Upper extremity fasciotomy techniques

INTRODUCTION — Compartment syndrome occurs when blood flow to the muscles and nerves is impaired as pressure in a muscle compartment increases (figure 1). Extremity fasciotomy is accomplished by making an incision through the unyielding fascia that envelops the muscles within the compartment to reduce pressure in the compartment. Fasciotomies are more often needed to treat acute compartment syndrome; failure to recognize acute upper extremity compartment syndrome and decompress the muscular compartments in a timely fashion can result in significant functional morbidity. On occasion fasciotomy is needed to treat chronic exertional compartment syndrome.

Fasciotomy is less often performed in the upper extremities compared with the lower extremities, accounting for approximately 20 percent of all extremity fasciotomies [1,2]. Among patients with extremity trauma, approximately 1 percent require an upper extremity fasciotomy [3,4]. Similar to the lower extremity, many cases of acute upper extremity compartment syndrome are associated with fractures or vascular disorders [1,5]. However, injury mechanisms, such as penetrating injuries and amputations, are more likely to cause acute compartment syndrome in the upper extremities than in the lower extremities.

The indications for and techniques of upper extremity fasciotomy for the treatment of compartment syndrome of the shoulder, arm, forearm, hand, and digits will be reviewed here. Minimally invasive techniques for chronic upper extremity compartment syndromes are briefly discussed. Patient management following fasciotomy, including wound care, is discussed separately. (See "Patient management following extremity fasciotomy".)

The clinical evaluation and diagnostic criteria for acute compartment syndrome and chronic exertional compartment syndrome are discussed in separate reviews. (See "Acute compartment syndrome of the extremities" and "Chronic exertional compartment syndrome".)

INDICATIONS — Upper extremity fasciotomy is primarily indicated in the management of acute extremity compartment syndrome (impending or established). Fasciotomies are sometimes used as damage control for a severe trauma. In cases of upper extremity replantation during which the time until revascularization is over three hours, a prophylactic fasciotomy should be conducted. On occasion, upper extremity fasciotomy may be needed to manage chronic exertional compartment syndrome. (See "Acute compartment syndrome of the extremities" and "Chronic exertional compartment syndrome".)

Acute compartment syndrome — Upper extremity fasciotomy is indicated for clinical evidence of acute extremity compartment syndrome (impending or established) and supported by objective evidence of elevated compartment pressure, if possible (table 1). The clinical features and diagnosis of acute extremity compartment syndrome, and the pathophysiology and classification of acute extremity compartment syndrome, are reviewed in detail separately and summarized below. (See "Acute compartment syndrome of the extremities" and "Pathophysiology, classification, and causes of acute extremity compartment syndrome", section on 'Classification'.)

●A diagnosis of upper extremity compartment syndrome relies mainly on the patient's history, symptoms, and signs based on physical examination, looking for signs referable to a particular compartment (table 2). During an examination, the classical Ps of acute compartment syndrome (pain, pressure, paresthesia, paralysis, pallor, and pulselessness) aid in the diagnosis. Especially important findings are severe pain disproportionate to the physical findings, passive extension causing pain of the compartment constituent muscles, or tense fascia by palpation [6-11]. (See "Acute compartment syndrome of the extremities", section on 'Anatomic compartments and related clinical signs' and "Acute compartment syndrome of the extremities", section on 'Clinical features'.)

●Objective compartment pressure measurements ensure an accurate and timely diagnosis (eg, handheld manometer [Stryker device], Whitesides apparatus) [12-14]. A threshold increase of compartment pressure indicates the need for fasciotomy. (See "Acute compartment syndrome of the extremities", section on 'Measurement of compartment pressures'.)

