112 Fl. T. SAKELLARIDES AND J. W.

DEWEESE

20. STRANDELL, GUNNAR: Total Rupture ofthe Ulnar Collateral Ligament ofthe Melacarpophalangeal Joint of the Thunib. Results of Surgery in 35
Cases. Acta Chir. Scandinavica, 118: 72-80, 1959.
21. ZIL.BERMAN. Zwy: ROTSCHII.D, EI.IEZER: and KRAUSS. LUDWIG: Rupture ofthe UlnarCollateral Ligament oflhe Thumb. J. Trauma. 5: 477-481,
1965.

Fasciotomy in the Treatment of the Acute Compartment Syndrome*

BY GEOFFREY W. SHERIDAN, M.D.t, AND FREDERICK A. MATSEN III, M.D.t, SEATTLE, WASHINGTON
Downloaded from http://journals.lww.com/jbjsjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 10/17/2021

ABSTRACT: Sixty-six cases of acute compartment sure at fasciotomy in association with preoperative signs
syndrome were treated by fasciotomy in forty-six ex- of dysfunction or ischemia of the contents of the compart-
tremities of forty-four patients. Fasciotomy performed ment: motor weakness, pain on passive muscle stretch, or
early, that is, less than twelve hours after the onset of hypesthesia in the distribution of the appropriate nerve.
the compartment syndrome, resulted in normal func- We defined the onset of the syndrome as the time when
tion in 68 per cent of the extremities. Only 8 per cent of any of these signs first appeared. The cases were analyzed
those having late fasciotomy had normal function. The for age and sex distribution, etiology and location of the
complication rates for the early and late fasciotomized compartment syndrome, time from onset of the syndrome
extremities were 4.5 per cent and 54 per cent, respec- to fasciotomy, functional end result, and complications of
tively. No significant differences in residual function or fasciotomy.
complication rate were noted with “open” or “closed”
Results
fasciotomy.
During this ten-year period forty-nine patients were
Elevated tissue pressure in the osteofascial compart- diagnosed as having a compartment syndrome. Inadequate
ments of the extremities may cause loss of function or ne- records or insufficient follow-up resulted in the exclusion
crosis of the enclosed nerve and muscle. This condition, of five patients from this study. In the remaining forty-four
known as a compartment syndrome, is a source of patients, sixty-six compartments were decompressed in
significant morbidity following trauma 2 revascularization forty-six extremities. The average age of the patients was
procedures 7.17, burns 19, and exercise 3.15 Irrespective of 29.2 years, with a range of from six to eighty years. Seven
the etiology or location of the compartment syndrome, in- were female and thirty-seven, male. The duration of
creased intracompartmental pressure is the underlying follow-up was from forty-two days to 2.75 years (one pa-
pathogenetic factor, and prompt decompression by fas- tient died eighteen days after fasciotomy). The mean
ciotomy is the logical treatment 13 In spite of the wide use follow-up, omitting the death, was 229 days. The loca-
of fasciotomy, the factors affecting the results following tions of the affected compartments are shown in Figure 1.
this procedure remain unclear. For example, the duration The anterior compartment of the leg was involved most
of the grace period during which functional losses are re- commonly, followed by the deep posterior and lateral
versible is unknown. Furthermore, the efficacy of open as compartments of the leg and the flexor compartment of the
opposed to closed fasciotomy has not been explored. forearm. The types of etiology of the compartment syn-
We report here an analysis of the results of a consecu- dromes are shown in Figure 2. Traumatic causes were
tive series of fasciotomies performed at the University of most common, followed by postischemic swelling. In
Washington affiliated hospitals. Particular reference is eight patients non-operative therapy was attempted, con-
made to the timing of fasciotomy and to the handling of sisting either of administration of low-molecular-weight
the skin at the time of and subsequent to the procedure. dextran or sympathetic-nerve blocks. All of these patients
subsequently had fasciotomy.
Material Two variables were of special interest: (1) the time
The records of the University of Washington from the onset of the compartment syndrome to fas-
affiliated hospitals from January 1965 to February 1975 ciotomy, and (2) whether or not the skin was left open at
were reviewed for patients in whom a fasciotomy had been the end of the procedure. With regard to the former van-
performed to decompress an extremity with an acute corn- able, the affected extremities were divided into two
partment syndrome. For inclusion in this study a patient groups. Twenty-two extremities were in the early group,
had to have obviously increased intracompartmental pres- decompressed within twelve hours of the onset of symp-
toms (mean, 5.3 hours). Twenty-four were in the late
* Supported by an NIH training grant.
y University of Washington School of Medicine. Seattle, Washing-
group, decompressed after more than twelve hours (mean,
ton 98195. 37. 1 hours). The mean interval from the etiological event

