Curr Trauma Rep (2015) 1:35–44

DOI 10.1007/s40719-014-0002-7

TRAUMA TO THE LOWER EXTREMITIES (H ALAM, SECTION EDITOR)

Lower Extremity Fasciotomy: Indications and Technique

Mark W. Bowyer

Published online: 25 December 2014

# Springer International Publishing AG (outside the USA) 2014

Abstract All clinicians caring for traumatically injured pa- identify and treat CS properly leads to tissue necrosis, perma-
tients must be able to recognize and treat (or refer for treatment) nent functional impairment, possible amputation, and poten-
compartment syndrome (CS) of the extremities. CS results tial renal failure and death [2, 7••, 8, 9•, 10–14]. Feliciano and
from a number of etiologies (traumatic and non-traumatic) with colleagues [15] reported that 75 % of amputations in a 9-year
the final common being ischemia and necrosis as a result of review of extremity trauma were related to a delay in
impaired arterial inflow due to increased compartmental pres- performing fasciotomy or an incomplete fasciotomy.
sures. Preventable morbidity and mortality results from failure Disability resulting from CS is significant [16–18], and
to identify and treat CS in a timely fashion and is a common failure to diagnose or properly treat a CS is one of the most
source of litigation. Successful treatment of CS requires prompt common causes of medical litigation, with significant malprac-
recognition and complete surgical release of the compartments tice liability [4, 7••]. Bhattacharyya and Vrahas [19] reported an
involved, and requires a thorough understanding of the relevant average indemnity payment of $426,000 in nine cases settled
anatomy. CS most commonly affects the lower extremity below between 1980 and 2003 in Massachusetts, and awards as high
the knee. This article will present the pathophysiology, epide- as $14.9 million have been made in cases of missed CS.
miology, diagnosis, relevant anatomy, and treatment of CS, The average number of fasciotomies reported in case logs
emphasizing the proper performance of a two incision four submitted to the American Board of Surgery for 2013 gradu-
compartment fasciotomy of the lower extremity. ates of US surgical residencies was 0.7 [20], and the average
number of fasciotomies reported by graduates of US vascular
Keywords Compartment syndrome . Fasciotomy . Two fellowships in the last decade has been between 0.8 and 2.0
incision four compartment fasciotomy . Lower leg fasciotomy per year [21]. As a result, otherwise well-trained surgeons are
ill prepared to recognize and manage CS and to perform
complete and adequate fasciotomies. Optimal outcomes result
from early recognition of CS and aggressive, properly per-
Introduction formed fasciotomy. Proper fasciotomy requires extensive
knowledge of the anatomical landmarks and anatomy of the
Compartment syndrome (CS) results when increased pressure compartments of the extremities.
within a limited space compromises the circulation and func- The goal of this article is to review the pathophysiology,
tion of affected tissues [1–6, 7••]. Arising from a wide variety epidemiology, diagnosis, relevant anatomy, and treatment of
of circumstances (Table 1), this condition is a limb and poten- CS with an emphasis on the proper performance of a two
tially life-threatening condition with which every surgeon incision four compartment fasciotomy of the lower leg.
should have intimate knowledge. The failure to promptly

This article is part of the Topical Collection on Trauma to the Lower

Extremities Pathophysiology

M. W. Bowyer (*)
Groups of muscles and their associated nerves and vessels are
The Norman M. Rich Department of Surgery, Uniformed Services
University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA surrounded by thick fascial layers that define the various
e-mail: mark.bowyer@usuhs.edu compartments of the extremities which are of relatively fixed
36 Curr Trauma Rep (2015) 1:35–44

Table 1 Factors implicated with the development of acute limb Epidemiology/Risk Factors
compartment syndrome [1, 8, 12, 23••]