In the upper extremity, a compartment pressure greater than 30 mmHg strongly indicates the presence of compartment syndrome. Normal ranges for forearm compartment pressure are as follows [15]:

●0 to 25 mmHg for the forearm extensor compartment

●0 to 21 mmHg for the forearm flexor compartment

There is no literature describing normal ranges or pressure thresholds defining compartment syndrome of the brachium, shoulder, or hand. Generally, we perform fasciotomy in the shoulder and upper arm when the pressure is >30 mmHg. The measurement of compartment pressure in compartments of the hand or finger is difficult with a manometer. Therefore, we usually decide whether to perform fasciotomy based on clinical findings rather than using pressure.

Impending — With impending compartment syndrome, tissue pressure is not sufficiently high enough to cause muscle or nerve damage. Prophylactic fasciotomy may be indicated.

●For clinical scenarios in which compartment syndrome is more likely to occur (eg, reperfusion after prolonged ischemia >3 hours), prophylactic fasciotomy is appropriate. Surgeons should note that a shorter duration of ischemia does not exclude the development of compartment syndrome.

●In children, it is difficult to accurately estimate the actual amount of pain, and the classic five Ps (pain, pallor, paresthesia, paralysis, and pulselessness) are also unreliable. An increased need for analgesics is a more sensitive indicator of impending compartment syndrome [16].

●Fasciotomy should be performed immediately upon worsening of symptoms among those in whom careful monitoring is elected in this population.

Established — For early established acute compartment syndrome (<4 hour duration), the following indicate the need for fasciotomy [17,18]:

●Obvious clinical diagnosis of acute upper extremity acute compartment syndrome

●Compartment pressure within 30 mmHg of diastolic pressure

Patients with late established acute compartment syndrome (>4 hour duration) are not likely to have any functional benefit from fasciotomy. Some surgeons regard cases with late diagnosis or missed diagnosis as an absolute contraindication to fasciotomy based on a perceived increased risk of postoperative infection. However, late intervention may serve a purpose to mitigate infection by debridement of necrotic tissue during the fasciotomy, preventing the contracture of the joints.

Chronic exertional compartment syndrome — The literature on chronic exertional syndrome of upper limbs, especially forearms, consists mainly of individual case reports [19-22]. Most reported cases occur in the forearm flexor compartment, in addition to a few cases reported in the extensor compartment or intrinsic muscles [23]. Some cases were bilateral [24,25]. Patients describe the symptoms as ambiguous pain of the forearm, fatigue, and feeling heavy with onset of symptoms 5 to 30 minutes into exercise. Sometimes the symptoms radiate from the forearm to the hand. In one review, patients described the symptoms with the terms "useless," "bursting," and "loss of hand control" [21]. Continued exercise often aggravates the discomfort, whereas pausing exercise alleviates it.

The diagnosis is usually made with dynamic compartment pressure testing, which is measurement of the compartment pressure before, during, and after exercise. A series of three exercises and the abnormal threshold of peak pressure during exercise of 30 mmHg have been used as criteria for intervention [20]. However, some asymptomatic individuals may show a high value of intramuscular pressure in exercise load; the diagnosis based on it might not be sufficient. Magnetic resonance (MR) imaging may aid the diagnosis by demonstrating swollen muscles or fascia (increased T2 signal intensity of the muscles in the affected compartment after exercise) [23].

COMPARTMENT ANATOMY — The upper limb muscle compartments consist of the shoulder, brachium, forearm, and hand compartments (table 2). Each myofascial compartment is separated by a muscular septum.

Shoulder and brachium — The risk for compartment syndrome in the shoulder or brachium is lower compared with the forearm partly because edema or hematomas of the brachium, which is connected to the shoulder girdle, can dissipate toward the trunk. In addition to trauma, inadvertent intramuscular injections and poor operative positioning have been reported as causes for shoulder compartment syndrome [26,27]. (See "Pathophysiology, classification, and causes of acute extremity compartment syndrome", section on 'Causes of acute compartment syndrome'.)

The deltoid compartment is subdivided into the anterior, middle, and posterior compartments, and each is independently controlled by the axillary nerve [28]. The deltoid muscle fascia has a thick epimysium, which can compress the axillary nerve due to an increase in deltoid volume.

