Lower extremity fasciotomy techniques

INTRODUCTION — Extremity fasciotomy is the only recognized treatment for acute compartment syndrome. The leg is the most frequently affected site in the lower extremity requiring fasciotomy [1,2]. Although less common, acute compartment syndrome can occur in the thigh, buttock, and foot [3-7]. In addition, patients who suffer from chronic compartment lower extremity syndromes may also benefit from fasciotomy.

For acute compartment syndrome, failure to recognize and decompress the muscular compartments in a timely fashion can compromise the extremity or the patient's life. The indications for and techniques of lower extremity fasciotomy for emergent fasciotomy of the leg, thigh, buttock, and foot will be reviewed here. Alternative techniques for chronic compartment syndromes are briefly discussed. Patient management following fasciotomy, including wound care, is discussed elsewhere. (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 — Any pathologic process that results in increased pressure within a muscular compartment that exceeds the perfusion pressure of the tissue has the potential to cause compartment syndrome and extremity ischemia. These etiologies are discussed elsewhere. (See "Pathophysiology, classification, and causes of acute extremity compartment syndrome".)

Acute compartment syndrome — Fasciotomy is indicated for clinical evidence of acute compartment syndrome (impending or established) that may be supported by objective evidence of elevated compartment pressure in some cases (table 1). The pathophysiology and classification of acute extremity compartment syndrome, as well as clinical features and diagnosis of acute compartment syndrome, including measurement of compartment pressure, are discussed elsewhere. (See "Acute compartment syndrome of the extremities" and "Pathophysiology, classification, and causes of acute extremity compartment syndrome", section on 'Classification'.)

Impending — With impending compartment syndrome, symptoms may not be classic and compartment pressure may not meet criteria for acute compartment syndrome, but there is a high probability of a compartment syndrome evolving over time. Fasciotomy is performed earlier in the course in this population based on the clinical judgment that a compartment is highly likely to develop. Fasciotomy should be performed immediately upon worsening of the symptoms among those in whom careful monitoring has been elected.

Established — For early established acute compartment syndrome, the following indicate the need for fasciotomy [8,9]:

●Obvious clinical diagnosis of acute lower extremity acute compartment syndrome.

●Elevated compartment pressure: >30 mmHg or 30 mmHg below diastolic blood pressure. Using the diastolic blood pressure as a reference point for compartment pressures may provide increased diagnostic accuracy for the diagnosis of established acute compartment syndrome. A compartment less than 30 mmHg below diastolic blood pressure is an indication for fasciotomy [10-12]. As an example, for a patient with a systemic blood pressure of 100/70 mmHg, a compartment pressure exceeding 40 mmHg is indicative of an established acute compartment syndrome. (See "Acute compartment syndrome of the extremities".).

Patients with late established acute compartment syndrome 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. In some cases, however, late intervention may serve a purpose by debriding necrotic tissue and preventing the contracture of the joints. (See 'Contraindications' below.)

Prevention — In many patients without the above indications for fasciotomy, progression will not occur and fasciotomy will not be needed. Ideally, careful clinical assessment and compartment pressure monitoring will indicate progression and the need for fasciotomy in the patient at risk for but without impending or established compartment syndrome. However, monitoring for a compartment syndrome is resource intensive and requires skilled clinicians in a monitored or intensive care setting. Nursing staff should not be relied upon to recognize acute compartment syndrome. Moreover, when a compartment syndrome is diagnosed, it can take some time to get a patient into an open, staffed operating room in many centers. Thus, in selected cases it may be better to perform a "prophylactic" fasciotomy if there is a high risk of progression to acute compartment syndrome, rather than taking the risk of delayed diagnosis or surgical delay once acute compartment syndrome has become established. Whether complications are reduced or outcomes are improved for prophylactic fasciotomy compared with waiting until a compartment syndrome is definitively diagnosed is debated. (See 'Outcomes' below.)

Prophylactic fasciotomy should be considered prior to the development of elevated compartment pressure in patients undergoing certain vascular or orthopedic procedures in which a significant increase in extremity swelling, especially muscle swelling, is probable. Prophylactic fasciotomy is most often performed as an adjunct to another operation when there is no ability to examine the patient (since the patient is under general anesthesia), and for those at high risk for developing acute compartment syndrome in the postoperative period. In such cases, prophylactic fasciotomy should be performed in conjunction with the index operation, which prevents the need to return to the operating room. The techniques for prophylactic fasciotomy are the same as for emergent fasciotomy. (See 'Open fasciotomy' below.)

The need to perform prophylactic fasciotomy is not always easily defined in vascular patients because of potential problems with subsequent wound healing, or in orthopedic patients with hardware-related issues.

