Patient management following extremity fasciotomy
- 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 Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
Extremity fasciotomy is the only recognized treatment for acute compartment syndrome and may be limb saving. Reperfusion following fasciotomy causes local and systemic effects that can be life-threatening and can complicate wound management.
The management of the patient following extremity fasciotomy, including management of reperfusion, wound care, and methods and timing of fasciotomy wound closure, will be reviewed here. Preoperative management and the indications, diagnosis, and techniques used to perform fasciotomy are discussed elsewhere. (See "Acute compartment syndrome of the extremities" and "Lower extremity fasciotomy techniques".)
Local and systemic consequences of ischemia-reperfusion occur after fasciotomy. Increased blood flow in the muscle following restoration of normal tissue pressure usually causes muscle edema. The extent of extremity swelling depends upon the duration and severity of ischemia, the predominant muscle cell type within a muscle, the location and mass of ischemic muscle, and the status of the venous circulation.
Animal studies show that cellular damage starts about three hours after a complete ischemic insult and is nearly complete by six hours . In humans, the level of tolerance to an ischemic insult varies and not all ischemic insults are complete. Patients with underlying peripheral artery disease may exhibit less than expected swelling due to the protective effects of pre-existing arterial collaterals that lessen the severity of ischemia . There is also evidence from animal studies that ischemic preconditioning in skeletal muscle may mitigate the severity of muscle injury, remote organ injury, and mortality after major ischemic events [3,4].
Swelling may be limited if there is incomplete reperfusion due to microvascular thrombosis. With prolonged ischemia, a “no reflow phenomenon” occurs that is characterized by capillary occlusion from endothelial swelling, plugging of capillaries with red and white blood cells, and increased interstitial pressure [5,6]. Reperfusion may occur at the macrovascular level, but there is no tissue perfusion. Clinically, this manifests as myonecrosis with minimal extremity swelling.
- Lindsay TF, Liauw S, Romaschin AD, Walker PM. The effect of ischemia/reperfusion on adenine nucleotide metabolism and xanthine oxidase production in skeletal muscle. J Vasc Surg 1990; 12:8.
- Adiseshiah M, Round JM, Jones DA. Reperfusion injury in skeletal muscle: a prospective study in patients with acute limb ischaemia and claudicants treated by revascularization. Br J Surg 1992; 79:1026.
- Eberlin KR, McCormack MC, Nguyen JT, et al. Ischemic preconditioning of skeletal muscle mitigates remote injury and mortality. J Surg Res 2008; 148:24.
- Vaillancourt C, Shrier I, Vandal A, et al. Acute compartment syndrome: how long before muscle necrosis occurs? CJEM 2004; 6:147.
- Brooks, B. Pathologic changes in muscle as the result of disturbances of circulation. Arch Surg 1922; 5:188.
- Menger MD, Rücker M, Vollmar B. Capillary dysfunction in striated muscle ischemia/reperfusion: on the mechanisms of capillary "no-reflow". Shock 1997; 8:2.
- Steinau, H-U. Major Limb Replantation and Postischemia Syndrome: Investigation of Acute Ischemia-Induced Myopathy and Reperfusion Injury, Springer Verlag, New York 1988.
- Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin 2004; 20:171.
- Odeh M. The role of reperfusion-induced injury in the pathogenesis of the crush syndrome. N Engl J Med 1991; 324:1417.
- Blaisdell FW. The pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review. Cardiovasc Surg 2002; 10:620.
- Zorrilla P, Marín A, Gómez LA, Salido JA. Shoelace technique for gradual closure of fasciotomy wounds. J Trauma 2005; 59:1515.
- Berman SS, Schilling JD, McIntyre KE, et al. Shoelace technique for delayed primary closure of fasciotomies. Am J Surg 1994; 167:435.
- Narayanan K, Futrell JW, Bentz M, Hurwitz D. Comparative clinical study of the sure-closure device with conventional wound closure techniques. Ann Plast Surg 1995; 35:485.
- Janzing HM, Broos PL. Dermatotraction: an effective technique for the closure of fasciotomy wounds: a preliminary report of fifteen patients. J Orthop Trauma 2001; 15:438.
- Barnea Y, Gur E, Amir A, et al. Our experience with Wisebands: a new skin and soft-tissue stretch device. Plast Reconstr Surg 2004; 113:862.
- Singh N, Bluman E, Starnes B, Andersen C. Dynamic wound closure for decompressive leg fasciotomy wounds. Am Surg 2008; 74:217.
- Kakagia D, Karadimas EJ, Drosos G, et al. Wound closure of leg fasciotomy: comparison of vacuum-assisted closure versus shoelace technique. A randomised study. Injury 2014; 45:890.
