Stryker Manometer for measuring compartment pressure
Leg Fasciotomy Technique
The leg has four compartments. These include the anterior, lateral, superficial posterior, and deep posterior compartments . Before proceeding with a leg fasciotomy, the surgeon must have a thorough understanding of the anatomy (Fig. 12.3). The standard operation used to perform the fasciotomy is a two-incision technique. Through lateral and medial incisions, all four compartments can be released. A single-incision technique has been described for leg fasciotomy. In the setting of acute CS, we do not recommend this procedure.
First, the leg should be circumferentially prepped out and draped from the inguinal crease down to the feet. Next, identify and mark bony landmarks. At the superior aspect of the leg, mark the tibial tuberosity anteriorly and the fibular head laterally. At the inferior aspect, mark the medial and lateral malleolus .
The most common compartment involved with CS is the lateral compartment, so one begins decompression with the lateral incision. An incision is made about 2 finger breadths lateral to the tibia or about 1 fingerbreadth anterior to the fibula (Fig. 12.4). This craniocaudal incision extends from 3 fingerbreadths below fibular head to 3 fingerbreadths above the lateral malleolus. The incision is extended using cautery through the subcutaneous fat to the level of the fascia. Skin flaps of about 3 cm are raised in each direction. Once completed, the intermuscular fascial septum between the anterior and lateral compartments are identified.
The lateral compartment is incised and then decompressed using Metzenbaum scissors. A single jaw of the scissor is inserted into the compartment and the scissors are pushed along the line of incision to cut the fascia superiorly and inferiorly. Bulging muscle indicates CS. Tips of the scissor should be pointed away from the intermuscular septum to avoid damage to the peroneal nerve. Next, a second lateral incision should be made on the anterior compartment fascia to decompress the anterior compartment in a similar fashion to the lateral compartment using Metzenbaum scissors. Some authors have advocated for connecting the two fascial incisions across the intermuscular septum to form an “H” type incision (Fig. 12.5).
Attention is now turned to the medial incision to decompress the superficial posterior and deep posterior compartments. An incision is made about 1 thumb breadth posterior to the tibia (see Fig. 12.4). This craniocaudal incision extends from 3 fingerbreadths below tibial tuberosity to 3 fingerbreadths above the medial malleolus. While extending the skin incision through the subcutaneous tissue, the surgeon should be careful not to damage the greater saphenous vein. The fascia of the superficial posterior compartment is now encountered and is decompressed via a longitudinal incision along the gastrocnemius fascia. Once this compartment is decompressed, the soleus muscle is identified and separated from the underside of the tibia. This maneuver exposes the fascia overlying the tibialis posterior and one enters the deep posterior compartment, which may also be confirmed by identifying the posterior tibial neurovascular bundle. The soleus muscle is essentially “stripped” from the back of the tibia bluntly to expose the deep posterior compartment (Fig. 12.6).
An important step to this procedure is assess the viability of the muscle. All muscle that is seen and appears dead and does not contract with stimulation (Bovie electrocautery can be used) should be debrided so that the metabolites do not get disseminated within the patient.