The brachial compartment is subdivided into two compartments (anterior, posterior) (figure 2). The muscles of the anterior compartment are the biceps, brachialis, and coracobrachialis [29]. They are dominated by the musculocutaneous nerve, which becomes the lateral antebrachial cutaneous nerve below the elbow. In addition to the musculocutaneous nerve, the median, ulnar, radial, and medial antebrachial cutaneous nerves are also present in the anterior compartment. Brachium compartment syndrome can cause dysfunction of the hand and forearm, particularly if fasciotomy is delayed. The posterior compartment contains only the triceps. The proximal half of the compartment contains the radial nerve, which passes through the radial nerve groove before transitioning to the anterior compartment [30].

Forearm (antebrachium) — The forearm has three compartments (dorsal, volar, mobile wad) that are separated by fascia and the interosseous septum (figure 3). The dorsal and volar compartments are divided into superficial and deep subcompartments.

The volar compartment occupies more than one half of the transverse diameter of the forearm and is separated from the dorsal compartment by the tight interosseous membrane. Many muscles are present in the volar compartment, in addition to the median and ulnar nerves.

The dorsal compartment contains the anconeus muscle in the proximal part, and some authors recognize it as an individual compartment.

The compartment of mobile wad contains the brachioradialis, extensor carpi radialis brevis, and extensor carpi radialis longus muscles. The compartment is named the mobile wad because these muscles move as a wad during the pronation and supination of the forearm. The mobile wad is separated from the volar and dorsal compartments by connective tissue septum, which is continuous from the forearm fascia [28]. Swelling of any muscle of the mobile wad can easily irritate the radial nerve.

Hand — The hand has a total of 11 compartments (thenar, hypothenar, adductor, 7 interosseous, carpal tunnel), excluding finger compartments (figure 4 and table 2). (See 'Fingers' below.)

There are seven compartments of the interosseous muscles, four of which are dorsal interosseous muscles and three of which are composed of palmar lateral interosseous muscles.

The carpel tunnel compartment consists of many tendons and the median nerve without any muscles (figure 5).

Fingers — Each finger has a compartment on the radial side and one on the ulnar side. There is no muscle in finger compartments, and the nerve and blood vessel are surrounded by the Cleland and Grayson ligaments (figure 6).

Since these ligamentous tissues are hard and poorly distensible, swelling of the fingers can easily induce occlusion of the digital artery, leading to ischemic necrosis of the finger.

PREPARATION — While upper extremity fasciotomy is typically performed in the operating room with the patient under general or regional anesthesia, at times, a critically ill patient with acute extremity compartment syndrome may be too unstable for transport. Under these circumstances, fasciotomy can be undertaken in the intensive care unit with local anesthesia and conscious sedation, as needed.

●Instrumentation – In most cases, the only instruments required to perform a fasciotomy are a scalpel for the skin incision, electrocautery for the skin incision and hemostasis, and scissors for the fasciotomy. The type of scissors depends upon the anatomic location. We use scissors with a dull apex to avoid injuring the tissues located beneath the fascia.

●Prophylactic antibiotics – Prior to fasciotomy, antibiotic prophylaxis to cover skin organisms is recommended, ideally one hour prior to the incision (table 3) [31]. (See "Overview of control measures for prevention of surgical site infection in adults".)

●Antithrombotic therapy – Platelet count, prothrombin time, and partial thromboplastin time are typically obtained to evaluate blood coagulation function. If any of these values are abnormal, and the cause not known, it may be necessary to consult with a specialist before proceeding with surgery, provided it will not cause an undue delay. Similar with the lower extremity, upper extremity fasciotomy can generally be performed safely in the face of known antithrombotic therapy. (See "Lower extremity fasciotomy techniques", section on 'Preparation' and "Patient management following extremity fasciotomy", section on 'Role of anticoagulation'.)

