chronic compartment syndromes are briefly discussed. Patient management following fasciotomy, including wound care, is discussed elsewhere. (See "Patient management following extremity fasciotomy".)
The clinical evaluation and diagnostic criteria for acute compartment syndrome and chronic exertional compartment syndrome are discussed in separate reviews. (See "Acute compartment syndrome of the extremities" and "Chronic exertional compartment syndrome".)
Any pathologic process that results in increased pressure within a muscular compartment that exceeds the perfusion pressure of the tissue has the potential to cause compartment syndrome and extremity ischemia.
Acute compartment syndrome — Fasciotomy is indicated for the treatment of acute compartment syndrome. Recognition of the syndrome should prompt treatment. The clinical features and intra-compartment pressure criteria for the diagnosis of acute compartment syndromes are discussed elsewhere. (See "Acute compartment syndrome of the extremities", section on 'Clinical features' and "Acute compartment syndrome of the extremities", section on 'Measurement of compartment pressures'.)
- Velmahos GC, Theodorou D, Demetriades D, et al. Complications and nonclosure rates of fasciotomy for trauma and related risk factors. World J Surg 1997; 21:247.
- Ritenour AE, Dorlac WC, Fang R, et al. Complications after fasciotomy revision and delayed compartment release in combat patients. J Trauma 2008; 64:S153.
- Mithöfer K, Lhowe DW, Vrahas MS, et al. Clinical spectrum of acute compartment syndrome of the thigh and its relation to associated injuries. Clin Orthop Relat Res 2004; :223.
- Su WT, Stone DH, Lamparello PJ, Rockman CB. Gluteal compartment syndrome following elective unilateral internal iliac artery embolization before endovascular abdominal aortic aneurysm repair. J Vasc Surg 2004; 39:672.
- Heyn J, Ladurner R, Ozimek A, et al. Gluteal compartment syndrome after prostatectomy caused by incorrect positioning. Eur J Med Res 2006; 11:170.
- Ojike NI, Roberts CS, Giannoudis PV. Compartment syndrome of the thigh: a systematic review. Injury 2010; 41:133.
- Thakur NA, McDonnell M, Got CJ, et al. Injury patterns causing isolated foot compartment syndrome. J Bone Joint Surg Am 2012; 94:1030.
- Papalambros EL, Panayiotopoulos YP, Bastounis E, et al. Prophylactic fasciotomy of the legs following acute arterial occlusion procedures. Int Angiol 1989; 8:120.
- Patel RV, Haddad FS. Compartment syndromes. Br J Hosp Med (Lond) 2005; 66:583.
- Rizvi, S, Catenacci, M. Responding promptly to acute compartment syndrome. Emerg Med 2008; 40:12.
- Park S, Ahn J, Gee AO, et al. Compartment syndrome in tibial fractures. J Orthop Trauma 2009; 23:514.
- Meskey T, Hardcastle J, O'Toole RV. Are certain fractures at increased risk for compartment syndrome after civilian ballistic injury? J Trauma 2011; 71:1385.
- Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin 2004; 20:171.
- Steinau, H-U. Major Limb Replantation and Postischemia Syndrome: Investigation of Acute Ischemia-Induced Myopathy and Reperfusion Injury, Springer Verlag, New York 1988.
- Ruland RT, April EW, Meinhard BP. Tibialis posterior muscle: the fifth compartment? J Orthop Trauma 1992; 6:347.
- Raveendran SS, Kumaragama KG. Arterial supply of the soleus muscle: anatomical study of fifty lower limbs. Clin Anat 2003; 16:248.
- Barrett SL, Dellon AL, Rosson GD, Walters L. Superficial peroneal nerve (superficial fibularis nerve): the clinical implications of anatomic variability. J Foot Ankle Surg 2006; 45:174.
- Williams EH, Dellon AL. Intraseptal superficial peroneal nerve. Microsurgery 2007; 27:477.
- Apaydin N, Basarir K, Loukas M, et al. Compartmental anatomy of the superficial fibular nerve with an emphasis on fascial release operations of the leg. Surg Radiol Anat 2008; 30:47.
- Adkison DP, Bosse MJ, Gaccione DR, Gabriel KR. Anatomical variations in the course of the superficial peroneal nerve. J Bone Joint Surg Am 1991; 73:112.
- Ling ZX, Kumar VP. The myofascial compartments of the foot: a cadaver study. J Bone Joint Surg Br 2008; 90:1114.
- Frink M, Hildebrand F, Krettek C, et al. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res 2010; 468:940.
- Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
- Salzmann, G, Kirschner, et al. Perioperative antibiotic prophylaxis in paratibial fasciotomy. Phebologie 1995; 24:44.
