What are the steps for performing a lower extremity fasciotomy (fasciotomy of the lower extremity)?

From the Guidelines

A lower extremity fasciotomy is performed to relieve compartment syndrome by decompressing the affected compartments, and the procedure should be done promptly to prevent irreversible muscle and nerve damage, as recommended by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1. The procedure begins with patient positioning in supine position and appropriate anesthesia administration.

• For a two-incision four-compartment fasciotomy of the leg, make a 15-20 cm lateral incision about 2 cm anterior to the fibula, extending from below the fibular head to above the ankle.
• Through this incision, release the anterior and lateral compartments by incising their fascial coverings.
• Next, make a second 15-20 cm medial incision approximately 2 cm posterior to the medial border of the tibia to access the superficial and deep posterior compartments.
• Carefully identify and protect neurovascular structures, particularly the saphenous vein and nerve medially and the superficial peroneal nerve laterally. After decompression, inspect the muscle for viability, debride any necrotic tissue, and irrigate the wounds.
• The wounds are typically left open and covered with moist dressings or negative pressure wound therapy.
• Delayed primary closure or skin grafting is performed 3-7 days later once swelling subsides and tissue viability is confirmed. This procedure is crucial for preventing irreversible muscle and nerve damage from elevated compartment pressures, which can occur following trauma, vascular procedures, or severe exercise, and is supported by recent guidelines 1. Prophylactic fasciotomies at the time of revascularization or early in the presentation can avoid a later delay in diagnosis of compartment syndrome and devastating complications associated with this delayed diagnosis, as noted in the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1. The benefits of prophylactic fasciotomy should be balanced with the knowledge that the procedure is associated with a risk of complications, including dysesthesia related to nerve injury, incisional site complications, and infection 1. In patients with ALI who present with prolonged ischemia and dense regional symptoms, concurrent amputation with revascularization can be clinically appropriate, as discussed in the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1. Lower extremity four-compartment fasciotomies are sometimes performed to prevent a post-reperfusion compartment syndrome, especially in the setting of class IIb and III ischemia with surgical revascularization, as mentioned in the ESC guidelines on the diagnosis and treatment of peripheral artery diseases 1.

From the Research

Steps for Lower Extremity Fasciotomy

• The treatment goal for lower extremity compartment syndrome is to save the patient's life and salvage the affected limb 2
• Fasciotomy is the only accepted treatment of compartment syndrome and should be performed quickly after the diagnosis is made 2
• Diagnosis of compartment syndrome can be made using absolute compartment pressures above 30 mm Hg and a pressure differential of less than 30 mm Hg 2
• Patients with suspected acute compartment syndrome should be scored for likelihood of acute compartment syndrome based on muscle appearance, time to closure, neurologic deficit at final follow-up, and contracture at final follow-up 3
• Compartment pressure measurement is associated with higher likelihood of acute compartment syndrome in legs 3
• Increased morphine requirements are predictive of acute compartment syndrome in adults with tibia fractures 4
• Monitoring of subfascial pressures and using those pressures as a guide for decisions about time and dose of antivenom treatment may have permitted earlier surgical treatment after onset of compartment syndrome or even prevented the onset of this condition 5

Important Considerations

• Preinjury narcotic use does not affect treatment for compartment syndrome 6
• The likelihood and severity of acute compartment syndrome are comparable in the leg and the forearm 3
• Forearm fasciotomy is associated with documentation of poorer muscle appearance and contracture compared with leg fasciotomy 3
• Male sex and non-vascular mechanism of injury are associated with split-thickness skin graft in legs 3