Restriction of compartment size Increased compartment volume Given the consequences of missing a CS, it is important to
identify the population at risk. Trauma is the major cause of
From hemorrhage extremity CS requiring fasciotomy. In a 10-year retrospective
Fractures review of over 10,000 trauma patients sustaining extremity
Casts Vascular injury injury, Branco et al. described a fasciotomy rate of 2.8 % [9•].
Splints Drugs (anticoagulants) During this period, 315 fasciotomies were performed on 237
Burn eschar Hemophilia; Sickle cell patients with 68.4 % done below the knee, 14.4 % on the
Tourniquets From muscle edema/Swelling forearm, and 8.9 % on the thigh. In a review of 294 combat
Tight dressings Crush–trauma, drugs or alcohol injured soldiers undergoing 494 fasciotomies, Ritenour et al.
Fracture reduction Rhabdomyolysis/Blast injury reported the calf as the most common site (51 %) followed by
Closure of fascial defects Sepsis the forearm (22.3 %), thigh (8.3 %), upper arm (7.3 %), hand
Incomplete skin release Exercise induced (5.7 %), and the foot (4.8 %) [23••].
Military anti-shock trousers Envenomation or bee sting Branco et al. [9•] found that incidence of fasciotomy varied
Prolonged extrication trapped limb Massive resuscitation widely by mechanism of injury (0.9 % after motor vehicle
Localized external pressure Intracompartmental fluid infusion collision to 8.6 % after a gunshot wound). Additionally, the
Long leg brace Phlegmasia cerulea dolens need for fasciotomy was related to the type of injury ranging
Automated BP monitoring Electrical burns from 2.2 % incidence for patients with closed fractures up to
Malpositioning on OR table Reperfusion injury 41.8 % in patients with combined venous and arterial injuries.
Post partum eclampsia Young males, with penetrating or multi-system trauma, re-
quiring blood transfusion, with open fractures, elbow or knee
dislocations, or vascular injury (arterial, venous, or combined)
volume. CS occurs either when compartment size is restricted are at the highest risk of requiring a fasciotomy after extremity
or when compartment volume is increased. It is imperative trauma [9•].
that all clinicians be aware of the traumatic as well as numer-
ous non-traumatic causes (Table 1) of extremity CS, especially
sepsis, massive resuscitation, and reperfusion as the diagnosis
of CS in these settings is often delayed, as it is frequently not Diagnosis
considered by many otherwise well-trained physicians.
Cellular hypoxia is the final common pathway of all com- The diagnosis of CS depends on a high clinical suspicion and
partment syndromes. As ischemia continues, irreparable dam- an understanding of risk factors, pathophysiology, and subtle
age to tissue ensues and myoneural necrosis occurs. Develop- physical findings. Time to diagnosis and treatment is the most
ment of CS depends on many factors, including the duration important prognostic factors. Incomplete knowledge of the
of the pressure elevation, the metabolic rate of the tissues, natural history and signs and symptoms primarily account
vascular tone, associated soft tissue damage, and local blood for delays in diagnosis [7••, 14]. The aim is to recognize and
pressure [7••, 12]. Nerves demonstrate functional abnormali- treat raised intracompartmental pressure before irreversible
ties (paresthesias and hypoesthesia) within 30 min of ischemic cell damage occurs.
onset. Irreversible functional loss will occur after 12 to 24 h of Numerous authors have stated that the diagnosis of CS is a
total ischemia [1]. Muscle shows functional changes after 2 to clinical diagnosis [1, 6, 7••, 14, 24•]. The classically described
4 h of ischemia with irreversible loss of function beginning at five “Ps”, pain, pallor, paresthesias, paralysis, and
4 to 12 h [1]. Clinically, there is no precise pressure threshold pulselessness, are said to be pathognomonic of CS. However,
and duration above which significant damage is irreversible these are usually late signs and extensive and irreversible
and below which recovery is assured. damage may have taken place by the time they are manifested.
Tissue previously subjected to intervals of ischemia is espe- In the earliest stages of CS, patients may report some tingling
cially sensitive to increased pressure. Bernot and colleagues and an uncomfortable feeling in their extremity followed
[22] showed that tissue compromised by ischemia prior to an closely by pain with passive stretching of the muscles of the
elevated compartment pressure has a lower threshold for met- affected compartment. The most important symptom of CS is
abolic deterioration and irreversible damage. Polytrauma or pain greater than expected due to the injury alone. Wide
otherwise critically ill patients with low blood pressures can consensus in the literature suggests that the clinical features
sustain irreversible injury at lower compartment pressures than of CS are more useful by their absence in excluding the
patients with normal blood pressures, and a very high index of diagnosis, than when they are present in confirming the
suspicion should be maintained in this group. diagnosis.
Curr Trauma Rep (2015) 1:35–44 37

