Overview of Fasciotomy
A fasciotomy is a medical procedure carried out during emergencies to alleviate a condition called acute compartment syndrome. Acute compartment syndrome is a situation where the pressure within a muscle compartment in your body rises to dangerous levels. This increased pressure can block the blood flow and lead to harm to the muscle and nerves in that area. This mostly happens in parts of the body such as the forearm, leg, or anywhere else where muscle is enclosed by a thick tissue layer known as fascia. Fascia can be found in various parts of the body such as the hand, foot, thigh, or buttock.
We can identify two kinds of compartment syndrome: acute and chronic. Acute compartment syndrome usually follows a severe injury, a fracture, severe burns, serious crushing injuries, or having a plaster cast that’s too tight. On the other hand, chronic compartment syndrome usually comes about with repetitive muscle use. This is common in runners or military personnel who repeatedly use their leg muscles or in weightlifters and rowers who use their forearm muscles excessively. Sometimes, acute compartment syndrome can also happen suddenly after an intense physical effort.
Anatomy and Physiology of Fasciotomy
The lower leg, typically where we see ‘compartment syndrome’ and the associated treatment, ‘fasciotomy’, happening most often, is divided into four distinct sections. These include the front (anterior), outer side (lateral), shallow back part (superficial posterior), and deep back part (deep posterior). Listed below you’ll find which muscles, arteries, and nerves are located in each of these four compartments:
– Front (Anterior) Compartment: Contains the muscles that help the foot to lift up and extends the toes, and the arteries and nerves that supply blood flow and movement. Commonly referred to as the Tibialis anterior, Extensor halluces longus, Extensor digitorum longus, Peroneus tertius muscles, Deep fibular nerve, and Anterior tibial artery.
– Outer Side (Lateral) Compartment: Includes the muscles that help in moving the foot side to side and the arteries and nerves associated with it. These include the Peroneus longus and Peroneus tertius muscles, Superficial fibular nerve, and Fibular artery.
– Shallow Back Part (Superficial Posterior) Compartment: This compartment is mainly responsible for the muscles involved in standing on your toes and the nerve supplying them. The main structures are the Gastrocnemius, Soleus, Plantaris muscles, and Sural nerve.
– Deep Back Part (Deep Posterior) Compartment: It holds muscles responsible for turning your foot inward and curling your toes. It also includes the arteries and nerves that manage these actions. Such structures are Tibialis posterior, Flexor hallucis longus, Flexor digitorum longus, Popliteus muscles, Tibial nerve, and Posterior tibial artery.
In the upper limb, compartment syndrome frequently occurs in the forearm. This forearm is also divided into four sections – superficial volar or front (keyword for the palm side of the hand), deep volar, back side (dorsal), and the movable pack of muscles known as the “mobile wad of Henry”. The volar or front compartments are most affected.
Detailed below are the muscles, arteries and nerves found within each compartment in the forearm:
– Superficial Volar (Front of forearm): Comprises muscles that control wrist and finger movement, and the nerves, and arteries supporting them. It houses Flexor carpi ulnaris, Flexor carpi radialis, Pronator teres, Palmaris longus, Flexor digitorum superficialis muscles, Ulnar nerve, and Ulnar artery.
– Deep Volar (Deep front of forearm): It involves the muscles that help in curling fingers and thumb, along with the arteries and nerves required for the action. It holds Flexor digitorum profundus, Flexor pollicis longus, Pronator quadratus muscles, Median nerve, Anterior interosseous artery, and Anterior interosseous nerve.
– Dorsal (Back-side of forearm): Encompasses the muscles responsible for finger, wrist, and thumb extension, with the arteries and nerves necessary for running these actions. It includes Extensor digitorum, Extensor digiti minimi, Extensor carpi ulnaris, Supinator, Extensor indicis, Extensor pollicis longus, Extensor pollicis brevis muscles, and corresponding nerves and arteries.
Also important to note, the median and ulnar nerves (that control many of the hand’s movements) are found at the front of your forearm between certain muscles. The radial nerve, responsible for many movements of the hand, is found deep to the mobile wad.
Why do People Need Fasciotomy
Compartment syndrome is a painful condition where the pressure inside a muscle compartment in the body increases to harmful levels. This can be caused due to injury or conditions that restrict blood flow. This condition is characterized by six key features: limited blood supply (ischemia), intense pain more than expected from the injury, unusual sensations like numbness or tingling (parasthesia), paleness (pallor), inability to move the affected area (paralysis), and pain when the impacted compartment is stretched or moved.