- Zannis J, Angobaldo J, Marks M, et al. Comparison of fasciotomy wound closures using traditional dressing changes and the vacuum-assisted closure device. Ann Plast Surg 2009; 62:407.
- Yang CC, Chang DS, Webb LX. Vacuum-assisted closure for fasciotomy wounds following compartment syndrome of the leg. J Surg Orthop Adv 2006; 15:19.
- Wattel F, Mathieu D, Nevière R, Bocquillon N. Acute peripheral ischaemia and compartment syndromes: a role for hyperbaric oxygenation. Anaesthesia 1998; 53 Suppl 2:63.
- Strauss MB, Hargens AR, Gershuni DH, et al. Delayed use of hyperbaric oxygen for treatment of a model anterior compartment syndrome. J Orthop Res 1986; 4:108.
- Tibbles PM, Edelsberg JS. Hyperbaric-oxygen therapy. N Engl J Med 1996; 334:1642.
- Weiland DE. Fasciotomy closure using simultaneous vacuum-assisted closure and hyperbaric oxygen. Am Surg 2007; 73:261.
- Abdullah MS, Al-Waili NS, Butler G, Baban NK. Hyperbaric oxygen as an adjunctive therapy for bilateral compartment syndrome, rhabdomyolysis and acute renal failure after heroin intake. Arch Med Res 2006; 37:559.
- Nylander G, Lewis D, Nordström H, Larsson J. Reduction of postischemic edema with hyperbaric oxygen. Plast Reconstr Surg 1985; 76:596.
- Uhl E, Sirsjö A, Haapaniemi T, et al. Hyperbaric oxygen improves wound healing in normal and ischemic skin tissue. Plast Reconstr Surg 1994; 93:835.
- Kolski JM, Mazolewski PJ, Stephenson LL, et al. Effect of hyperbaric oxygen therapy on testicular ischemia-reperfusion injury. J Urol 1998; 160:601.
- Greensmith JE. Hyperbaric oxygen therapy in extremity trauma. J Am Acad Orthop Surg 2004; 12:376.
- Wiger P, Tkaczuk P, Styf J. Secondary wound closure following fasciotomy for acute compartment syndrome increases intramuscular pressure. J Orthop Trauma 1998; 12:117.
- Johnson SB, Weaver FA, Yellin AE, et al. Clinical results of decompressive dermotomy-fasciotomy. Am J Surg 1992; 164:286.
- Papalambros EL, Panayiotopoulos YP, Bastounis E, et al. Prophylactic fasciotomy of the legs following acute arterial occlusion procedures. Int Angiol 1989; 8:120.
- Jensen SL, Sandermann J. Compartment syndrome and fasciotomy in vascular surgery. A review of 57 cases. Eur J Vasc Endovasc Surg 1997; 13:48.
- Sheridan GW, Matsen FA 3rd. Fasciotomy in the treatment of the acute compartment syndrome. J Bone Joint Surg Am 1976; 58:112.
- Ojike NI, Roberts CS, Giannoudis PV. Compartment syndrome of the thigh: a systematic review. Injury 2010; 41:133.
- Rush DS, Frame SB, Bell RM, et al. Does open fasciotomy contribute to morbidity and mortality after acute lower extremity ischemia and revascularization? J Vasc Surg 1989; 10:343.
- Heemskerk J, Kitslaar P. Acute compartment syndrome of the lower leg: retrospective study on prevalence, technique, and outcome of fasciotomies. World J Surg 2003; 27:744.
- Lagerstrom CF, Reed RL 2nd, Rowlands BJ, Fischer RP. Early fasciotomy for acute clinically evident posttraumatic compartment syndrome. Am J Surg 1989; 158:36.
- Fitzgerald AM, Gaston P, Wilson Y, et al. Long-term sequelae of fasciotomy wounds. Br J Plast Surg 2000; 53:690.
- 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.
- Bermudez K, Knudson MM, Morabito D, Kessel O. Fasciotomy, chronic venous insufficiency, and the calf muscle pump. Arch Surg 1998; 133:1356.
- Ritenour AE, Dorlac WC, Fang R, et al. Complications after fasciotomy revision and delayed compartment release in combat patients. J Trauma 2008; 64:S153.
- Kim JY, Buck DW 2nd, Forte AJ, et al. Risk factors for compartment syndrome in traumatic brachial artery injuries: an institutional experience in 139 patients. J Trauma 2009; 67:1339.
- Kosir R, Moore FA, Selby JH, et al. Acute lower extremity compartment syndrome (ALECS) screening protocol in critically ill trauma patients. J Trauma 2007; 63:268.