Nerve tissue is affected first by the subsequent hypoxia Treatment

causing pain on passive motion seen early in the development
of CS, sparing distal pulses until late in the course [24•]. The The definitive treatment of CS is early and aggressive
loss of pulse is a late finding, and the presence of pulses and fasciotomy. In patients with vascular injury in whom a
normal capillary refill do not rule-out CS. The presence of fasciotomy in conjunction with a vascular repair is planned,
open wounds does not exclude CS. In fact, the worst open it is advisable to perform the fasciotomy before doing the
fractures are actually more likely to have a CS. repair. The rationale for this is that the ischemic compartment
Since clinical findings may be absent in patients with is likely to be already tight and thus will create inflow resis-
altered sensorium (common in the intensive care setting), tance to the vascular repair, making it susceptible to early
under the influence of drugs or alcohol, distracting inju- thrombosis.
ries, or paralysis, many authors advise using tissue pres-
sure measurements as an adjunct to clinical findings [25].
There are also some who advocate the use of compart- Fasciotomy of the Lower Leg
ment pressure measurement as a principle criterion for
the diagnosis of CS. The lower leg (calf) is the most common site for CS requiring
In actual practice, tissue pressure (compartment pres- fasciotomy. The preferred technique in trauma for fasciotomy
sure) measurements have a limited role in making the diag- of the below the knee CS is the two incision four compartment
nosis of CS. However, in polytrauma patients with associ- fasciotomy. An alternative single incision approach in which
ated head injury, drug and alcohol intoxication, intubation, the fibula is resected has been championed by some, but has
spinal injuries, use of paralyzing drugs, extremes of age, been condemned by others as being unnecessarily mutilating,
unconsciousness, or low diastolic pressures, measuring more likely to result in injury to the peroneal nerve, and likely
compartment pressures may be of use in determining the to result in incomplete release of the compartments.
need for fasciotomy. Successful fasciotomy of the lower extremity requires a
The pressure threshold for making the diagnosis of CS is thorough understanding of the anatomy and the relevant land-
controversial. A number of authors recommend 30 mmHg, marks. The most commonly missed compartments are the
and others cite pressures as high as 45 mmHg. Many surgeons anterior followed closely by the deep posterior [23••], and this
use the “Delta-P” system. The compartment pressure is likely occurs as a result of incomplete knowledge of the
subtracted from the patient’s diastolic blood pressure to obtain anatomy of the lower extremity. The lower leg has four major
the Delta-P. Whitesides in 1975 proposed that muscle was at tissue compartments bounded by investing muscle fascia
risk when the compartment pressure was within 10–30 mmHg (Fig. 1). The two incision four compartment fasciotomy is
of the diastolic pressure [25]. If the Delta-P is less than 30, the not performed frequently by the majority of general or even
surgeon should be concerned that a CS may be present. For vascular surgeons, and the rate of delayed, incomplete, or
instance, if the diastolic blood pressure was 60 and the mea- improperly performed fasciotomy is alarmingly high with
sured compartment pressure was 42 (60−42=18), the “Delta- preventable morbidity and mortality [23••]. The following
P” would be 18 and the patient is likely to have CS. section will focus on the recommended technique for
The use of pressure measurements to decide if fasciotomy performing fasciotomy of the lower extremity emphasizing
is necessary can be very useful if the pressure is significantly the landmarks, relevant anatomy, and pitfalls.
elevated, but there are several potential pitfalls. The pressure There are several key features that will enable the perfor-
in one compartment could be normal whilst that in the com- mance of a successful two incision four compartment
partment immediately adjacent could be elevated. fasciotomy. Proper placement of the incisions is essential.
Many other non-invasive techniques have been proposed As extremities needing fasciotomy are often grossly swollen
for making the diagnosis of CS such as near-infrared spec- or deformed marking the key landmarks will aid in placement
troscopy, laser doppler flowmetry, pulsed phase-locked loop of the incisions. The tibial spine serves as a reliable midpoint
ultrasound, magnetic resonance imaging, skin quantitative between the incisions. The lateral malleolus and fibular head
hardness measurement, vibratory sensation, and scintigraphy are used to identify the course of the fibula on the lateral
using 99Tcm-methoxyisobutyl isonitril (MIBI). Though some portion of the leg (Fig. 2). The lateral incision is usually made
of these techniques have shown early promise, none have just anterior (~1 fingerbreadth) to the line of the fibula, or
reached clinical use outside of protocols [26•]. ONE FINGER IN FRONT OF THE FIBULA. It is important
CS remains primarily a clinical diagnosis fueled by a high to stay anterior to the fibula as this minimizes the chance of
index of suspicion and supported by objective examination. damaging the superficial peroneal nerve. The medial incision
The reliance on clinical examination with a low threshold for is made one thumb-breadth below the palpable medial edge of
fascial release may result in unwarranted fasciotomies, but it the tibia, or A THUMB BELOW THE TIBIA (Fig. 3). The
avoids the grave consequences of a missed diagnosis. extent of the skin incision should be approximately three
38 Curr Trauma Rep (2015) 1:35–44

