Fasciotomy
Parth B. Amin
W. John Sharp
Fascial envelopes surround the major muscle groups in the leg, dividing them into compartments. Arterial bleeding, venous hemorrhage, or severe edema within a compartment can cause the pressure within this close space to rise rapidly. If severe enough, neuromuscular function can be threatened, and fasciotomy indicated. Burns, electrical injury, crush injuries, reperfusion injury, and venous outflow obstruction can all result in increased compartment pressures. Most commonly, this occurs within the four muscle compartments below the knee. Clinical suspicion should be balanced with intracompartmental pressure measurements. Substantial data suggests that a difference between systemic diastolic pressure and intracompartmental pressure less than 30 mm Hg, should warrant a fasciotomy. Four-compartment fasciotomy is described in this chapter.
SCORE™, the Surgical Council on Resident Education, classified fasciotomy for injury as an “ESSENTIAL UNCOMMON” procedure.
STEPS IN PROCEDURE
Four-compartment fasciotomy
Medial incision along the posterior edge of tibia
Identify and preserve the greater saphenous vein and saphenous nerve
Decompress superficial and posterior compartments
Lateral incision along the anterior edge of the fibula
Identify and preserve saphenous vein and peroneal nerve
HALLMARK ANATOMIC COMPLICATIONS
Inadequate fasciotomy
Injury to the lesser or greater saphenous vein
Injury to the superficial peroneal nerve
Injury to the 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 Two Incisions (Fig. 134.1)
Technical Points
The double-incision technique allows decompression of all four compartments through two skin incisions. Prep and drape the leg circumferentially in the usual sterile fashion. Make a medial incision, starting about 1 cm posterior to the edge of the tibia (Fig. 134.1A). Identify the greater saphenous vein and nerve to avoid injury to these structures when incising the fascia. The medial incision will provide access to the superficial and deep posterior compartments. The deep posterior compartment is often missed altogether or inadequately decompressed. Expose the fascia enclosing the gastrocnemius muscle and incise it along its length. Separate the fibers of the gastrocnemius and soleus muscles to gain entrance to the deep posterior compartment. Decompress the deep posterior compartment by incision of its fascia.
The lateral incision provides access to the lateral and anterior compartments. The incision should extend along the
anterior edge of the fibula (Fig. 134.1B). Incise the fascia of the lateral compartment from the knee down to the ankle. Undermine the anterior skin flap to gain exposure to the anterior compartment (Fig. 134.2). The underside of the tibia needs to be felt in order for the anterior compartment to be adequately decompressed.
anterior edge of the fibula (Fig. 134.1B). Incise the fascia of the lateral compartment from the knee down to the ankle. Undermine the anterior skin flap to gain exposure to the anterior compartment (Fig. 134.2). The underside of the tibia needs to be felt in order for the anterior compartment to be adequately decompressed.
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