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Fasciotomy of the Leg

- See:
        - Compartment Syndrome Menu
        - Compartment Syndromes resulting from Tibial Fractures
        - Anterior Compartment
        - Lateral Compartment
        - Deep Posterior Compartment
        - Superfical Posterior

- Anterolateral Incision: (Two Incision Technique)
    - anterior & lateral compartments are approached thru single longitudinal incision placed halfway down leg 2 cm anterior to fibular
           shaft, or alternatively placed halfway between the tibial crest and the fibula;
           - incision is therefore placed over anterior intermuscular septum separating anterior & lateral compartments &
                   allowing access to each;
           - in an elective chronic syndrome, a small 4-5 cm incision can be used;
           - in the acute traumatic syndrome, a 15 cm incision is used;
    - transverse incision is made over fascia of anterior & lateral compartments, which allows clear view of the intermuscular septum;
           - attempt to identify the superficial peroneal nerve near the septum;
    - tension is maintained on the fascia w/ a Kocher clamp;
    - blunt tipped scissors are used to spread above and below the fascia on both sides of the intermuscular septum, both proximally
           and distally;
    - anterior compartment:
          - after identifying septum, small nick is made in fascia of anterior intermuscular septum midway between the septum
                 & tibial crest;
          - tension is maintained on the fascia w/ a Kocher clamp;
          - blunt tipped scissors are used to spread above and below the fascia both proximally and distally;
          - fascia is opened proximally & distally w/ long, blunt-pointed scissors;
                 - proximally aim for the patella and distally to the center of the ankle inorder to ensure that the fasciotomy stays in anterior
                       - distally, avoid straying too medially so as too avoid injury to the dorsalis pedis;
    - lateral compartment fasciotomy:
          - made in line w/ fibular shaft;
          - distally direct scissors toward lateral malleolus inorder to keep instrument posterior to superficial peroneal nerve;
                 - superficial peroneal nerve exits from lateral compartment about 10 cm above lateral malleolus and courses into anterior
    - if tip of scissors has strayed from fascia, instrument is left in place and two centimeter incision is made over its tip & fasciotomy is
          - once the fascia has been partially transected, tension on the fascia will be lost, which means that the scissors cannot re-enage the
                   edge of the fascia in a blind fashion;

- Posteromedial Incision: (Two Incision Technique)
    - deep and superficial posterior compartments are approached thru a single 15 cm longitudinal incision in distal part of leg 2 cm
           posterior to posterior medial palpable edge of the tibia;
    - once down to fascia undermine anteriorly to posterior tibial margin, which will avoid saphenous vein and nerve;
           - the saphenous vein should be retracted anteriorly;
    - superficial compartment:
           - retract saphenous vein & nerve & release fascia over superfical posterior compartment;
           - tension is maintained on the fascia w/ a Kocher clamp;
           - blunt tipped scissors are used to spread above and below the fascia both proximally and distally;
    - deep posterior compartment:
           - soleus takes origin from the proximal 1/3 of the tibia and fibula and covers the proximal portion of the deep posterior
           - detach soleal bridge and retract it to expose fascia covering FDL & tibialis posterior;
                  - note that the FDL lies just posterior to the tibia, and this fascia needs to be released to decompress the compartment;
                  - the neurovascular bundle is protected, lying between the tibialis posterior and the soleus;
           - in the distal half of the tibia the deep posterior compartment lies just below the subcutaneous tissue;
                  - again, releasing the fascia over the FDL is required to decompress the deep posterior compartment;
           - fascia is opened distally and proximally under the belly of soleus;
           - ref: Compartment Syndrome of the Leg Associated With Frx: An Algorithm to Avoid Releasing the Posterior Compartments.
    - wound closure:

           - wounds are left open if swelling is too much to allow for primary skin closure;
           - skin grafting is rarely needed if full week is allowed for dissipation of edema;

- One Incision Technique:
    - performed thru one long incision over lateral compartment
    - make incision in line w/ fibula extending just distal to head of fibula to 3 to 4 cm proximal to the lateral malleolus;
         - the incision should be either directly over or slightly posterior to the fibula;
    - proximally identify the common peroneal nerve;
    - undermine skin anteriorly & avoid injuring superficial peroneal nerve;
    - perform longitudinal fasciotomy of anterior and lateral compartments;
    - undermine skin posteriorly & perform fasciotomy of superfical posterior compartment;
    - define the interval between the soleus and the FHL;
    - identify interval between superficial & lateral components distally & develop this interval proximally by detaching soleus
             from fibula;
    - subperiosteally dissect the flexor hallucis longus from the fibula;
    - retract the muscle and the peroneal vessels posteriorly;
    - now identify fascial attachment of the tibialis posterior muscle to fibula and incise this fascia longitudinally;
    - exposure of deep fascia for a short distance anterior & posterior to this incision, followed by transverse incision through fascia at
             midpoint, allows easy identification of vertical fascial planes separating compartments;
    - release each compartment independently w/ longitudinal incision extending the full length of the compartment;
    - after releasing superfical posterior compartment bluntly dissect posterior to lateral compartment & release fascia of
             deep posterior compartment;
    - ref: Single-incision fasciotomy for compartmental syndrome of the leg in patients with diaphyseal tibial fractures

- Post Operative Care:
    - wound care:
          - Wound closure of leg fasciotomy: Comparison of vacuum-assisted closure versus shoelace technique. A randomised study.
          - Comparison of vacuum-assisted closure device and conservative treatment for fasciotomy wound healing in ischaemia-reperfusion syndrome: preliminary results.
          - Delayed Primary Closure of Fasciotomy Incisions in the Lower Leg: Do We Need to Change our Strategy?

Double-incision fasciotomy of the leg for decompresion in compartment syndromes.  

Compartment Syndromes of the Lower Leg.

Effect of lower extremity fasciotomy length on intracompartmental pressure in an animal model of compartment syndrome: the importance of achieving a minimum of 90% fascial release.