A simple test known as two-point discrimination can be used to evaluate whether the nerves in the affected compartment are deprived of blood supply, leading to these unusual sensations. However, these signs and symptoms can be hard to assess, particularly in patients who have limited consciousness, a disturbed sensory state, or poor communication ability. Therefore, measuring the pressure inside the compartment can be helpful in these situations.
There are several ways to measure the pressure inside a muscle compartment, but these methods don’t have strong scientific evidence to back them up fully. In fact, there’s no widespread agreement about when emergency surgery (known as a fasciotomy) should be performed based on these pressure measurements. Some medical teams prefer to operate when the difference between the pressure inside the compartment and the patient’s lowest blood pressure during heart rest (diastolic pressure) is less than 20 millimeters of mercury (mmHg). On the other hand, some surgeons opt to perform surgery when the pressure inside the compartment is greater than 30 mmHg, especially when this is accompanied by clinical signs of compartment syndrome.
When a Person Should Avoid Fasciotomy
There aren’t any absolute reasons to avoid a fasciotomy, a surgical procedure where the fascia is cut to relieve tension or pressure. Things that might cause a doctor to reconsider doing this procedure depend on each patient’s specific medical situation and injury. Usually, a senior team member will decide if a fasciotomy is the best course of action.
One reason a doctor might decide against a fasciotomy is if the patient comes in late. If the doctor thinks the compartment syndrome (a painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues) has been going on for more than 12 hours, there could be a risk of reperfusion injury, which is damage caused when blood supply returns to the tissues after a period of lack of oxygen.
One research study showed that patients who had a fasciotomy within 6 hours almost fully regained use of their limb. If the surgery was done between 6 and 12 hours, about 68% of patients regained normal use of their limb. However, if the surgery was done after 12 hours, only about 8% of patients regained normal use of their limb. On the other hand, another more recent study found no difference in the number of limbs saved, whether the surgery was done early (less than 12 hours) or late (more than 12 hours), though they did find more infections in patients who had late surgeries.
A study in 2008 of 336 patients who were treated from combat injuries showed that patients who had late fasciotomies were twice as likely to need amputations, and three times more likely to die. Therefore, considering the possibility of permanent nerve and muscle damage, and a higher risk of infection, emergency surgery may not be necessary if the compartment syndrome has been missed and not treated promptly.
Equipment used for Fasciotomy
The tools the doctor uses to do a fasciotomy – a surgery to relieve pressure or tension in an area of your body – are listed below:
- Antiseptic solution – this is used to clean the skin before the surgery.
- Skin scalpel and Inside scalpel – these are sharp-bladed instruments used to make precise cuts on the skin and inside the body.
- Forceps – tool used to grab or hold onto things, similar to a pair of tongs.
- Simple hand-held retractor (Langenbeck) – this is a simple tool used to hold back, or retract, tissue or other objects during surgery.
- Diathermy device – a device that uses heat produced by electric currents to destroy or cut through tissue.
- Dressing – special materials that are used to cover a wound and help it heal.
Who is needed to perform Fasciotomy?
The procedure can be done by a medical professional who has received the right training. This is often a surgeon who is still learning (a surgical resident) or a fully qualified surgeon (an attending). The person who does the operation, known as a fasciotomy, needs help from a scrub nurse (a nurse who helps during surgeries) and an anesthetist (a doctor who puts you to sleep during the operation).
Preparing for Fasciotomy
Before the operation starts, the team of surgeons needs to go through a safety checklist created by the World Health Organization. This checklist helps ensure that everything is ready for the surgery. If the procedure is to relieve pressure in the leg (fasciotomy), the patient will lie flat on their back. The leg is then prepared for surgery and covered with a sterile drape up to the knee. If the procedure is on the forearm, the patient still lies flat on their back, but with the arm lifted out to the side at a right angle to the body. The arm is then prepared for the procedure and covered with a sterile drape up to the elbow.
How is Fasciotomy performed
Single-Incision Leg Fasciotomy (Davey, Rorabeck, and Fowler Technique)
Here’s a simplified idea of how a one-cut method of leg fasciotomy works. Fasciotomy is a surgical procedure that opens up a compartment in the body to relieve pressure. This particular method starts with a cut beginning at the outer ankle (lateral malleolus) and extending along the smaller leg bone (fibula) for the entire length of the compartment. They then slowly go through the tissues just beneath the skin to reveal the strong, fibrous layer (fascia). The doctor will be careful to avoid harming the outer leg nerve (superficial peroneal nerve). Now, they will create a straight-cut along the fascia of the front and outer leg compartments.
