What is the procedure for performing a fasciotomy on the leg?

How to Perform a Leg Fasciotomy

Perform immediate two-incision, four-compartment fasciotomy when compartment syndrome is diagnosed, as this is the standard surgical approach that decompresses all leg compartments and prevents irreversible muscle necrosis and limb loss. 1, 2

Indications for Fasciotomy

Immediate fasciotomy is indicated when:

• Compartment pressure exceeds 30 mmHg with clinical signs of compartment syndrome 2, 3, 4
• Clinical evidence of compartment syndrome exists (pain out of proportion, pain on passive stretch, elevated creatine kinase) 1, 4
• Acute limb ischemia with prolonged or severe tissue ischemia is present, even before clinical compartment syndrome develops (prophylactic fasciotomy) 1
• High-energy trauma with tibial fractures, crush injuries, or vascular injuries occurs 1, 4

Critical timing: Fasciotomy must be performed before definitive fracture fixation in compound fractures to prevent irreversible tissue damage. 2

Standard Surgical Technique: Two-Incision, Four-Compartment Approach

The two-incision technique is the gold standard and releases all four compartments of the lower leg: 5, 6

Lateral Incision

• Make a longitudinal incision approximately 2 cm anterior to the fibula, extending from just below the fibular head to 4 cm proximal to the lateral malleolus 5
• Release the anterior compartment by incising the fascia over the tibialis anterior muscle 5, 6
• Release the lateral (peroneal) compartment by incising the fascia over the peroneus muscles, posterior to the intermuscular septum 5, 6
• Pitfall: Avoid injury to the superficial peroneal nerve, which exits the lateral compartment approximately 10-12 cm proximal to the lateral malleolus 7, 5

Medial Incision

• Make a longitudinal incision 2 cm posterior to the medial tibial border, extending from the tibial tuberosity to 4 cm proximal to the medial malleolus 5
• Release the superficial posterior compartment by incising the fascia over the gastrocnemius-soleus complex 5, 6
• Release the deep posterior compartment by incising the fascia over the flexor digitorum longus and tibialis posterior, deep to the soleus muscle 5, 6
• Pitfall: Protect the greater saphenous vein and nerve during the medial approach 7, 5

Alternative Single Lateral Incision Approach

• When fasciotomy is associated with a tibial fracture requiring fixation, a single lateral incision can access all four compartments while staying distant from fracture hardware 5
• This approach is "easy, effective and safe" but requires more extensive dissection 5

Selective Fasciotomy Consideration

Selective fasciotomy (opening only compartments with pressure >30 mmHg) is feasible but requires intraoperative pressure measurement: 6

• The anterior compartment requires release in essentially all cases (100% in one series) 6
• In 67% of cases, releasing only 2 compartments was sufficient 6
• However, this approach carries risk: One patient required reoperation 8 hours later for missed compartments 6
• Recommendation: Given the catastrophic consequences of missed compartment syndrome versus the relatively low morbidity of four-compartment fasciotomy, the standard four-compartment approach remains safer in most clinical scenarios 1

Alternative Equipment for Austere Environments

When traditional surgical instruments are unavailable, fasciotomy can be performed with alternative devices: 7

• Use a scalpel or knife for initial skin incision 7
• Fascia can be released using rescue hooks (Benchmade, Leatherman Raptor), Z-Rex multitool, or PenBlade 7
• Hook devices require "pull technique" and skin incisions equal in length to fascia incisions 7
• PenBlade uses "push technique" similar to scissors and requires smaller skin incisions 7
• This is particularly relevant for military or remote settings where evacuation is delayed 1, 7

Wound Management After Fasciotomy

Leave fasciotomy wounds open initially and plan for delayed closure: 1

Early Delayed Primary Closure

• If minimal tissue bulge occurs or resolves with systemic diuresis and leg elevation, attempt early delayed primary closure at median 5 days 1, 8, 9
• This approach reduces wound morbidity compared to prolonged open wounds 1

When Primary Closure Not Possible

• Negative pressure wound therapy (NPWT/VAC) facilitates wound closure or prepares wound bed for skin grafting 1, 8
• Shoelace technique is an effective, safe alternative that is significantly less expensive (14 euros/day vs 135 euros/day for VAC) 8
• VAC requires longer time to definitive closure (mean difference 4 days) and may require split-thickness skin grafts in some cases 8
• Skin grafting is performed at median 11 days when primary closure fails 8, 9

Critical Pitfalls to Avoid

• Never delay fasciotomy for pressure measurements alone when clinical signs are present—late signs like pulselessness and sensory loss indicate tissue damage is already progressing 1, 2
• Do not rely solely on pressure measurements without clinical correlation—the absence of clinical signs is more accurate in excluding compartment syndrome than their presence is in confirming it 3
• Recognize that fasciotomy is not benign but carries risks including hemorrhage, nerve damage, infection, and difficult wound closure; however, these risks are far outweighed by the risk of limb loss from untreated compartment syndrome 1
• Monitor for rhabdomyolysis with elevated CPK levels and myoglobinuria to prevent acute kidney injury 2
• In prophylactic fasciotomy for acute limb ischemia, early intervention is associated with lower amputation rates and shorter hospitalization 1, 9