OPEN FASCIOTOMY TECHNIQUES — For acute extremity compartment syndrome, fasciotomy is conducted under direct observation. The skin incision is placed overlying the swollen muscles where the fascia is tense. By incising the fascia, the compartment will be decompressed, and the muscles in the compartment will be seen to bulge outward. The different incisions used to release the forearm, hand, and finger compartments are presented below. (See 'Shoulder/brachium fasciotomy' below and 'Forearm fasciotomy' below and 'Hand fasciotomy' below and 'Digit fasciotomy' below.)

Clinical symptoms and pressure assessments may be used to indicate the use of fasciotomy [32]. Although unnecessary fasciotomies should be avoided, surgeons must be cautious to minimize the risk for a missed compartment and the potentially severe sequelae. Thus, we recommend that surgeons perform concomitant release of upper extremity compartment(s) adjacent one that meets criteria for decompression. Muscle cells in the neighboring compartment can be injured to the same extent, which can lead to subsequent neighboring compartment syndrome. Compartments in the fingers are an exception because each compartment is isolated and does not include muscle as a source of future swelling.

Decompression of muscle compartments may release products of cellular breakdown if significant myonecrosis has occurred, which manifests clinically as acidosis and hyperkalemia. In the operating room, it is prudent to forewarn the anesthesia team of the expected severity and timing of reperfusion, so that the patient can be monitored and intravascular volume optimized. Mannitol has been used to treat crush injury, and some have speculated that it may also be an effective adjunct treatment to minimize the consequences of compartment syndrome [3]. Hypertonic mannitol has been shown to reduce compartment pressures in an animal model, and in a small study of patients undergoing revascularization for acute ischemia [33,34]. (See "Crush-related acute kidney injury", section on 'Use of mannitol'.)

After the fasciotomy, the color of the muscle may continue to appear pale. This is especially true with ischemic etiologies, for which swelling of the muscle tends to become severe. In these cases, an additional incision may be needed in the epimysium covering the muscle [35].

The skin incision is left open for ease of postoperative follow-up to evaluate muscle viability. Moreover, leaving the skin open prevents recurrent elevation in pressure that occurs for several days after fasciotomy. (See 'Wound management' below.)

However, the incision can be closed after carpal tunnel release since the carpel tunnel has no muscles that may swell after the fasciotomy, and there is little possibility of recurrent pressure increase. In addition, closure of the wound protects the median nerve located in the superficial layer of the compartment, which is vulnerable to drying out.

Shoulder/brachium fasciotomy — Both anterior and posterior incisions are typically used to release the shoulder compartment (figure 7). Skin incisions are created along the anterior and posterior edges of the deltoid muscle. Approximately 10 percent of cases of shoulder compartment syndrome are complicated by pectoralis compartment syndrome [36]. If a simultaneous release of the pectoralis compartment is required, a typical deltopectoral incision as an extension of the anterior incision position should be used [36].

The brachium compartment is released with one medial incision (figure 7). The skin incision line is placed just above the medial intermuscular septum. In neutral shoulder position, this is located on the medial aspect of the upper arm; when the shoulder is rotated externally, it is anteriorly located. From this incision, both compartments (anterior, posterior) can be decompressed by dissecting both fascia of biceps and triceps.

Forearm fasciotomy

●Volar release – Several approaches to volar fasciotomy are described. Extended incisions should not be orthogonal to the elbow flexion crease or wrist crease. The authors' preferred technique for volar release is using separated radial and ulnar incisions (figure 8 and picture 1). Fasciotomy should release the fascia of the superficial layer, the deep layer that contains the pronator quadratus, and the deep flexor compartment. From the separate radial skin incision, the dorsal compartment and the mobile extensor wad can also be released without the need for a dorsal incision. Using this approach, the surgeon should take care to prevent insufficient decompression, particularly in the volar deep compartment. Moreover, the superficial branch of the radial nerve is located just beneath the radial incision with this approach. Failure to protect it can easily cause an iatrogenic nerve injury to the nerve.