For vascular procedures, prophylactic fasciotomy may be indicated for patients when [13]:

●Ischemic time is prolonged (eg, prolonged clamp time), but the severity of ischemia is probably a more important factor.

●Acute arterial occlusion is sudden in onset and collateral flow is not sufficient (eg, thromboembolism).

●Combined arterial and venous injuries are present as seen in traumatic injuries.

For orthopedic procedures, prophylactic fasciotomy may be indicated for patients with [14-17]:

●Comminuted fractures

●Tibial fractures, especially those involving the diaphysis

●Fractures associated with arterial injury

The timely recognition of a postoperative acute compartment syndrome is predicated on the ability to perform serial examinations on a responsive, neurologically intact patient. Thus, prophylactic fasciotomy may be more appropriate in patients at risk for compartment syndrome but for whom a reliable clinical examination (altered mental status, neurologic deficit) cannot be performed.

Chronic exertional compartment syndrome — Patients with chronic compartment syndromes (chronic anterior compartment syndrome, chronic exertional compartment syndrome) who fail conservative management or are unable to curtail their athletic activities may benefit from fasciotomy. The clinical features and compartment pressure criteria for the diagnosis of chronic compartment syndromes are discussed elsewhere. (See "Chronic exertional compartment syndrome", section on 'Clinical features' and "Chronic exertional compartment syndrome", section on 'Compartment pressure measurement'.)

Contraindications — Fasciotomy is contraindicated when the extremity is nonviable either due to multiple injuries or due to severe tissue ischemia. The duration of ischemia is often unknown and is unreliable for judging the degree of ischemia. Waxing and waning perfusion/hypoperfusion may have a worse prognosis compared with sudden complete hypoperfusion. Grade III extremity ischemia (irreversible) is generally a contraindication to revascularization and is clinically evident as a cold extremity with muscle rigor, complete neurologic deficit, and no audible Doppler signals. (See "Clinical features and diagnosis of acute lower extremity ischemia", section on 'Clinical presentations' and "Severe lower extremity injury in the adult patient", section on 'Predicting limb loss'.)

Crush injuries involving large muscle groups (eg, buttock, thigh) may be prone to life-threatening complications from reperfusion [18]. The magnitude of the reperfusion insult may be so severe that sudden cardiac arrest can occur as a consequence. To avoid this outcome, some authors have advocated primary amputation if profound ischemia is present for greater than 10 hours in a patient with limited collaterals. The rationale for this seemingly radical approach is based upon the potential for life-threatening complications, coupled with a low potential for functional recovery after prolonged, profound ischemia [19]. (See "Patient management following extremity fasciotomy", section on 'Ischemia-reperfusion' and "Severe lower extremity injury in the adult patient".)

COMPARTMENT ANATOMY — The relationship of compartment anatomy to clinical symptoms is discussed elsewhere. (See "Acute compartment syndrome of the extremities", section on 'Anatomic compartments and related clinical signs'.)

The various muscle compartments of the lower extremity, including the muscles and neurovascular structures contained within, are presented below.

Thigh — The thigh has three muscle compartments (ie, anterior, posterior, and medial) (figure 1) [6].

●Anterior compartment – Sartorius and quadriceps muscles (rectus femoris, vastus lateralis, vastus intermedius, vastus medialis). The femoral nerve and superficial femoral artery supply these muscles.

●Medial compartment – Pectineus, obturator externus, gracilis, and adductor muscles (longus, brevis, magnus, minimus). The obturator nerve innervates the medial compartment.

●Posterior compartment – Biceps femoris, semimembranous, and semitendinous muscles. The sciatic nerve innervates the posterior compartment. The deep femoral artery supplies the posterior compartment.

Leg — The leg has four muscle compartments (ie, anterior, lateral, superficial posterior, deep posterior) (figure 2). Anatomy to these compartments can vary [20-23].

●Anterior compartment – Tibialis anterior, extensor muscles of the foot, and peroneus tertius muscles. The anterior tibial artery and deep peroneal nerve supply the anterior compartment.

●Lateral compartment – Peroneus longus and peroneus brevis muscles. The superficial peroneal nerve and branches from the anterior tibial artery supply these muscles.

●Superficial posterior compartment – Gastrocnemius, soleus, and plantaris muscles. Tibial nerve branches supply these muscles. The arteries that supply these muscles descend from the popliteal artery. The sural arteries (medial, lateral) supply the gastrocnemius. The soleus is variably supplied by the popliteal artery, posterior tibial artery, and peroneal artery.