THE JOURNAL OF BONE AND JOINT SURGERY

 FASCIOTOMY IN THE TREATMENT OF THE ACUTE COMPARTMENT SYNDROME 113

to the onset of the compartment syndrome was similar for residual deficits - sensory or motor - and in fifteen of
both of these groups: 11.7 and 17.9 hours, respectively twenty-two (68 per cent) of the extremities that were the
(p > 0.2). sites of early fasciotomy no functional loss was noted at
A potential source of error is implicit in these tem- follow-up. In only two of twenty-four (8 per cent) of those
poral factors: prompt recognition of compartmental dys- having hate fasciotomy was there normal function. This
function is necessary for the determination of the time of difference is significant (p < 0.01). Whether the fas-
onset of a compartment syndrome. If the signs of the corn- ciotomy was open or closed had no significant effect (ten
phication are initially missed, the case may erroneously be of fifteen versus five of seven, and two of sixteen versus
grouped in the early category. However, lacking a better none of eight).
criterion and assuming our vigilance for neuromuscular Complications following fasciotomy included infec-
deficits was similar to that in other hospitals, we deter- tions of soft tissue and bone, amputation, renal failure,
mined the onset of the compartment syndrome from the and death. Like the functional result, the incidence of
record, as described previously. complications was strongly related to the timing of fas-
A standard fasciotomy technique was not used in this ciotomy. Whether or not the skin was closed had a less
series. The procedures may be divided into two groups: In obvious effect. Only one complication, a soft-tissue infec-
the ‘ ‘closed’ ‘ group (fifteen extremities) fasciotomy was tion, occurred in the twenty-two early fasciotomies in a pa-
either performed through a small skin incision on the skin tient whose incision was closed. In contrast, eleven of
was closed immediately following open fasciotomy. In the twenty-four (46 per cent) of the late fasciotomies became
‘ ‘open’ ‘ group (thirty-one extremities) the skin was infected (p < 0.01); two-thirds of these were due to
opened widely, closure being attempted at a later time. In coagulase-positive Staphylococcus. Five, or almost one-
all instances the compartments were considered to be satis- half, of these infections led to amputation. One case of Os-
factonily decompressed by the operating surgeon. teomyehitis occurred in a patient with an initially closed
Fibulectomy-fasciotomy 8 was not employed in this series. tibial fracture who underwent fasciotomy with primary
The functional results after fasciotomy were as fol- closure twenty-eight hours after the onset of a compart-
lows: Normal function was defined as the absence of any ment syndrome. One death from overwhelming sepsis oc-
curred in a brittle diabetic patient who had a late fas-
ciotomy. In two patients who had closed late fasciotomy,
myoglobinunic renal failure intervened. Both required
25 dialysis, but normal renal function eventually returned.
The hospital stay averaged 28.9 days for this series of
patients, 16.7 days for those having early fasciotomy and
40.2 days for those having late fasciotomy. Seventy-five
per cent of the late group required at least one subsequent
,
5

I2

3 tO E
. 9.

5. 6

; 3.

.0
v,

;:
lb

c::
v
.0
::

Q 0
-
‘.

0
.

Qi
HHHHHHHH
.
rai
q’

0 -J 0 ‘; 0

cx .

‘-
t . l
q .
- .
qa . .‘J
c::3 a #{176}i -.. ‘. 0 n
. ..- 0 rai i,

cx -
ui
::
“. . rai ‘- 0
Q t x ‘ : :
(r
FIG. 1 FIG. 2

Distribution of compartment syndromes. The ordinate represents the Etiology of compartment syndromes. The ordinate represents the
number of compartments. the abscissa is the compartment affected. number of compartments, the abscissa is the etiological factor.