- Wall CJ, Richardson MD, Lowe AJ, et al. Survey of management of acute, traumatic compartment syndrome of the leg in Australia. ANZ J Surg 2007; 77:733.
- Jensen SL, Sandermann J. Compartment syndrome and fasciotomy in vascular surgery. A review of 57 cases. Eur J Vasc Endovasc Surg 1997; 13:48.
- Cohen MS, Garfin SR, Hargens AR, Mubarak SJ. Acute compartment syndrome. Effect of dermotomy on fascial decompression in the leg. J Bone Joint Surg Br 1991; 73:287.
- Sheridan GW, Matsen FA 3rd. Fasciotomy in the treatment of the acute compartment syndrome. J Bone Joint Surg Am 1976; 58:112.
- Mubarak SJ, Owen CA. Double-incision fasciotomy of the leg for decompression in compartment syndromes. J Bone Joint Surg Am 1977; 59:184.
- Cooper GG. A method of single-incision, four compartment fasciotomy of the leg. Eur J Vasc Surg 1992; 6:659.
- Schwartz JT Jr, Brumback RJ, Lakatos R, et al. Acute compartment syndrome of the thigh. A spectrum of injury. J Bone Joint Surg Am 1989; 71:392.
- Pacheco RJ, Buckley S, Oxborrow NJ, et al. Gluteal compartment syndrome after total knee arthroplasty with epidural postoperative analgesia. J Bone Joint Surg Br 2001; 83:739.
- Schmalzried TP, Neal WC, Eckardt JJ. Gluteal compartment and crush syndromes. Report of three cases and review of the literature. Clin Orthop Relat Res 1992; :161.
- Jagadesham, VP, Mavor, et al. Unilateral gluteal compartment syndrome: A complication of open abdominal aortic aneurysm repair using an aortobifemoral bypass graft. Eur J Vasc Endovasc Surg 2008; 15:14.
- Myerson MS. Experimental decompression of the fascial compartments of the foot--the basis for fasciotomy in acute compartment syndromes. Foot Ankle 1988; 8:308.
- Manoli, A II, Fakhouri, et al. Compartmental catheterization and fasciotomy of the foot. Operative Techniques in Orthopaedics 1992; 2:203.
- Blackman PG. A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc 2000; 32:S4.
- Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 1990; 18:35.
- de Fijter WM, Scheltinga MR, Luiting MG. Minimally invasive fasciotomy in chronic exertional compartment syndrome and fascial hernias of the anterior lower leg: short- and long-term results. Mil Med 2006; 171:399.
- Turnipseed W, Detmer DE, Girdley F. Chronic compartment syndrome. An unusual cause for claudication. Ann Surg 1989; 210:557.
- Turnipseed WD. Clinical review of patients treated for atypical claudication: a 28-year experience. J Vasc Surg 2004; 40:79.
- Kashuk JL, Moore EE, Pinski S, et al. Lower extremity compartment syndrome in the acute care surgery paradigm: safety lessons learned. Patient Saf Surg 2009; 3:11.
- Fulkerson E, Razi A, Tejwani N. Review: acute compartment syndrome of the foot. Foot Ankle Int 2003; 24:180.
- Mithoefer K, Lhowe DW, Vrahas MS, et al. Functional outcome after acute compartment syndrome of the thigh. J Bone Joint Surg Am 2006; 88:729.
- McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br 2000; 82:200.
- McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br 1996; 78:99.
- Williams AB, Luchette FA, Papaconstantinou HT, et al. The effect of early versus late fasciotomy in the management of extremity trauma. Surgery 1997; 122:861.
- Frink M, Klaus AK, Kuther G, et al. Long term results of compartment syndrome of the lower limb in polytraumatised patients. Injury 2007; 38:607.
- Acute compartment syndrome
- Chronic compartment syndrome
- Prophylactic fasciotomy
- COMPARTMENT ANATOMY
- - Superficial peroneal nerve
- Prophylactic antibiotics
- Antithrombotic therapy
- Other considerations
- FASCIOTOMY TECHNIQUES
- Leg fasciotomy
- - Double incision fasciotomy
- - Single incision fasciotomy
- Thigh fasciotomy
- Buttock fasciotomy
- Foot fasciotomy
- Alternative fasciotomy techniques for elective compartment decompression
- WOUND MANAGEMENT
- TECHNICAL COMPLICATIONS
- Incomplete fasciotomy
- Neurovascular injury
- Consequences of a delayed fasciotomy
- Prophylactic versus therapeutic fasciotomy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS