Immediate Fasciotomy
In a 67-year-old man six hours post-femoral artery surgery presenting with swelling and worsening neurological signs, immediate fasciotomy is the only appropriate intervention to prevent permanent limb loss and irreversible nerve damage.
Clinical Recognition of Compartment Syndrome
This presentation represents acute compartment syndrome (ACS) following vascular surgery, a time-sensitive surgical emergency that demands immediate recognition and treatment 1, 2. The combination of:
- Swelling (increased compartment pressure)
- Worsening neurological signs (progressive nerve ischemia indicating manifest compartment syndrome)
- Post-revascularization timing (6 hours is the critical window)
...confirms this is a manifest compartment syndrome with compromised circulation and loss of tissue function, not merely an imminent one 3.
Why Fasciotomy is Mandatory
The 2024 ESC Guidelines explicitly state: "It is recommended to monitor for compartment syndrome after revascularization and treat (fasciotomy)" 1. This is a Class I, Level C recommendation—the highest strength of recommendation.
Pathophysiology Driving Urgency
- Reperfusion injury after arterial surgery causes massive fluid shifts into muscle compartments, rapidly elevating intracompartmental pressure 2, 4
- Neurological deterioration indicates that perfusion pressure has already fallen below the critical threshold for nerve function 3, 2
- Irreversible damage begins within 4-6 hours of onset; by 8 hours, permanent nerve injury and muscle necrosis are inevitable 2, 5
Why Other Options Are Wrong
- Backslap/traction: These are not recognized interventions for compartment syndrome and would waste critical time 3, 2
- Nerve repair: Cannot be performed until compartment syndrome is relieved; attempting repair in an ischemic compartment guarantees failure and worsens outcome 3, 2
- Fascioectomy (if this means partial fascial excision): Inadequate—full-length fasciotomy with skin left open is required 3, 5
Surgical Technique Requirements
Therapeutic fasciotomy for manifest compartment syndrome requires 3, 5:
- Long incisions of both skin and fascia (not just subcutaneous fasciotomy)
- Complete release of all involved compartments—in the lower extremity this typically means all four compartments via double-incision technique 5
- Skin must remain open—primary closure is absolutely contraindicated as it will cause rebound compartment syndrome from postoperative swelling 3
- Debridement of any necrotic tissue encountered 3
- Delayed closure at 4-8 days after edema subsides, often requiring skin grafting 3
Critical Pitfalls to Avoid
- Never delay for pressure measurements: With clear neurological deficits, clinical diagnosis is sufficient and pressure monitoring wastes precious time 2
- Never attempt conservative management: Removing dressings or elevating the limb is inadequate once neurological signs appear 3, 2
- Never close the skin: This is the most common technical error leading to treatment failure 3
- Never assume arterial patency alone is sufficient: Even with successful revascularization, compartment syndrome develops in the reperfusion phase 1, 4
Post-Fasciotomy Management
After emergency fasciotomy 1, 3:
- Monitor for rhabdomyolysis with serial creatine kinase and urine myoglobin
- Aggressive fluid resuscitation to prevent acute kidney injury
- Second-look operation at 4-8 days for re-debridement and delayed wound closure
- Assess clinical and hemodynamic success of the original revascularization
The amputation rate when fasciotomy is delayed or inadequate approaches 45%, versus preservation of the limb when performed emergently 6. With worsening neurological signs already present at 6 hours, this patient is at the threshold where permanent disability becomes likely without immediate surgical decompression 2.