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Compartment syndrome develops as the result of increased pressure within the confines of a fixed space. This may occur in the extremities as the result of ischemia, trauma, or burn injuries. Management involves not only the treatment of the underlying pathology, but also the physical release of the compartment to prevent further damage due to impaired capillary perfusion and increased venous resistance.
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Diagnosis of compartment syndrome can be made by obtaining formal intracompartmental pressures (tissue perfusion becomes impaired around 20 mm Hg) (figure 1) or based on physical signs and symptoms. These may include tense and tender muscle groups, pain on passive motion, and numbness or impaired motor function in the distribution of the nerve within the compartment. The most common site for compartment syndrome is the lower leg, often due to ischemia or the restoration of flow after a period of ischemia. To be complete, all four compartments, anterior, lateral, superficial posterior, and deep posterior, should undergo fasciotomy (figures 2a and 2b).
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PREOPERATIVE PREPARATION
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Attention should be given to hemodynamic stability of the patient, as well as close fluid and electrolyte management. Preoperative antibiotics are essential to prevent infection.
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In the case of fasciotomy, general anesthesia and close hemodynamic monitoring will usually be required due to the complex nature of these patients. As is routine before making any type of skin incision, the skin should be prepared with topical cleansers.
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For lower-leg fasciotomy the entire leg should be prepared and draped in the usual fashion. This may have been preceded by a procedure to restore flow to the leg (i.e., thrombectomy/embolectomy, bypass, or thrombolytic therapy). The most common approach to a four compartment fasciotomy can be accomplished through two lower-leg incisions (figure 3).
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The posterior compartments are approached through a skin incision made over the medial calf, 1 cm posterior to the posterior edge of the tibia, for a similar length and the superficial posterior compartment fascia is incised in a similar fashion (figure 4). To access the deep posterior compartment, the gastrocnemius–soleal muscle complex is taken down from its attachments to the tibia (figure 2b).
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For the anterior and lateral compartments an incision is made several centimeters lateral to the anterior tibia for a length of approximately 10 cm. The anterior compartment fascia is encountered and incised for the length of the skin incision, taking care not to invade into the underlying muscle to avoid bleeding, especially if the patient is anticoagulated postoperatively. The tip of Metzenbaum scissors are inserted into the edges of the fascial incision proximally and distally and advanced under the skin, completing the fasciotomy (figure 5). The lateral compartment is incised similarly within the same site. Care ...