The gentle S-shaped incision on the volar side of the forearm is referred to as the volar incision (figure 8). The volar incision provides improved visibility of the compartment than a separated incision approach, particularly with respect to deep compartment anatomy. For this reason, the volar incision is the more popular approach for volar release, particularly among orthopedic surgeons. The incision starts 1 cm proximal to the medial condyle and curves medially, reaching the midline at the junction of the middle and distal third of the forearm. Some surgeons prefer a volar ulnar incision rather than the volar incision (figure 8). Visibility of the deep compartments with a volar ulnar incision is similar to that of a volar incision. With both volar and volar ulnar incisions, the distal incision can be extended to the hand; however, the incision that crosses the wrist may cause difficulty with wrist wound closure, which can expose the median nerve. When the incision is extended to the hand region or connected to the approach of the carpal tunnel release, the approach should be via the ulnar side of the palmaris longus tendon. This approach can help avoid the palmar cutaneous branch of the median nerve. The palmar branch of the median nerve exits from the median nerve, located beneath the forearm fascia.

●Dorsal release – A longitudinal incision dorsally beginning 3 to 4 cm distal to the lateral epicondyle and toward the Lister tubercle is used (figure 9). In the authors' separate approach described above, it is possible to decompress all compartments of the dorsal compartment and mobile wad in addition to part of the volar compartment with a volar radial incision.

●Mobile wad – Before making an incision, it is necessary to evaluate the need for decompression because the mobile wad may have been decompressed completely during decompression of the volar or dorsal compartment. If necessary, a skin incision may be made just above the compartment.

Hand fasciotomy — All seven interosseous and adductor compartments can be accessed from the dorsal side. The compartments containing the carpal tunnel, thenar, and hypothenar muscles are accessed from the volar side. The abductor is decompressed using a volar approach or, more commonly, with the dorsal approach as discussed below (figure 10).

●Dorsal approach to interosseous compartments and adductor compartments – Both the palmar and dorsal interosseous subcompartments are decompressed using the dorsal approach.

The first dorsal incision is placed over the dorsal side of the index metacarpal bone, and either side of the metacarpal should be dissected. The approach allows access to the fascia of the first and second dorsal interosseous, the adductor pollicis, and the first palmar interosseous muscles. Although the compartments of the volar interosseous muscle and dorsal interosseous muscle are separated, decompression of both the volar and the dorsal interosseous compartments is possible by approaching along the bone.

The second dorsal incision is centered over the dorsal side of the fourth metacarpal bone. This provides access to the third and fourth dorsal interosseous muscles and second and third palmar interosseous muscles.

●Thenar decompression – A longitudinal incision is made along the radial side of the thumb metacarpal bone.

●Hypothenar decompression – A longitudinal incision is made along the ulnar aspect of the little finger metacarpal bone.

●Carpal tunnel release – There are no muscles in this subcompartment, but an edematous change in compartment syndrome of the hands and forearms will increase the pressure of the carpal tunnel, which can injure the median nerve [37,38]. The incision is usually connected by a volar forearm incision, but this leaves the median nerve exposed after incision. The authors prefer to release the carpel tunnel through a separate incision from the forearm volar release, essentially the same approach as for open carpal tunnel release. (See "Surgery for carpal tunnel syndrome", section on 'Open technique'.)

The incision is made between the thenar and hypothenar muscles, starting at the level of Kaplan's cardinal line, slightly ulnar to the thenar crease, and extending proximally to a point distal on the distal wrist crease (figure 11). The transverse carpal ligament should be dissected from distal to proximal with protection of the median nerve. If further dissection proximally is necessary, the distal portion of the antebrachial fascia can be released using the carpal tunnel incision.

In the distal part of the forearm, the palmar branch of the median nerve exits from the median nerve, located beneath the forearm fascia. It should be protected because injury of the nerve sometimes causes neuroma formation and persistent pain. Once the carpal tunnel has been opened, the skin should be sutured closed to prevent the nerve from drying out.