The next step is starting to work on the back, forming a straight-cut into the superficial rear compartment. The surgeon will look for a muscle known as the soleus and start to develop the plane (space) between the lower third of this muscle and the outer compartment. This involves removing the soleus and the deeper muscle, flexor hallucis longus, from the back of fibula. They must be careful as the bundle of nerves and blood vessels to the outer leg (peroneal neurovascular bundle) will be just inside of the fibula.
These vessels will be moved to the back to showcase the fibrous connections of the tibialis posterior to the fibula and a straight-cut is made. They then apply an appropriate dressing to the wound.
Double-Cut Leg Fasciotomy (Mubarak and Harges Technique)
This type of leg fasciotomy involves two cuts. The first step is making a large cut on the skin in the front, between the ridge of the larger leg bone (tibia) and the smaller one (fibula). The next step is to locate a structure called the anterior intramuscular septum and make a straight-cut on both sides into the front and outer compartments. Now for the second cut, starting about 2 cm up and 2 cm to the outside of the inner malleolus of the tibia and going up along the tibia. Now, using a blunt instrument to avoid unnecessary injury, they will locate the fascia and the long saphenous vein and nerve, moving these towards the front. Then a straight-cut is made along the back fascial compartment.
A further fascial cut is made over a long muscle, flexor digitorum longus, just behind and inside the tibia to release the back compartment.
Forearm Fasciotomy
Similar to the leg procedure, a really long incision is made just outside the flexor carpi ulnaris (a muscle in the forearm), extending to the large knobby bone at the inside of the elbow (medial epicondyle). The cut is then extended towards the wrist and diagonally across the crease of the wrist to the palm area for carpal tunnel release. They cut the fascia along the length of the superficial compartment. They move the flexor carpi ulnaris and the bundle of nerves and blood vessels on the ulnar (inside) side of the wrist to the inside, as well as the flexor digitorum superficialis muscle, which exposes the fascia of the deep compartment. A fascial cut is then made onto the flexor digitorum profundus muscle and both fascial cuts are extended to the transverse carpal ligament.
For the back of the forearm, a cut starts about 2 cm down and slightly to the outside of the lateral epicondyle, about midway between the extensor digitorum communis muscle and the extensor carpi radialis brevis muscle. After making the cut, the fascia over the “mobile wad” (a group of muscles) is released immediately. The next step involves developing the tissue underneath the skin on the back side and making a release of the fascia to decompress the back compartment.
Follow-up
After your fasciotomy, the doctor will check the wound after 48 hours. If the compartments (areas that were pressurized) are soft, the wounds can start to close up, either through natural healing, stitching, or through a procedure called split-thickness skin grafting which uses a thin layer of your skin to cover the wound. In about half of the cases, this skin grafting is necessary. They can also use special stitches that draw the wound edges together over time (vessel loop shoelace stitch). Another option would be to use a device that applies a gentle vacuum to the wound (negative pressure wound management device).
Possible Complications of Fasciotomy
If your muscles start to die, a condition called rhabdomyolysis, this can often lead to acute renal failure, which is when your kidneys stop working properly. The usual treatment for this is receiving fluids into your veins and a process called dialysis, which helps clean your blood when your kidneys can’t.
Sometimes, after an operation called a fasciotomy (where a cut is made in your connective tissue to relieve pressure), it might not be fully completed. This could mean that another operation is needed either to extend the cut or to make a cut in a different compartment of the body that was missed the first time. This is more common when the body’s structure has drastically changed, like after severe injuries or previous surgeries that have caused scarring. If this happens, the risk of death increases fourfold.
Delaying a fasciotomy also has risks. These patients have double the rate of needing an amputation and triple the risk of death. Even if the procedure is done on time, the affected limb may not return to normal and might still need to be amputated.
Wound complications can also happen after a fasciotomy. This may include:
* The need for skin grafting, which is adding new skin to the wound
* Scarring
* Tendon tethering, which is when your tendon “sticks” to nearby tissue
* Muscle herniation, where muscle pushes through a weak spot in the surrounding tissue
* Recurrent ulceration, or when sores keep coming back
* Swelling in limbs
* Wounds changing color
* Itchiness
* Dry, flaky skin
* Changes in feeling or sensation in the skin
What Else Should I Know About Fasciotomy?
Early detection and proper treatment of compartment syndrome, a condition where increased pressure in a muscle compartment can lead to muscle and nerve damage, can greatly reduce the risk of poor health outcomes, including the need for amputation and risk of death. Additionally, delays in performing a certain procedure called fasciotomy, which is used to relieve pressure in the affected compartment, can lead to legal concerns. The longer the time from when symptoms first appear to when the fasciotomy is carried out, the higher the chance of medical negligence claims being successful. In general, the sooner a fasciotomy is carried out, the better it is both for the patient’s health and for legal reasons.