VOL. 58.A, NO. I. JANUARY 1976

1 14 G. W. SHERIDAN AND F. A. MATSEN III

hospital admission for further treatment of the affected ex- sive muscle stretch, or nerve hypesthesia marks the begin-
tremity, compared with 14 per cent of the early group ning of the ischemic period, and that twelve hours of total
(p 0.01).
< ischemia produces essentially complete necrosis of muscle
Skin-grafting was necessary in 77 per cent of the open fibers 10.15 Functional return following decompression of
fasciotomies. The remainder of the open fasciotomy necrotic muscle is unlikely, whereas the chance of infec-
wounds were closed by delayed primary closure. Early tion following the surgical exposure of this devitalized tis-
and late fasciotomies did not differ significantly in this sue would seem to be great. Sudden death following fas-
regard. ciotomy was reported previously , attributed to the
sudden return to the heart of a large quantity of acidic
Discussion blood, rich in potassium, producing fatal arrhythmia, but
Since Jepson’s original demonstration that decom- no such complication occurred in this series.
pression may prevent ischemic contracture, clinicians It is difficult to draw conclusions concerning the rela-
have become increasingly aware of the effectiveness of tive efficacy of closed and open fasciotomy from this
prompt fasciotomy in the treatment of compartment study. There seemed to be no differences in residual func-
syndrome 2.5.6 Coincident with this awareness has come tion and complication rate with the two procedures. Pa-
the realization that fasciotomy may be attended by tients who had the open procedure required a subsequent
significant complications: problems with skin closure, surgical procedure and 77 per cent of them received skin
soft-tissue and bone infection, and amputation. Previous grafts. However, it is quite likely that the groups treated
studies of the deep posterior compartment syndrome of the closed and open were not comparable: those extremities
leg suggested that decompression within twelve hours of that were grossly swollen could not have been closed fol-
the onset of the compartment syndrome will preserve the lowing fasciotomy, whereas the surgeon would be tempted
function of the nerve and muscle within the to perform a closed fasciotomy in mildly swollen ex-
compartment 14The present study demonstrates that early tremities.
fasciotomy diminishes not only the incidence of residual
functional deficits, but also the incidence of post- Conclusions
fasciotomy complications. Fasciotomy should be consid- The early diagnosis and treatment of a compartment
ered a surgical emergency. syndrome requires that the extremities at risk be examined
In this series, only seven of twenty-two extremities frequently. Since pain is not a reliable indicator of this
(32 pen cent) decompressed less than twelve hours from the condition 14, muscle strength, passive muscle stretch, and
onset of the compartment syndrome had residual sensory sensation should be closely monitored. If the diagnosis of
or motor deficits. Four of these seven impaired extremities a compartment syndrome is made, a thorough decompres-
had had intra-artenial injection of irritating drugs, an etiol- sion of the compressed structures is indicated if the condi-
ogy known to indicate a poor prognosis i.9.12#{149} Similarly, tion is of short duration. Epimysiotomy 6.16 should be
only one of twenty-two extremities having early fas- combined with fasciotomy if individual muscle bellies re-
ciotomy had a complication. These figures are in contrast quire decompression.
to the late fasciotomy group, of which 92 per cent had re- Compartments decompressed after more than twelve
sidual functional impairment and a total of thirteen of hours have elapsed have a smaller chance of functional re-
twenty-four extremities had complications. The amputa- turn and a higher complication rate. Primary skin closure
tion rate of the group that had late treatment was 21 per should be attempted only when the skin may be closed
cent. These results are not surprising if one accepts the without tension and minimum additional swelling is
suggestion that the onset of muscle weakness, pain on pas- anticipated.

References
I . ALBO, DOMINIC, JR.: CHEUNG, LARRY; RUTH, LARRY: SNYDER, CLIFFORD: and REEMTSMA, KEITH: Effect of Intra-Arterial Injections of Bar-
biturales. Am. J. Surg. , 120: 676-678, 1970.
2. BRADLEY. E. L. III: The Anterior Tibial Compartment Syndrome. Surg. , Gynec. and Obstet. , 136: 289-297, 1973.
3. CARTER, A. B.: RICHARDS, R. L.: and ZACHARY, R. B.: The Anterior Tibial Syndrome. Lancet, 2: 928-934, 1949.
4. COUPLAND, G. A. E.: Anterior Tibial Syndrome following Restoration of Arterial Flow. Australian and New Zealand J. Surg., 21: 338-341.
1972.
5. CYWES, S., and Louw, J. H.: Phlegmasia Cerulea Dolens: Successful Treatment by Relieving Fasciolomy. Surgery, 51: 169-176, 1962.
6. EATON, R. G.. and GREEN, W. T.: Epimysiolomy and Fasciotomy in the Treatment of Volkmann’s lschemic Contracture. Orthop. Clin. North
America, 3: 175-186, 1972.
7. ERNST, C. B.. and KAUFER, HERBERT: Fibuleclomy-Fasciolomy, An Important Adjunct in the Management of Lower Extremity Arterial
Trauma. J. Trauma, 11: 365-380, 1971.
8. FEAGIN, J. A., and WHITE, A. A., III: Volkmann’s Ischemia Treated by Transfibular Fasciolomy. Mil. Med., 138: 497-499, 1973.
9. GASPAR. M. R.. and HARE. R. R.: Gangrene due to Intra-Arterial Injection of Drugs by Drug Addicts. Surgery, 72: 573-577, 1972.
10. HARMAN, J. W.: The Significance of Local Vascular Phenomena in the Production of lschemic Necrosis in Skeletal Muscle. Am. J. Path., 24:
625-641, 1948.
II. JEPSON. P. N.: lschemic Contraction. Experimental Study. Ann. Surg., 84: 785-795, 1926.
12. KAUFER, HERBERT; SPENG[.ER, D. M.: NOYES, F. R.: and Louis, D. S.: Orthopaedic Implications of the Drug Subculture. J. Trauma. 14:
853-867. 1974.
13. MATSEN. F. A.: Compartmental Syndromes: A Unified Concept. Clin. Orthop. (in press).
14. MATSEN, F. A. 111, and CLAWSON, D. K.: The Deep Posterior Compartmental Syndrome of the Leg. J. Bone and Joint Surg.. 57-A: 34-39, Jan.
1975.

