Forearm and Cruris

Fasciotomy
Compartement syndrome was a condition where tissue pressure reaches between 30 and 20 mmHg below diastolic blood
pressure.

As a general rule, when in doubt, the compartement should be released

If a fasciotomy should have been done but was not, loss of muscle tissue and worse may result.

A delay in diagnosis was the most important determining factor for poor outcome.
Indication of Fasciotomy
01
Normotension patient with
positive clinical findings and
compartement pressure of
greater than 30 mmHg
02
Duration of increades
pressure is unknown or more
than 8 hours
03
Uncooperative or
unconscious patient with
compartemen pressure grater
than 30 mmHg
04
Patient with low blood
pressure and compartement
pressure of greater than 20
mmHg
Volar Fasciotomy
Make anterior curvilinear skin
incision medial to biceps
tendon, crossing elbow flexion
crease at an angle. Carry the
incision distally and radially
over the brachioradialis then
distally and ulnarward.
Eventually coursing medial to
palmaris longus.
Cross the wrist flexion crease
at an angle and continue in the
midline of palm to allow for a
carpal tunnel release. The
underlying subcutaneous
tissue should be spread
longitudinally, protecting
lateral and medial antebrachial
cutaneous nerve and palmar
cutaneous bracnch of median
nerve.
Divide lacertus fibrosus
proximally and evacuate any
hematoma.
In patient with suspected
brachial artery injury, expose
brachial arteri and determine if
there is free blood flow. If the
flow unsastifactory, remove
the adventitia to expose any
underlying clot, spasm, or
initial tear. Resect the
adventitia if necessary and
anastomose or graft the artery.

Volar Fasciotomy
Release the superfiocial volar
compartemene throughout its
length with open scissors.
Freeing the fascia over the
superficial compartemen
muscles.
Identify the flexor carpi
ulnaris and retract it with its
underlying ulnar
neurovascular bundle medially
and then retract the flexor
digitorum superficialis and
median nerver laterally.
If muscle is gray or dusky,
prognosis for recover may be
poor. However, muscle may
still be viable and should be
allowed to perfuse.
Continue the dissection
distally by cising the
transverse carpal ligament
along ulnar border of palmaris
longus tendon and median
nerve.
In case of median nerve palsy
or paresthesia, observe the
median nerve along the entire
zone of injury to ensure that
its not severed, contused, or
entrapped between ulnar and
humeral head.
In a patient with
supracondylar fracture, reduce
fracture, pint with kirschner
wires, and control the
bleeding.
 Volar Fasciotomy

In postoperative care, arm is Alternatively, closure of

elevated for 24 to 48 fasciotomy wounds can be
hour after surgery. A accomplished gradually using
split thickness skin graft jvessel loops that are
should be applied if progressively tightened
closure is not possible postoperatively during
within 5 days dressing change.
Volar Fasciotomy
Fasciotomy fo Acute Compartemen Syndrome of
Thigh
Prepare and drape thigh in
sterile fashion, exposing limb
from iliac crest to knee joint
Make a lateral incision
beginning just distal to
intertrochanters line,
extending to lateral
epicondyle.
Use subcutaneous dissection
After anterior and posterior
to expose illiotibial band then
compartemen released,
make straigh incision in line
measure pressure of medial
with skin incision through
compartement. If elevated,
iliotibial band
make separate medial incision
Carefully reflect vastus to release the adductor
lateralis off the lateral compartement
anteromuscular septum,
Pack wound open and apply
making sure to coagulate all
large bulky dressing
perforating vessel as they are
encountered
Make 1.5 cm incision in
lateral intermuscular septum
and using metzenbaum
scissors, extend proximally
and distally of incision
Fasciotomy fo Acute Compartemen Syndrome of
Thigh
Patient returnet to OR for
debridement after 48 to 72
hour for any necrotic material.
Intracenous fluorescein and
wood light can be helpful
evaluating muscle viability. If
no evidence of muscle
necrosis, the skin is loosely
closed.
Apply a negative pressure
wound device if closure
is not accomplished.
Debridement repeated
after another 48 to 72
hours interval, after
which skin closure or
skin grafting can be
done
Single-Incision Fasciotomy for lower leg
compartemen syndrome
Make a single longitudinal
lateral incision in line with
fibula, extending from just
distal to head of fibula to 3 to
4 cm proximal to lateral
maleolus
Undermine skin anteriorly and
avoid injuring superficial
peroneal nerve.
Perform a longitudinal
fasciotomy of anterior and
lateral compartement and
undermine skin posteriorly.
Perform fasciotomy of
superficial posterior
compartement.
Identify the interval between
superficial and lateral
compartemen distally and
develop this interval proximal
by detaching the soleus from
fibula.
Subperiosteally dissect the
flexor hallucis longus from
fibula then retract muscle and
peroneal vessel posteriorly
Identify the fascial attachment
of posterior tibial muscle to
fibula and incise this fascia
longitudinally. Close only the
skin over a suction drain or
negative pressure wound
device
Double-incision fasciotomy for lower leg
compartemen syndrome
Make 20 to 25 cm incision in
arterior compartement,
centered halfway between
fibular shaft and the crest of
tibia. Use subcutaneous
dissection for wide exposure
of the fascial compartement
Make a transverse incision to
expose the lateral
intermuscular septum and
identify the superficial
peroneal nerver just posterior
to the septum
Release anterior
compartement proximally and
distally in line with anterior
tibial muscle using
Metzenbaum scissors
Perform fasciotomy of lateral
compartement proximally and
distally in line with fibular
shaft and make second
longitudinal incision 2 cm
posterior to posterior margin
of tibia. Use wide
subcutaneous dissection to
allow identification of fascial
planes.
Retract saphenous vein an
nerver anteriorly then make a
transverse incision to identify
septum between the deep and
superficial posterior
compartements. Release the
fascia over gastrocnemius-
solleus complex for the length
of the compartement
Make another fascial incision
over the flexor digitorum
longus muscle and release
entire deep posterior
compartement
After release posterior
compartemenet, identify the
deep posterior muscle
compartement.
Double-incision fasciotomy for lower leg
compartemen syndrome
Pack the wound open and
apply a posterior plaster plint
with foot plantigrade.
Make another fascial incision
over the flexor digitorum Management of fasciotomy
muscle and release the entire wound has included primary
deep posterior compartements. closure, healing by secondary
As dissection is carried intention or split-thickness
proximally, if the soleus skin graft to cover defect
bridge externd more than which is necessary in
halfway down the tibia, approximately 50% of patient.
release this extended origin.
After that, identify the deep
posterior muscle
compartement. Release it over
the extent of muscle belly if
there is increased tension
References

● Campbell’s Operative Orthopaedics 2017-V5 13th Ed

Thanks!

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