Digit fasciotomy — Digital compartment decompression is conducted using a midaxial incision along the noncontact side of the finger to minimize potentially adverse effects to the sensibility of the digit: radial for index and thumb, ulnar for middle, ring, and little fingers (figure 12). Since the neurovascular bundles are covered with Cleland ligaments and Grayson ligaments, it is necessary to dissect either ligament with retracting the neurovascular bundles toward a volar direction. With this approach, the sheath of the flexor tendon can be decompressed concurrently.

ENDOSCOPIC FASCIOTOMY — For chronic exertional compartment syndrome (CECS), fasciotomy is usually performed endoscopically [39-43]. Endoscopic fasciotomy can be accomplished using a surgical scissor inserted in a small skin incision. The fascia is incised, decompressing the compartment. For the release of the volar compartment, a straight line connecting the midpoint of the wrist crease to the medial condyles is designed, and a small incision is made at the midpoint. An endoscope and scissors are inserted in both the distal and proximal directions to dissect the fascia. One report used a specialized device (Knifelight), which is a sharp blade illuminated by light, to dissect the fascia, instead of scissors [43]. Separation of subcutaneous tissue and fascia is done using a dissector.

The surgeon must avoid causing nerve damage during the operation (eg, palmar branch of the median nerve in the distal forearm, medial antebrachial nerve in the proximal forearm). Dorsal decompression is also possible. If there are any concerns during the procedure, switching to an open approach will ensure complete decompression and avoid nerve damage.

It is not necessary to leave the skin incision open with CECS for which the compartment pressure rises only during exercise; swelling of the muscle after fasciotomy is unlikely.

POSTOPERATIVE CARE

Extremity stabilization and mobilization — Postoperatively, the extremity should be splinted in a stable and functional position.

With compartment syndrome of the hand, it is sometimes necessary to fix in the intrinsic plus position (70 to 90º flexion position of the metacarpophalangeal joint) to prevent an extension contracture resulting in shortening of the collateral ligament (figure 13). The duration of fixation should be decided by the individual's condition. To prevent joint contractures, the joint, which does not need to be stabilized, should be mobilized with good pain control.

Early joint exercise is important to prevent dysfunction of the upper extremity. Since pain is much reduced in many cases after the fasciotomy, aggressive rehabilitation is often possible. Active and passive joint mobilization should be promoted with the assistance of an occupational or physical therapist. After closing the wound or after skin grafting, mobilization of the joints should be reinforced to prevent tendon adhesion and joint contracture.

Wound management — Following fasciotomy, the wounds are left open and covered with a dressing. The wound is reevaluated approximately every 48 hours in the operating room to perform debridement or wound closure, as indicated. If insufficient decompression of the compartment was found due to worsening edema, additional decompression is necessary [44]. (See "Patient management following extremity fasciotomy", section on 'Wound management'.)

The timing of fasciotomy wound closure depends on the condition of the patient. For severe upper extremity injuries, covering exposed neurovascular bundles, joints, and tendons should be prioritized. Also, if all the tissue cannot be covered because of the prolonged swelling, the flexion side should be closed first. Some authors have introduced the shoelace technique as a method of wound closure (picture 2) [45-48]. Tissue expansion devices for wound closure are also available [49,50]. If the wound closure is judged to be difficult, skin grafting may be necessary. (See "Skin autografting".)

Negative pressure wound therapy (NPWT) may reduce the need for secondary skin grafts and the duration of the treatment as has been demonstrated for the lower extremity [51-53]. In the upper extremity, one retrospective study demonstrated a higher rate of primary closure and shorter time to wound closure for patients treated with NPWT compared with those managed with conventional wet-to-dry dressing [53]. However, they could not demonstrate that it reduced the need for secondary skin grafts [53]. NPWT should be used for wounds without the exposure of nerves or arteries. Some surgeons recommend NPWT use with lower pressures to seal the dressing [54]. NPWT is also used to aid fixation of skin grafts. (See "Negative pressure wound therapy" and "Patient management following extremity fasciotomy", section on 'Negative pressure wound therapy' and "Skin autografting", section on 'Graft immobilization'.)