●Deep posterior compartment – Tibialis posterior, flexor muscles of the foot, and popliteus muscles. The deep posterior compartment is innervated by the tibial nerve and supplied by the posterior tibial and peroneal arteries [21].

Superficial peroneal nerve — The superficial peroneal nerve is the most commonly injured nerve during fasciotomy of the leg, and knowledge of its normal and variant anatomy is important to prevent injury during anterior and lateral compartment fasciotomy [24]. (See 'Leg fasciotomy' below.)

The superficial peroneal nerve branches from the common peroneal nerve at or below the proximal fibular head. The nerve descends in its "normal" course in the lateral compartment adjacent to the intermuscular septum of the anterior and lateral compartments (figure 3) [25]. Between 27 and 43 percent of patients have the superficial peroneal nerve in either the anterior compartment or both the anterior and the lateral compartment of the leg [22]. The superficial peroneal nerve has also been found to run within the septum that separates the anterior from the lateral compartment [23].

Buttock — The buttock is composed of three major muscles, each within its own compartment.

●Gluteus maximus muscle – This muscle extends from the proximal ilium to the proximal posterior femur along the iliotibial tract and is supplied by branches of the superior and inferior gluteal arteries and the inferior gluteal nerve.

●Gluteus medius muscle – This muscle arises from the ilium and extends to the greater trochanter. It is supplied by the superior gluteal artery and nerve.

●Gluteus minimus muscle – This follows a course similar to the gluteus medius muscle and shares its innervations and arterial inflow with the gluteus medius.

Foot — Currently, there is no agreement on the number of compartments of the foot [26]. The foot compartments include the medial, lateral, superficial, calcaneal (ie, central), and interosseous (ie, intrinsic) muscle compartments (figure 4). The medial and lateral plantar neurovascular bundles run along the longitudinal axis of the foot, and care must be taken not to inadvertently cause injury. The muscles contained within these compartments are as follows [27]:

●Medial – Abductor hallucis and flexor hallucis brevis muscles

●Lateral – Flexor digiti minimi and abductor digiti quinti

●Superficial – Flexor digitorum brevis, lumbricals, flexor digitorum longus tendons

●Calcaneal – Flexor digitorum brevis, quadratus plantae, and adductor hallucis

●Interosseous – Interosseus muscles, each in its own compartment

PREPARATION — Lower extremity fasciotomy is usually performed in the operating room with the patient under general or regional anesthesia. However, at times, a critically ill patient may be too unstable for transportation. Under these circumstances, fasciotomy can be undertaken in the intensive care unit with local anesthesia and conscious sedation as tolerated.

●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. For lower leg fasciotomy, a pair of large, blunt-tipped scissors (eg, Cooley or Metzenbaum) is ideal. Releasing compartments in the foot requires greater precision and a finer pair of scissors (eg, Jameson, Iris).

●Prophylactic antibiotics – Prior to fasciotomy, we recommend antibiotic prophylaxis to cover skin organisms, ideally one hour prior to the incision (table 2) [28]. (See "Overview of control measures for prevention of surgical site infection in adults".)

One trial evaluated the use of antibiotics in 100 patients prior to leg fasciotomy. Patients were randomly assigned to receive a single preoperative dose of 200 mg ciprofloxacin or no antibiotics [29]. The incidence of wound infection was significantly reduced in the group that received antibiotic prophylaxis (2.2 versus 12.9 percent). Prophylactic antibiotics are especially important since the risk of wound infection may be as high as 17 percent with patients who have trauma or burns at the highest risk of fasciotomy wound infection [30].

●Antithrombotic therapy – Fasciotomy can be performed safely in the face of antithrombotic therapy, although meticulous attention to technique and hemostasis are needed to minimize perioperative bleeding. Antiplatelet agents pose no contraindication to fasciotomy and may be beneficial in limiting thrombosis of the microcirculation. Among patients with vascular etiologies for acute compartment syndrome who are anticoagulated, it is preferable to continue therapy. (See "Patient management following extremity fasciotomy", section on 'Role of anticoagulation'.)

In contrast, patients with an orthopedic etiology for the acute compartment syndrome or patients with multiple injures may have a greater risk of bleeding. Thus, the maintenance or discontinuation of antithrombotic therapy prior to fasciotomy should be individualized.

OPEN FASCIOTOMY — The nature of the fasciotomy technique depends upon the underlying condition or mechanism that precipitated the compartment syndrome. The discussion that follows will focus primarily on the treatment of acute compartment syndrome. Prophylactic fasciotomy is performed using the same techniques. Alternative considerations for elective fasciotomy are discussed below. (See 'Alternative fasciotomy techniques for CECS' below.)

