- 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
compartment;
- 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
compartment;
- if tip of scissors has strayed from fascia, instrument is left in place and two centimeter incision is made over its tip & fasciotomy is
completed;
- 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
compartment;
- 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.