Upper and Lower Extremity Fasciotomy: Michael J. Mosier and Gregory J. Jurkovich

CHAPTER
26
Upper and Lower
Extremity Fasciotomy
Michael J. Mosier and Gregory J. Jurkovich
Clinical Anatomy
Lower Leg
♦ The lower leg has four cross-sectional compartments: (1) the anterior compartment, composed
of the tibialis anterior, extensor hallucis longus, extensor digitorum longus, anterior tibial
artery and veins, and deep peroneal nerve; (2) the lateral compartment, composed of the pero-
neus longus and brevis; (3) the superficial posterior compartment, composed of the gastrocne-
mius and soleus; and (4) the deep posterior compartment, composed of the tibialis posterior,
flexor digitorum longus, flexor hallucis longus, peroneal artery and veins, posterior tibial
artery and veins, and tibial nerve (Figure 26-1).
Anterior
Tibia compartment
Lateral
compartment
Fibula
Superficial
posterior
compartment
Deep posterior compartment

Figure 26-1
289
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290 Section V • Extremities and Pelvis
Forearm
♦ The forearm also has four cross-sectional compartments: (1) the superficial volar compartment,
consisting of the palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris, flexor
carpi radialis, ulnar artery and nerve, and median nerve; (2) the deep volar compartment,
consisting of the flexor pollicis longus and flexor digitorum profundus; (3) the mobile wad
compartment, consisting of the brachioradialis, extensor carpi radialis longus, extensor carpi
radialis brevis, and radial artery and nerve; and (4) the dorsal compartment, consisting of the
abductor pollicis longus, extensor pollicis longus, extensor digitorum, extensor digiti minimi,
and extensor carpi ulnaris (Figure 26-2).
Preoperative Considerations
♦ Compartment syndrome occurs when pressure rises within a limited anatomic space, com-
promising perfusion.
♦ Local tissue injury results in tissue swelling and extravascular edema, which in turn increases
intracompartmental pressures. The elevated compartment pressures cause decreased venous

outflow and a decrease in the arteriovenous pressure gradient, leading to hypoperfusion,
anoxia, edema, and tissue necrosis.
♦ On palpation, the compartment is tense and swollen, and passive stretching of the digits of
the extremity increases the pain.

♦ Paresthesia occurs early and should be actively watched for; paralysis develops when ischemia
has caused permanent damage (Figure 26-3).
Chapter 26 • Upper and Lower Extremity Fasciotomy 291
Superficial volar compartment
Mobile wad
compartment
Deep volar
Dorsal compartment
compartment
Figure 26-2
Suspected
compartmental
syndrome
Unequivocally Patient not alert/unreliable

positive Polytrauma victim
clinical findings Inconclusive clinical finding
Compartmental pressure
measurement
>30 mm Hg <30 mm Hg
Continuous compartmental
pressure monitoring and
serial clinical evaluation
<30 mm Hg
Clinical
>30 mm Hg
diagnosis made
Fasciotomy
Figure 26-3
Operative Steps
Lower Leg (Figure 26-4A-D)
♦ The two-incision, four-compartment fasciotomy technique popularized by Mubarak and

Owen can be performed quickly and safely and is used by most trauma surgeons.
♦ The first skin incision extends from the knee to the ankle and is centered over the interval
between the anterior and lateral compartments. This can be done with a long anterolateral
incision 2 cm anterior to the shaft of the fibula.
♦ The second incision also extends from the knee to the ankle and is centered 1 to 2 cm
behind the posteromedial border of the tibia.

♦ The skin and subcutaneous tissue are separated from the fascia overlying the anterior and
lateral compartments after completion of the vertical anterior incision.

♦ Care must be taken to identify and to protect the superficial peroneal nerve.
♦ A fasciotomy of the anterior compartment 1 cm in front of the intermuscular septum is per-
formed, followed by a fasciotomy of the lateral compartment 1 cm behind the intermuscular
septum.
♦ It is imperative to extend the fasciotomy distally beyond the musculotendinous junction and
proximally as far as the origin of the muscle.

♦ The posteromedial incision is made with care taken to protect the saphenous vein and nerve.
♦ The fascia overlying the gastrocnemius-soleus complex is incised, exposing the deep posterior
compartment of the distal third of the leg.

♦ To decompress the deep posterior compartment adequately in the proximal direction, it is
necessary to detach part of the soleal bridge from the back of the tibia. Doing so exposes the
fascia overlying the flexor digitorum longus and the deep posterior compartment, which is
then incised, completing the fasciotomy of the deep posterior compartment of the leg.
Anterior
fasciotomy Superficial Deep
posterior posterior
Lateral fasciotomy fasciotomy
incision site
Medial
incision
site
Lateral
fasciotomy
A B
Anterolateral
incision
Posteromedial
incision
Medial
incision
Lateral
incision
D
Figure 26-4
Forearm (Figure 26-5)
♦ For the volar fasciotomy, make a curvilinear incision starting with an anterior curvilinear
incision medial to the biceps tendon, crossing the elbow flexion crease at an angle. Carry the
incision distally into the palm to allow a carpal tunnel release but avoid crossing the wrist
flexion crease at a right angle.
♦ In patients with suspected brachial artery injury, expose the brachial artery and determine
whether there is free blood flow. If the flow is unsatisfactory, remove the adventitia to expose
any underlying clot, spasm, or intimal tear. Resect the injured segment of artery, if necessary,
and anastomose or graft the artery.
♦ Release the superficial volar compartment throughout its length with open scissors, freeing
the fascia over the superficial compartment muscles.