THE JOURNAL OF BONE AND JOINT SURGERY

 FASCIOTOMY IN THE TREATMENT OF THE ACUTE COMPARTMENT SYNDROME 115

15. MILLER, H. H., and WELCH, C. S.: Quantitative Studies on the Time Factor in Arterial Injuries. Ann. Surg., 130: 428-438, 1949.
16. OSBORNE, A. H.: DOREY. L. R.; and HARVEY. J. P., JR.: Volkmann’s Conlracture Associated with Prolonged External Pressure on the Forearm.
Arch. Surg. , 104: 794-798, 1972.
17. PATMAN. R. D.: THOMPSON. J. E.: and PERSSON, A. V.: Use and Technique of Fasciotomy as an Adjunct to Limb Salvage. Southern Med. J.,
66: 1108-1116. 1973.
18. RENEMAN, R. S.: The Anterior and Lateral Compartment Syndrome of the Leg. The Hague, Mouton, 1968.
19. SALISBURY, R. E.; MCKEEL, D. W.; and MASON, A. D., JR.: Ischemic Necrosis of the Intrinsic Muscles of the Hand after Thermal Injuries. J.
Bone and Joint Surg. , 56-A: 1701-1707, Dec. 1974.

Congenital Anomaly of the Thumb:

Absent Intrinsics and Flexor Pollicis Longus*
BY BERISH STRAUCH, M.D.t, AND MORTON SPINNER, M.D4, BRONX, NEW YORK

ABSTRACT: Congenital absence of the median- manifesting different degrees of penetrance. The full-
innervated intrinsic muscles and flexor polhicis longus blown syndrome demonstrating almost all of the findings
was seen in varying degrees of severity in eleven hands was seen in eight of the eleven hands (Table I). In the
of eight patients. Three members were involved in one other three the muscles were absent and the adduction con-
family in which the anomaly was probably an au- tracture was present, but the other deformities were mild.
tosomal dominant. There were no chromosomal ab- Seven hands showed complete absence of the flexor pol-
normahities. Surgical treatment of seven hands, includ- hicis hongus. Flexion of the thumb in them was accom-
ing release of the adduction contracture and transfer of plished at the metacarpophalangealjoint, either by means of
the ring-finger superficiahis tendon to provide opposi- the adductor attachment to the extensor mechanism or by
tion and to reinforce the ulnar collateral ligament of the deep head of the flexor brevis. In three hands active
the metacarpophalangeal joint, resulted in significant flexion of the thumb amounted to only 20 to 25 degrees of
improvement in pinch and grasp.

As noted by Kaplan, the characteristic features of the

human hand are a comparatively long thumb and an effec-
tive thumb flexor, the flexor polhicis longus. In an anomaly
first described in 1895 2, the median-innervated thenar in-
trinsic muscles are absent as well as the flexor pollicis lon-
gus tendon. We have seen eight patients with this anomaly
in eleven hands. These patients ranged in age from four-
teen months to thirty-seven years old, and in all of them
the normally median-innervated abductor pollicis brevis,
opponens, and short flexors were absent, with concomitant
flattening of the thenar eminence (Fig. 1). In addition,
there was an adduction contracture of the first web space
caused by the relatively unopposed adductor. The com-
bination of these abnormalities limited the use of the in-
volved hand, since opposition, fine pinch, key pinch, and
grasp were markedly impaired or absent.
In addition to these abnormalities, which were found
in all of the involved hands, there were other deformities

* Read at the Annual Meeting of the American Society for Surgery

olthe Hand. Dallas, Texas. January 15, 1974.
FIG. I
. Montefiore Hospital and Medical Center. 3331 Bainbridge
Avenue. Bronx, New York 10467. Infant with characteristic flattening of the Ihenar eminence and ab-
: Brookdale Hospital Medical Center, 580 Rockaway Parkway. sence of the interphalangeal fiexion crease. The flexor pollicts longus
Brooklyn. New York 11212. was absent.

VOL. 58-A, NO. I. JANUARY 1976