Hyperbaric oxygen therapy (HBO) may be an adjuvant therapy following compartment decompression. There are some reports that HBO reduces compartment pressure in animal models and human cases by increasing the dissolved oxygen in the blood [55,56]. We do not use HBO in this manner, preferring expedient fasciotomy when indicated; however, HBO can aid the demarcation of nonviable tissue in the postoperative fasciotomy wound. One review suggested 7 to 14 days of HBO as post-fasciotomy adjuvant therapy [57]. (See "Patient management following extremity fasciotomy", section on 'Wound management'.)

Treatment of patients with functional deficits is followed by subsequent reconstructive surgery. The surgeon needs to plan the reconstructive surgery based on observations of surgical findings in fasciotomy and following conditions of the wound. (See "Surgical reconstruction of the upper extremity".)

TECHNICAL COMPLICATIONS — Most fasciotomies are performed in cases of severe trauma that can also induce various complications. Therefore, it can be difficult to distinguish between complications caused by the fasciotomy and those caused by the initial trauma. Known problems related directly to upper extremity fasciotomy include the following:

●Nerve injury – Nerve injury was the most frequent complication in a review of forearm fasciotomy occurring in 18 percent of patients [58]. Forearm nerve injuries include injury to the medial antebrachial nerve in the proximal forearm and injury to the palmar branch of the median nerve in the distal forearm. Injury to the palmar branch of the median nerve is often overlooked because it manifests as numbness in a limited area of the hand, but it can lead to neuroma formation and persistent pain.

●Postoperative infection – Most postoperative infections can be prevented with timely administration of antibiotics and appropriate wound management. (See "Overview of control measures for prevention of surgical site infection in adults".)

In a retrospective analysis of 115 patients with forearm compartment syndrome, the 14 percent of patients who had fasciotomy had surgical site infection (SSI) [59]. The presence of diabetes or open fractures were significant predictors of SSI. Some surgeons also believe that delayed fasciotomy increases the risk of SSIs [54]. (See "Overview of control measures for prevention of surgical site infection in adults" and "Overview of the evaluation and management of surgical site infection".)

●Contractures – In cases where a skin graft is used to cover the wound after the fasciotomy, it often tethers tendons, possibly limiting motion of the joint [58].

In a systematic review of forearm compartment syndrome, other types of neurologic deficits, contractures, bone atrophy, and infections following the fasciotomy also occurred. In particular, neurologic deficit, complex regional pain syndrome, and Volkmann contracture due to muscle ischemia were reported, in addition to joint contracture [60].

OUTCOMES — The goal of fasciotomy is to prevent tissue necrosis and permanent upper extremity dysfunction. Severe complications can be avoided by early diagnosis and rapid fasciotomy (table 1).

Long-term sequelae of upper extremity fasciotomy are reported in only a few publications. In a retrospective review of acute pediatric compartment syndrome in the upper extremity, increased time to decompression was significantly associated with an increased risk for complications and the need for revision surgery [61]. Avoiding skin grafting may reduce the incidence of neurologic symptoms following fasciotomy. In a report on 60 patients who underwent fasciotomies (15 upper extremity) with an average follow-up of 59 months, 50 percent of the patients complained of chronic pain in the extremities, and 84 percent of the patients had some change in local sensation confined to the fasciotomy site, which is caused by irritation of the cutaneous nerves. This sensory change was more common after skin grafting than after primary closure, and 23 percent of patients complained about the appearance of the grafted lesion.

A common issue following upper extremity fasciotomy is unsatisfactory scarring (one fourth of patients in one pediatric review [62]). Skin grafting to achieve closure, which may be more common in pediatric populations, is associated with worsened scar appearance. Some patients may elect to undergo revisional surgery to improve appearance, which is accomplished in a manner similar to skin graft revisions following burn injury as discussed in the linked topic. (See "Overview of surgical procedures used in the management of burn injuries", section on 'Burn scar revision and timing'.)

