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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 a result of ischemia, trauma, or burn injuries. Management involves not only treatment of the underlying pathology but also physical release of the compartment to prevent further damage from 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 at 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 restoration of flow after a period of ischemia. To be complete, all four compartments, anterior, lateral, superficial posterior, and deep posterior, should undergo fasciotomy (FIGURE 2A, B).
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PREOPERATIVE PREPARATION
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Attention should be paid to the 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 usually are required because of the complex nature of these patients.
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OPERATIVE PREPARATION
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The skin is prepared with topical cleansers and sterilely draped. Then a time-out is performed.
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DETAILS OF THE PROCEDURE
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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 is 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. The superficial posterior compartment fascia is incised in 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 so as to avoid bleeding, especially if the patient is anticoagulated postoperatively. The tip of Metzenbaum scissors is 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 ...