General issues

Incision length — There is currently little consensus over what constitutes best practice for performing emergent lower extremity fasciotomy [31]. The available evidence comes from case series and retrospective reviews. It is our preference to manage acute compartment syndrome aggressively with techniques that include the use of generous skin incisions that are left open, generous fascial incisions, and opening any compartment affected by or at risk for developing compartment syndrome. Although it is tempting to limit the number of compartments to those with obviously elevated pressure, we advise fasciotomy on any muscle compartment within the zone of maximal ischemia or injury. One potential exception to this guideline relates to fasciotomy of the thigh, which is discussed below. (See 'Thigh fasciotomy' below.)

The length of the lower extremity skin incisions for emergent fasciotomy has been the focus of considerable debate. Some surgeons use minimal skin incisions with more extensive fascial incisions when profound muscle swelling is not anticipated. However, this approach places the patient at risk for recurrent compartment syndrome. The degree of muscle swelling following reperfusion is due to many factors and may not be predictable at the time of surgery. Peak muscle edema following decompressive fasciotomy may not be fully evident for many hours after surgery.

One retrospective study observed that 12 percent of lower extremity fasciotomies performed with minimal incisions required reoperation to achieve complete decompression of the compartments [32]. Decreased compliance of the overlying stretched skin can maintain elevated compartment pressures. In a study of eight trauma patients, compartment pressures were measured while performing four-compartment leg fasciotomy [33]. The initial 8 cm skin incision reduced compartment pressure from an average of 48 to 25 mmHg. However, one third of the compartments treated had residually elevated pressures. Extension of the incisions to achieve an average 16 cm incision length resulted in a reduction of the compartment pressures to an average level of 13 mmHg [34].

Ischemia-reperfusion — As each muscle compartment is opened, discoloration of the muscle, which may be focal or complete, confirms the presence of significant ischemia. Once a fascial compartment is released, increased perfusion of the muscle should improve its color. The local response to reperfusion leads to extremity swelling that frequently complicates wound management. (See "Patient management following extremity fasciotomy", section on 'Wound management'.)

Decompression of muscle compartments may liberate products of cellular breakdown if significant myonecrosis has occurred. Ischemia-reperfusion manifests clinically as acidosis and hyperkalemia. Metabolic acidosis from liberation of lactate may produce myocardial depression and hypotension, which is usually transient, but more persistent acidosis can occur. Release of potassium from necrotic and injured muscle may lead to significant hyperkalemia, which requires urgent treatment. In the operating room, it is prudent to forewarn the anesthesia team of the expected severity and timing of reperfusion, so that the patient is monitored and treated appropriately. Preemptive volume resuscitation and intravenous calcium may blunt the deleterious effects of acid and potassium, respectively, which are liberated during reperfusion.

Wound care — Following fasciotomy, the skin is left open and the wounds are dressed with moist saline gauze and wrapped with a loose bandage to maintain the dressings in place. The goals of postoperative wound management include prevention of tissue desiccation and identification and debridement of nonviable muscle. Closure of the skin is performed at an interval with skin closure or skin grafting. Wound management and the timing of skin closure are discussed in detail elsewhere. (See "Patient management following extremity fasciotomy", section on 'Wound management'.)

Leg fasciotomy — Although the anterior compartment of the leg is the most susceptible of the leg compartments to compartment syndrome, each of the four compartments of the leg should always be decompressed during emergent fasciotomy. Both double-incision and single-incision techniques for leg fasciotomy have been described [35,36]. There are no randomized trials to support one approach over the other, and retrospective studies have found no significant differences in overall outcomes between these two techniques. The double-incision fasciotomy is preferred by most surgeons due to its simplicity and improved exposure [35].

Double-incision fasciotomy — The two-incision four-compartment fasciotomy uses medial and lateral longitudinal incisions that should be at least 12 to 20 cm in length.

The lateral incision of the double-incision fasciotomy is centered between the fibular shaft and the crest of the tibia (figure 5). In this location, the incision overlies the intermuscular septum between the anterior and lateral compartments. In normal-weight patients, this septum is palpable as a subtle indentation approximately 4 to 5 cm lateral to the tibia. After the lateral incision has been made, skin and subcutaneous flaps are developed medially and laterally to expose the fascia of the intermuscular septum and the fascia of the anterior and lateral compartments (figure 6). The intermuscular septum must be identified to ensure that both the anterior and lateral compartments are decompressed. The anterior compartment fascia is incised (electrocautery or scalpel). The fascial incisions are extended proximally and distally using scissors (eg, Metzenbaum, Cooley), taking care to sufficiently elevate the posterior blade of the scissors off the muscle to avoid cutting muscle-associated nerves. Once the anterior compartment is decompressed, the procedure is performed on the lateral compartment. Extension of the anterior or lateral fascial incisions too proximally can injure the common peroneal nerve or its superficial and deep branches. Termination of the proximal extent of the fasciotomy at a point 4 to 5 cm distal to the fibular head minimizes the risk of a nerve injury.