♦ Identify the flexor carpi ulnaris and retract it with its underlying ulnar neurovascular bundle
medially, and retract the flexor digitorum superficialis and median nerve laterally to expose
the flexor digitorum profundus in its deep compartment. Check to see if its overlying fascia
is tight, and incise it longitudinally.
♦ If the muscle is gray or dusky, the prognosis for recovery may be poor; however, the muscle
may still be viable and should be allowed to perfuse.

♦ Continue the dissection distally by incising the transverse carpal ligament along the ulnar
border of the palmaris longus tendon and median nerve.

♦ In cases of median nerve palsy or paresthesias, observe the median nerve along the entire
zone of injury to ensure that it is not severed, contused, or entrapped between the ulnar and
humeral heads of the pronator teres. If it is, a partial pronator tenotomy is necessary.
♦ If the median nerve is exposed within the distal forearm, suture the distal radial-based forearm
flap loosely over the nerve.

♦ Check the dorsal compartments clinically, or repeat the pressure measurements. Usually, the
volar fasciotomy decompresses the dorsal musculature sufficiently, but if involvement of the
dorsal compartments is still suspected, release them also.
♦ Make the incision distal to the lateral epicondyle between the extensor digitorum communis
and the extensor carpi radialis brevis, extending approximately 10 cm distally. Gently under-
mine the subcutaneous tissue and release the fascia overlying the mobile wad and the extensor
retinaculum.
♦ Apply a sterile moist dressing and a long-arm splint. The elbow should not be left flexed
beyond 90 degrees.
Postoperative Care
Lower Leg
♦ At 48 to 72 hours, the patient is returned to the operating room for débridement of any
necrotic material. Intravenous administration of fluorescein and Wood’s lamp examination
can be helpful in evaluating muscle viability.
♦ If there is no evidence of muscle necrosis, the skin is loosely closed. If closure is not accom-
plished, the débridement is repeated after another 48- to 72-hour interval, after which skin
closure or skin grafting can be done.
♦ If fasciotomy is done within 25 to 30 hours after onset, prognosis is good. Little or no return
of function can be expected if diagnosis and treatment are delayed.
Delayed closure of a fasciotomy of the arm

using vascular loops and staples
Figure 26-5
Forearm
♦ The arm is elevated for 24 to 48 hours after surgery. If closure is not possible within 5 days,
a split-thickness skin graft should be applied. Alternatively, closure of fasciotomy wounds
can be accomplished gradually by progressive tension with vessel loops.
♦ The vessel loops are tightened progressively postoperatively during dressing changes. Wound
closure by this method usually can be accomplished in 2 weeks.

♦ The splint is worn until sutures are removed or as determined by fracture care.
Pearls and Pitfalls
♦ The biggest pitfall to the operation, other than failure to recognize the need for a decompres-
sive fasciotomy in a patient with acute compartment syndrome, is inadequate release of the
compartments.
♦ In a lower leg fasciotomy, the deep posterior compartment can be challenging to release
adequately; thus detachment of the soleal bridge from the tibia to improve exposure of the
deep compartment is crucial.
Selected Readings
Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop Relat Res 1989;240:97.
Canale ST, Beaty JH, editors. Campbell’s operative orthopaedics. 11th ed. Philadelphia: Mosby/Elsevier; 2008.
Mubarak SJ, Owen CA. Double-incision fasciotomy of the leg for decompression in compartment syndromes. J Bone Joint Surg Am
1977;59:184.

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CHAPTER

Deep posterior compartment

intracompartmental pressures. The elevated compartment pressures cause decreased venous

the extremity increases the pain.

has caused permanent damage (Figure 26-3).

Superficial volar compartment

Unequivocally Patient not alert/unreliable

Lower Leg (Figure 26-4A-D)

♦ The two-incision, four-compartment fasciotomy technique popularized by Mubarak and

behind the posteromedial border of the tibia.

lateral compartments after completion of the vertical anterior incision.

proximally as far as the origin of the muscle.

compartment of the distal third of the leg.

Forearm (Figure 26-5)

the fascia over the superficial compartment muscles.

may still be viable and should be allowed to perfuse.

border of the palmaris longus tendon and median nerve.

flap loosely over the nerve.

of function can be expected if diagnosis and treatment are delayed.

Delayed closure of a fasciotomy of the arm

closure by this method usually can be accomplished in 2 weeks.

Pearls and Pitfalls

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