Fig. 1 Cross-sectional anatomy

of the mid-portion of the left
lower leg depicting the four
compartments that must be
released when performing a lower
leg fasciotomy

fingerbreadths below the tibial tuberosity and above the does not serve as a constricting band. The skin and subcuta-
malleolus on either side. It is very important to mark the neous tissue are incised to expose the fascia encasing the
incisions on both sides prior to opening them, as the land- lateral and anterior compartments. Care should be taken to
marks of the swollen extremity will become distorted once the avoid the lesser saphenous vein and peroneal nerve when
incision is made. making these skin incisions.
Once the skin flap is raised the intermuscular septum is
sought and identified. This is the structure divides the anterior
The Lateral Incision of the Lower Leg and lateral compartments. In the swollen or injured extremity,
it may be difficult to find the intermuscular septum. In these
The lateral incision (Fig. 2) is made one finger in front of the circumstances, the septum can often be found by following the
fibula and should in general extend from three finger breadths perforating vessels down to it (Fig. 4). Classically, the fascia
below the head of the fibula down to three finger breadths of the lower leg is opened using an “H” shaped incision
above the lateral malleolus. The exact length of the skin (Fig. 5). This will be accomplished by making the cross piece
incision will depend on the clinical setting and care must be of the “H” using a scalpel which will expose both compart-
taken to make sure that it is long enough such that the skin ments and the septum. The legs of the “H” are made with

Fig. 2 The fibular head and

lateral malleolus are reference
points to mark the edge of the
fibula, and the lateral incision
(dotted line) is made one finger in
front of this. ONE FINGER IN
FRONT OF THE FIBULA
Curr Trauma Rep (2015) 1:35–44 39

Fig. 3 The medial incision

(dotted line) is made one thumb
breadth below the palpable
medial edge of the tibia (solid
line). A THUMB BELOW THE
TIBIA

curved scissors using just the tips which are turned away from peroneal nerve and/or the anterior tibial vessels confirm the
the septum to avoid injury to the peroneal nerve (Fig. 5). It is entry into the anterior compartment. The skin incision should
important to identify the intermuscular septum and open the be closely inspected and extended as need to ensure that the
fascia at least one centimeter from it on either side, because the ends do not serve as a point of constriction.
terminal branch of the deep peroneal nerve perforates the As previously stated, the anterior compartment is the one
septum in the distal one third of the lower leg and this could most commonly missed during lower extremity fasciotomy.
be cut if care is not taken. The anterior and lateral compart- One of the reasons for missing the anterior compartment stems
ments are then fasciotomized 1 cm in front and behind the from making the incision too far posteriorly, either directly
intermuscular septum. over or behind the fibula. When the incision is made in this
The fascia should be opened by pushing the partially manner, the septum between the lateral and the superficial
opened scissor tips in both directions on either side of the compartment may be directly below the incision and is erro-
septum opening the fascia from the head of the fibula down to neously identified as the septum between the anterior and
the lateral malleolus in a line that is 1–2 cm from the septum. lateral compartments (Fig. 6). When the lateral incision is
Inspection of the septum and identification of the deep made ONE FINGER IN FRONT OF THE FIBULA, the

Fig. 4 The intermuscular septum

separates the anterior and lateral
compartments and is where the
perforating vessels traverse. This
is a representation of the lateral
incision of the right lower leg
40 Curr Trauma Rep (2015) 1:35–44