Following fasciotomy for upper extremity chronic exertional compartment syndrome, more than 90 percent of patients returned to previous competition levels in three to six weeks, and there was little complaint of muscle bulging or pain due to fasciotomy [20,39-41].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Extremity compartment syndrome" and "Society guideline links: Severe blunt or penetrating extremity trauma".)

SUMMARY AND RECOMMENDATIONS

●Compartment syndrome – Compartment syndrome occurs when blood flow to the muscles and nerves is impaired as pressure in a muscle compartment increases (table 1). In the upper extremity, the forearm is the most common site, but the shoulder, brachium, or hand can also be affected. Acute compartment syndrome is often due to extremity trauma, acute limb ischemia, prolonged immobilization, or hematoma. Chronic exertional compartment syndrome can also occur, also most frequently affecting the forearm. (See 'Introduction' above.)

●Indications for upper extremity fasciotomy – Upper extremity fasciotomy is indicated for obvious clinical findings of acute compartment syndrome. Compartment pressure should be measured if there is any uncertainty, and fasciotomy should be performed if the pressure is greater than 30 mmHg, or lower than the diastolic blood pressure by 30 mmHg. Failure to recognize acute compartment syndrome and decompress the muscle compartments in a timely manner can compromise the extremity or lead to life-threatening complications. For cases of upper extremity ischemia (eg, acute embolism, replantation) for which the time until revascularization is over three hours, we perform prophylactic fasciotomy, rather than serial observation. Patients with chronic extremity compartment syndromes may also benefit from fasciotomy. (See 'Indications' above.)

●Upper extremity fasciotomy – Fasciotomy is a procedure in which an incision is made through the skin overlying a muscle compartment or group of compartments to expose and incise the fascia, thereby reducing the pressure.

•Compartment anatomy – Knowledge of upper extremity compartment anatomy is important to establish a diagnosis, ensure a complete fasciotomy, and decrease the potential for neurovascular complications. Compartmental regions include the shoulder and brachium, forearm, hand, and fingers. Each region also has small subcompartments. (See 'Compartment anatomy' above.)

•Open fasciotomy – The techniques for upper extremity fasciotomy are described above. For acute forearm compartment syndrome that requires release of the dorsal and volar compartments, we prefer separated volar incisions, rather than a single (classic S-shaped) volar incision. Using this approach, both the dorsal and mobile wad can also be released. However, this approach requires familiarity with the anatomy, particularly of the deep compartment. (See 'Open fasciotomy techniques' above.)

•Endoscopic fasciotomy – Fasciotomy is an effective treatment for patients with chronic exertional compartment syndrome. The techniques used to decompress the compartments are similar to those used for acute compartment syndrome, although compartments are selectively decompressed and minimally invasive techniques can be used. (See 'Endoscopic fasciotomy' above.)

●Postoperative care – Following open fasciotomy, wounds are left open and dressed with moist, saline-soaked gauze and lightly wrapped to maintain the dressings in place. Skin closure is delayed to allow frequent wound inspection and interval muscle debridement, as needed. If the wound cannot be closed primarily, skin grafting may be necessary. Appropriate upper extremity stabilization is important to prevent contracture. For hand compartment syndrome, splinting prevents contracture of the metacarpophalangeal joint. Mobilization is encouraged as soon as possible in consultation with physical or occupational therapists. (See 'Postoperative care' above.)

●Complications – Complications related to fasciotomy for acute compartment syndrome are most commonly a direct result of tissue ischemia caused by the increased compartment pressure. A delay in the diagnosis and treatment of acute compartment syndrome significantly increases morbidity and mortality following fasciotomy. Technical complications, including incomplete fasciotomy necessitating a return to the operating room, nerve injury, and muscle devascularization, can be minimized with meticulous surgical techniques. (See 'Technical complications' above and 'Outcomes' above.)

ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Jennifer M Sterbenz, BS, and You Jeong Kim, BS, who contributed to an earlier version of this topic review.