The medial incision of the double-incision fasciotomy is placed 1 to 2 cm medial to the tibial margin in a position similar to that used to expose the infrageniculate popliteal artery (figure 5). The distal extent of the medial incision should be based on the extent of muscle swelling. In cases in which there is profound swelling, the incision should extend at least two thirds of the distance to the medial malleolus. The saphenous vein and nerve should be identified and retracted to avoid injury. Failure to identify the vein and nerve is a frequent cause of injury to these structures. The superficial posterior compartment is decompressed by incising the gastrocnemius fascia in a longitudinal direction from proximal to distal (figure 6). The deep posterior compartment is decompressed by dividing the attachments of the soleus muscle to the tibia.

Single-incision fasciotomy — The single-incision four-compartment fasciotomy is technically more challenging but offers the obvious advantage of one incision [36]. The disadvantage of this approach is the difficulty visualizing the deep posterior compartment and, therefore, an increased risk of injury to the peroneal artery and nerve. Most surgeons find the double-incision technique simpler, more expeditious, and a safer method to decompress the leg. (See 'Double-incision fasciotomy' above.)

The single-incision technique uses a generous lateral leg incision 1 cm anterior to the fibula and parallel to it, extending from just inferior to the head of the fibula to 3 to 4 cm proximal to the lateral malleolus (figure 5). Extensive anterior flaps are created to expose the anterior and lateral compartments (figure 7). As with the double-incision technique, longitudinal incisions are made in the fascia of the anterior and lateral compartments, taking care to avoid injury to the common, superficial, and deep peroneal nerves near the fibular head.

The lateral flap is extended posteriorly to expose the superficial posterior compartment (figure 7). Once the gastrocnemius is identified, its fascia is incised longitudinally. The deep posterior compartment is accessed in a plane developed between the lateral and superficial posterior compartment, which exposes the posterior margin of the fibula (figure 7). The soleus is dissected from the posterior aspect of the fibula, beginning distally where the gastrocnemius and soleus muscles are more tendinous. During the peri-fibular dissection, the peroneal vessels should be retracted posteriorly to avoid injury.

Fibulectomy is no longer advocated because it unnecessarily risks injury to the peroneal artery and nerve [14]. However, some surgeons find that the deep posterior compartment is more easily decompressed by removal of the fibula when it is already fractured and displaced. When performing single-incision fasciotomy, it is argued that the fascia of the posterior tibial muscle should be decompressed separately; however, this is controversial [20].

Thigh fasciotomy — Thigh compartment syndrome is an uncommon clinical entity. Crush injuries and blunt trauma with femur fracture are the most common mechanisms associated with thigh compartment syndromes [3,6]. The mechanism of injury required to cause a thigh compartment syndrome places the patient at risk for "crush syndrome" and its complications, including acute kidney injury due to myoglobinuria. In a series of 17 patients with thigh compartment syndrome, "crush syndrome" with myoglobinuria and renal failure developed in nearly one-half of the patients [37]. The presence of a thigh compartment syndrome warrants careful monitoring for myoglobinuria and aggressive treatment to blunt the nephrotoxic effects. The anterior and posterior compartments of the thigh (figure 8) are more susceptible to acute compartment syndrome than the medial compartment. (See 'Ischemia-reperfusion' above.)

A single, generous lateral incision is made that originates from a point just distal to the intertrochanteric line and extended to the lateral epicondyle of the femur [6]. Through this incision, the iliotibial band and fascia of the vastus lateralis are incised the full length of the skin incision to decompress the anterior compartment. The posterior compartment is decompressed by reflecting the vastus lateralis muscle medially to expose the lateral intermuscular septum, which is incised the length of the skin incision.

Because the medial compartment of the thigh is less prone to acute compartment syndrome, the compartment pressure should be measured prior to undertaking medial compartment fasciotomy. A second incision overlying the adductor muscle group is used for medial thigh compartment decompression.

Buttock fasciotomy — Acute compartment syndrome of the buttocks can be a consequence of rupture of the superior gluteal or medial circumflex femoral arteries, pelvic fracture, hypogastric artery embolization, or prolonged immobilization (eg, intraoperative, unconsciousness due to overdose or intoxication) [38-40].