Fig. 5 The fascia overlying the

anterior and lateral compartments
is opened in a “H” shaped fashion
using scissors with the tips turned
away from the intramuscular
septum

intramuscular septum between the anterior and lateral com- this compartment. The key to entering the deep posterior
partments is found directly below the incision making suc- compartment is the soleus muscle. The soleus muscle
cessful decompression likely (Fig. 7). attaches to the medial edge of the tibia and dissecting
these fibers (the “soleus bridge”) completely free from
and exposing the underside of the tibia ensures entry into
The Medial Incision of the Lower Leg the deep posterior compartment (Fig. 8). Identification of
the posterior tibial neurovascular bundle confirms that the
The medial incision is made one fingerbreadth below the compartment has been entered.
palpable medial edge of the tibia (Fig. 3). When making As previously discussed, the deep posterior compartment
this incision is important to both, identify and preserve the can also be missed, and thorough understanding of the anat-
greater saphenous vein, as well ligate any perforators to it, omy is the key to ensuring that this does not happen. One
as these can bleed profusely. After dividing the skin and potential way to miss the deep posterior compartment is to get
subcutaneous tissues, the fascia overlying the superficial into the plane between the gastrocnemius and soleus muscle
posterior compartment which contains the soleus and gas- and believe that the compartment has been released (Fig. 9).
trocnemius muscle is exposed. The fascia should be Proper decompression of the deep posterior compartment
opened with partially opened scissors from the tibial tu- requires that the soleus fibers be separated from their attach-
berosity to the medial malleolus to effectively decompress ment on the underside of the tibia (Figs. 8 and 10).

Fig. 6 When the lateral incision

is made too far posterior, the
septum between the lateral and
superficial posterior
compartments may be mistaken
for that between the anterior and
lateral leading to the anterior
compartment not being opened
Curr Trauma Rep (2015) 1:35–44 41

Fig. 7 When the lateral incision

is made one finger in front of the
fibula, the septum between the
anterior and lateral compartments
is more readily identified
allowing for adequate
decompression of both the
anterior and lateral compartments

Wound Care room every 24 to 72 h for dressing changes, reevaluation

of muscle viability, and gradual closure of the wound. If
The muscle in each compartment should be assessed for the wounds cannot be primarily closed within 7–10 days,
viability. Viable muscle is pink, contracts when stimulated, split-thickness skin grafts (STSG) may be required when
and bleeds when cut. Dead muscle should be debrided back to both the patient and the wound are stable. Several tech-
healthy viable tissue when necessary. Generally, fasciotomy niques have been described to minimize skin retraction
wounds are not closed at the time of the initial procedure. and obviate the need for STSG.
These wounds are often large and tissue swelling, skin retrac- Both the vessel-loop or shoelace technique [27] and
tion, or tissue loss make these wounds impossible to close at Subatmospheric (negative pressure) wound dressings
the initial setting, and closure would also defeat pressure (e.g., Wound VAC™, Kinetic Concepts, Inc (KCI), San
decreases obtained by fasciotomy. Antonio, TX) have been used successfully to provide
Wound management focuses on swelling control, fasciotomy and open-wound control. Both techniques are
allowing recovery of injured tissues, and minimizing skin safe, reliable, and effective, though in small randomized
retraction. Patients are generally returned to the operating studies VAC™ treated wounds required longer time to

Fig. 8 The deep posterior

compartment is entered by taking
the soleus fibers down off the
underside of the tibia
42 Curr Trauma Rep (2015) 1:35–44

Fig. 9 A potential pitfall when

doing the medial incision is to
develop a plane between the
gastrocnemius and soleus
muscles and believing that this
represents the plane between the
superficial and deep posterior
compartment

closure with higher associated costs [28•]. Other observa- Complications

tional studies have failed to show superiority of modali-
ties used in achieving earlier closure [29•], or have shown In spite of numerous articles in the literature regarding
the superiority of VAC over traditional wet to dry dress- fasciotomy, there is surprisingly little published about the
ings [30], highlighting that there is unresolved controver- complications of this procedure. Patients with open
sy as to the ideal management of these wounds. fasciotomy wounds are at risk for infection, and

Fig. 10 Entry into and release of

the deep posterior compartment
requires separating both the
gastrocnemius and soleus from
the underside of the tibia.
Identification of the
neurovascular bundle confirms
that the deep posterior
compartment has been entered
Curr Trauma Rep (2015) 1:35–44 43

incomplete or delayed fasciotomies can lead to perma- References

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