Fasciotomy
Kenneth B. Simon
Strong fascial envelopes surround major muscle groups, dividing them into compartments. Hemorrhage or edema within a compartment causes the pressure within this closed space to rise rapidly. Fasciotomy (incision of the fascia) is indicated when the intracompartmental pressure rises to the point of compromising neuromuscular function. Burns, crush injuries, arterial occlusion or embolism, hypotension, venous occlusion, or trauma may result in compartmental hypertension.
The lower extremity below the knee is most commonly involved. There are four compartments that can be approached either through a single or a double incision. Each approach will be outlined in this section. Fibulectomy fasciotomy, not described in this section, can be found in the references at the end of the section.
Steps in Procedure
Four-compartment Fasciotomy through Single Incision
Lateral incision overlying the fibula
Separate tissues down to level of fascia
Identify and protect lesser saphenous vein
Incise fascia to decompress lateral compartment
Develop anterior skin flap to expose anterior fascia
Incise fascia to decompress anterior compartment
Create posterior flap and incise posterior fascia
Retract soleus and gastrocnemius muscles to expose and decompress deep posterior compartment
Obtain hemostasis and pack open
Double-incision Technique
Medial incision along posterior edge of tibia
Identify and preserve greater saphenous vein and saphenous nerve
Decompress superficial and deep posterior compartments
Lateral incision along anterior edge of fibula
Identify and preserve lesser saphenous vein and peroneal nerve
Obtain hemostasis, place skin sutures, and approximate edges when edema resolves
Hallmark Anatomic Complications
Inadequate fasciotomy
Injury to lesser or greater saphenous vein
Injury to superficial peroneal nerve
Injury to saphenous nerve
List of Structures
Anterior compartment
Boundaries
Tibia
Interosseous membrane
Fibula
Anterior intermuscular septum
Deep fascia
Contents
Tibialis anterior muscle
Extensor digitorum longus muscle
Peroneus tertius muscle
Extensor hallucis longus muscle
Deep peroneal nerve
Anterior tibial artery
Lateral compartment
Boundaries
Anterior intermuscular septum
Fibula
Posterior intermuscular septum
Deep fascia
Contents
Peroneus longus muscle
Peroneus brevis muscle
Common peroneal nerve
Superficial peroneal nerve
Superficial posterior compartment
Boundaries
Posterior intermuscular septum
Transverse crural septum
Deep fascia
Contents
Gastrocnemius muscle
Soleus muscle
Plantaris muscle
Deep posterior compartment
Boundaries
Tibia
Interosseous membrane
Fibula
Transverse crural septum
Contents
Popliteus muscle
Flexor hallucis longus muscle
Flexor digitorum longus muscle
Tibialis posterior muscle
Tibial nerve
Posterior tibial artery
Peroneal artery
Four-Compartment Fasciotomy through a Single Incision (Fig. 109.1)
Technical Points
Prep the leg circumferentially and drape it in the standard fashion. Make a lateral skin incision overlying the fibula; extend it from the level of the neck of the fibula proximally down to the lateral malleolus. Carry the incision through the skin and subcutaneous tissue down to the fascia encasing the muscles. Identify the lesser saphenous vein and avoid injuring it. The four compartments of the leg will be decompressed through this single incision by the development of skin flaps (Fig. 109.1A).
Incise the skin and subcutaneous tissue on the lateral surface of the leg to expose the fascia encasing the peroneal muscles. Incise the fascia from the head of the fibula down to the lateral malleolus. This decompresses the lateral compartment (Fig. 109.1B).
Undermine the skin flap anteriorly to expose the anterior compartment. Identify the fascia enclosing the anterior compartment. Incise the fascia longitudinally to decompress the compartment. Be careful to avoid damage to the superficial peroneal nerve where it exits between the anterior and lateral compartments in the distal one third of the leg.
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