Each of the three fascial compartments of the buttock should be incised for full decompression. Although there is no accepted standard, the limited case series usually describe using longitudinal incisions. Some reports also describe performing neurolysis of the sciatic nerve as an adjunctive component of the operation to ensure that the nerve does not come under tension from inflammatory adhesions [38].

Foot fasciotomy — Acute compartment syndrome of the foot is typically due to crush injury. Foot fasciotomy can be performed through either a dorsal, lateral, or medial approach. Regardless of which technique is used, each of the muscle compartments should be opened to fully decompress the foot [7,41,42]. The dorsal approach is described below (figure 9).

Two or three incisions are needed for the dorsal approach. Two dorsal longitudinal incisions provide access to each of the foot compartments. The incisions are positioned medial to the second metatarsal bone and lateral to the fourth metatarsal bone. Each of the four sub-compartments of the interosseous compartment are opened between the metatarsal bones through the dorsal incisions. The calcaneal compartment, which lies beneath the metatarsals, is opened directly. The medial compartment may be accessed by dissecting medial to the second metatarsal. Alternatively, the medial compartment can be accessed through another incision along the medial foot, immediately posterior to the first metatarsal. The lateral compartment is decompressed through the lateral dorsal incision.

ALTERNATIVE FASCIOTOMY TECHNIQUES FOR CECS — Chronic exertional compartment syndrome (CECS) is a condition that affects typically young, athletic patients. It is manifested by pain overlying the affected muscle compartment during exercise. Most commonly, the anterior compartment is affected, with pain beginning 20 to 30 minutes after exercise is initiated and ceasing after 15 to 30 minutes of rest [43]. Paresthesias in the cutaneous distribution of the nerves that traverse the affected compartment may be present. Diagnosis requires measurement of compartment pressures with criteria proposed by Pedowitz that include [44]:

●Pre-exercise pressure ≥15 mmHg

●1 minute postexercise pressure of ≥30 mmHg

●5 minute postexercise pressure ≥20 mmHg

The presence of typical symptoms with any of these compartment pressure criteria is sufficient to indicate the need for fasciotomy. (See "Chronic exertional compartment syndrome".)

The surgical techniques used for the management of chronic compartment syndrome differ somewhat compared with those used in the treatment of acute compartment syndrome. Both subcutaneous fasciotomy and fasciectomy have been used to open these compartments. Rather than opening all compartments, only those compartments with symptoms are treated. In most cases, symptoms affect the anterior and lateral compartments, and thus, treatment is targeted to these compartments. In a systematic review, two-compartment fasciotomy was equally effective compared with four-compartment fasciotomy for relieving symptoms [45].

In addition, minimally invasive techniques may be appropriate [46,47]. Endoscopic-assisted compartment release has been advocated especially in young athletes with CECS. In addition to being less invasive compared with open fasciotomy, the superficial peroneal nerve can be directly seen and injury to it avoided (see 'Neurovascular injury' below). A small retrospective case series reported superior patient satisfaction with the endoscopic-assisted fasciotomy compared with open fasciotomy [48].

The techniques are as follows:

●Fasciotomy – Subcutaneous fasciotomy of the anterior and lateral compartments is performed using two skin incisions overlying the anterolateral lower leg (figure 10) [49]. These incisions are oriented strategically at the proximal and distal ends of the planned fasciotomies in the anterior and lateral compartments. Using the two skin incisions, the anterior and lateral compartments are identified, and blunt-tipped (Cooley or Metzenbaum) scissors are used to extend the fascial incisions between the two skin incisions.

●Fasciectomy – Fasciectomy is performed through a lateral longitudinal skin incision overlying the intermuscular septum between the anterior and lateral compartments (figure 10). Using this incision, standard fasciotomies of the anterior and lateral compartments are first performed as described above for the double-incision fasciotomy. In addition, an ellipse of fascia is resected ("fasciectomy"), preserving the fascia overlying the intermuscular septum (figure 10). Based on a series of nearly 800 patients treated with these approaches, one author has advocated fasciectomy to ensure more complete fascial release for patients with CECS [50].

TECHNICAL COMPLICATIONS — The majority of complications associated with fasciotomy are due to the underlying condition or injury that resulted in the need for compartment decompression or are a result of tissue ischemia and reperfusion injury. However, technical errors occurring during the fasciotomy procedure and the open fasciotomy wounds can be a source of morbidity. Complications associated with the technical aspects of lower extremity fasciotomy are discussed below. Other associated complications are discussed elsewhere. (See "Patient management following extremity fasciotomy", section on 'Complications'.)

Incomplete fasciotomy — Incomplete fasciotomy occurs when the fascial incisions are not adequate to permit complete decompression of the compartment. In one study, recurrent compartment syndrome due to incomplete fasciotomy was reported in 13 percent of patients undergoing leg fasciotomy [32]. Generous skin and fascial openings (12 to 20 cm) are needed to fully decompress the leg [32-34]. (See 'Open fasciotomy' above.)

Incomplete fasciotomy may result from two distinct technical errors. Either a compartment is inadequately decompressed, or it was not opened because the operating surgeon elected to forego fasciotomy of certain compartments based upon a perception that these compartments were at low risk for developing a compartment syndrome. As an example, a decision to perform a fasciotomy on the anterior and lateral compartments of the leg may be based upon elevated compartment pressures, but the posterior compartments are spared due to lower pressure measurements. The danger of this approach lies in an inability to predict the evolution of muscle swelling and therefore compartment pressures in the compartments that have not been decompressed. (See "Patient management following extremity fasciotomy", section on 'Ischemia-reperfusion'.)

In other cases, the failure to decompress a muscle compartment may be unintentional. As an example, two parallel fasciotomies may have been performed within the same compartment, such as the anterior compartment of the lower leg, rather than in adjacent anterior and lateral compartments as intended. This technical error typically occurs because the intermuscular septum between the anterior and lateral compartments had not been identified at the time of the initial fasciotomy. With leg fasciotomies, one study found that the anterior and deep posterior compartments were the most likely to be unopened [2].

Neurovascular injury — Injuries to arteries and nerves due to technical issues are specific to the fasciotomy site. In one study, injury to the superficial peroneal nerve occurred in 6 percent of patients undergoing emergent leg fasciotomy for trauma [51]. Neurovascular injury is avoided first by knowledge of the normal and variant anatomy (figure 3). (See 'Compartment anatomy' above.)

Peroneal nerve injury is generally due to failure to recognize the nerve as leg fascial incisions for the anterior or lateral compartments are extended proximally toward the fibular head. In this region, the common peroneal nerve and its immediate branches are at risk for injury (figure 3). The techniques described above can minimize the risk of peroneal nerve injury during fasciotomy. Namely, the lateral skin incision is best extended the full length of the fascial incisions, so the nerve underlying the fascia can be seen and protected. When the fasciotomy is performed beneath intact skin ("blindly"), the fascial incisions for the anterior and lateral compartments should be terminated 6 to 8 cm inferior to the fibular head, to avoid the peroneal nerve. The clinical manifestations of peroneal nerve injury (eg, foot drop) are discussed separately (See "Traumatic peripheral neuropathies", section on 'Peroneal neuropathies' and "Foot drop: Etiology, diagnosis, and treatment".)

The peroneal artery is at risk for injury with the single-incision technique for lower leg fasciotomy, particularly if a fibulectomy is performed. (See 'Single-incision fasciotomy' above.)

Neurovascular injuries are rare in performing thigh fasciotomies because these structures are located deep within the muscle compartments. During fasciotomy of the buttocks, the sciatic nerve must be carefully identified for the purposes of neurolysis, which prevents subsequent nerve entrapment.

Foot fasciotomy places the medial and lateral plantar neurovascular bundles at risk, and care must be taken to avoid their injury [52]. These structures are most commonly encountered with the medial foot incision.

Subcutaneous fasciotomy for chronic exertional compartment syndrome is often performed through two small incisions. The result is a relatively high rate (5 percent) of neurovascular injury [50]. In contrast, in one case series, fasciectomy was associated with no neurovascular injuries, which is likely related to the larger incisions and improved exposure with this approach [50]. (See 'Alternative fasciotomy techniques for CECS' above.)

OUTCOMES — The outcome for fasciotomy depends upon the underlying condition or mechanism that precipitated the compartment syndrome. The discussion that follows will focus on the outcomes for emergent fasciotomy. The prognosis of the treatment of chronic compartment syndrome is discussed elsewhere. (See "Chronic exertional compartment syndrome", section on 'Prognosis'.)

For acute lower extremity compartment syndrome, the site in the extremity, presence or absence of underlying vascular disease and time interval between the development of the condition, its recognition, and definitive treatment impact morbidity and mortality. Appropriately timed and properly performed fasciotomy does not eliminate the risk of developing chronic nerve or muscle dysfunction [27].

Functional outcomes may be worse for thigh fasciotomy compared with fasciotomy of the more distal extremity or foot. In one study that evaluated the long-term outcomes of 18 patients who underwent thigh fasciotomy, functional deficits were present in eight patients, and only five patients had full recovery of thigh-muscle strength [53]. Poor outcomes correlated with high injury severity scores, ipsilateral femoral fracture, prolonged time intervals to decompression, the presence of myonecrosis at the time of fasciotomy, and an age >30 years.

Consequences of a delayed fasciotomy — A delay in time interval between the development and diagnosis and treatment of acute compartment syndrome leads to worse outcomes. The overall complication rate in one study was 10 times higher if fasciotomy was delayed more than 12 hours compared with fasciotomy performed earlier [34]. In this series, the amputation rate for patients with a delay in treatment was 50 percent; normal limb function was observed in only 8 percent of patients compared with 68 percent in those who were treated within 12 hours [10,54].

In another series of patients sustaining extremity injury in combat, patients who had a delay in treatment had an increased need for operative muscle debridement (25 versus 11 percent), amputation (31 versus 15 percent), and mortality (19 versus 5 percent) compared with patients whose treatment was not delayed [2]. In addition, wound infection rates are increased when fasciotomy is delayed [1,55].

A retrospective review that compared outcomes of isolated versus multiple trauma patients (average injury severity score, 20.2) found that the time between admission and surgical treatment of compartment syndrome was longer in patients with who were multiply injured (38 versus 13 hours) [56]. At follow-up, 15 percent of patients complained of pain at rest and 27 percent reported pain on exertion. However, no differences were seen between the two groups with respect to pain or limb function as measured by isokinetic strength testing.

Prophylactic versus therapeutic fasciotomy — Many clinicians have assumed that a "prophylactic" fasciotomy performed on a limb in anticipation that a compartment syndrome will develop has a lower complication rate compared with "therapeutic" fasciotomies to treat a diagnosed acute compartment syndrome [13]. In one study of 100 patients, the overall complication rate was not significantly different for patients who underwent prophylactic fasciotomy compared with those who underwent therapeutic fasciotomy [1]. (See 'Prevention' above.)

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".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Acute compartment syndrome (The Basics)" and "Patient education: Chronic compartment syndrome (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Acute compartment syndrome is due to trauma, vascular occlusion, immobilization, or hematoma. Failure to recognize acute compartment syndrome and decompress the muscle compartments in a timely fashion can compromise the extremity or lead to life-threatening complications. In the lower extremity, the leg is the site most commonly in need of fasciotomy, but the thigh, buttock, or foot can also be affected. Patients who suffer from chronic compartment syndromes may also benefit from fasciotomy. (See 'Introduction' above and 'Indications' above.)

●Knowledge of lower extremity compartment anatomy and anatomic variation is important to ensure a complete fasciotomy and decrease the potential for neurovascular complications. In general, fasciotomy is accomplished by making a skin incision overlying a muscle compartment or group of compartments. The skin is reflected to expose the fascia of the compartment, and an incision is made in the fascia and extended longitudinally to fully open the fascia proximally and distally. (See 'Compartment anatomy' above and 'Open fasciotomy' above.)

●We recommend prophylactic antibiotics prior to lower extremity fasciotomy (Grade 1B). Although there is only one trial in this specific population, the incidence of surgical site infection is reduced with antibiotic prophylaxis for procedures that involve similar incisions. (See 'Preparation' above.)

●We suggest an aggressive fasciotomy technique to treat lower extremity acute compartment syndrome that includes generous (12 to 20 cm) incisions with complete opening of the skin rather than minimal skin incisions (Grade 2C). The use of minimal incisions is associated with recurrent compartment syndrome, which requires a return to the operating room and worsens extremity outcomes. (See 'Open fasciotomy' above and 'Incomplete fasciotomy' above.)

●We suggest opening each of the four compartments of the leg when performing leg fasciotomy for acute compartment syndrome rather than selective compartment decompression (Grade 2C). Either a one- or two-incision technique can be used provided each of the four compartments is adequately decompressed at the completion of the procedure. (See 'Leg fasciotomy' above.)

●We suggest opening all compartments of the buttock or foot if the clinical presentation suggests an acute compartment syndrome of these anatomic sites (Grade 2C). In contrast, thigh fasciotomy often requires only a single lateral incision to open the anterior and posterior compartment. Medial thigh fasciotomy may not be needed but should be performed if compartment pressures are elevated.

●We suggest not routinely performing prophylactic fasciotomy in anticipation of compartment syndrome (Grade 2C). Compartment pressures should be carefully monitored in patients at risk. However, patients undergoing certain orthopedic or vascular surgical procedures in which significant increases in extremity swelling are anticipated may benefit from prophylactic fasciotomy. (See 'Prevention' above.)

●Fasciotomy is an effective treatment for patients with chronic 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 'Alternative fasciotomy techniques for CECS' above.)

●Following surgical decompression, fasciotomy wounds are left open, 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. (See 'Wound care' above.)

●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. (See 'Technical complications' above and 'Outcomes' above.)

●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.)