What are the steps for a forearm fasciotomy procedure?

From the Guidelines

A forearm fasciotomy is performed to relieve compartment syndrome by decompressing the forearm compartments, and the procedure involves making two incisions, a volar and a dorsal incision, to release the superficial and deep volar compartments and the dorsal compartment. The procedure begins with patient positioning supine with the arm extended on a hand table. After sterile preparation, two incisions are made: a volar incision from the antecubital fossa to the wrist (avoiding the palmar crease) and a dorsal incision from the lateral epicondyle to the wrist. For the volar approach, the superficial volar compartment is released first by incising the antebrachial fascia, followed by identifying and protecting the median nerve while releasing the deep volar compartment, as compartment syndrome can lead to increased pressure within a confined space, compromising blood flow and tissue function, and potentially resulting in rhabdomyolysis, as noted in 1. The dorsal approach involves incising the antebrachial fascia to decompress the dorsal compartment, then identifying and protecting the superficial radial nerve while releasing the mobile wad compartment.

The diagnosis of compartment syndrome is based on clinical findings, including pain, paresthesia, paresis, and pain with stretch, as well as the '6 Ps' of ACS, which include pain, paresthesia, paresis, pain with stretch, pallor, and pulselessness, as described in 1. The pressure of a normal limb muscle compartment is less than 10 mm Hg, and fasciotomy is indicated in hypotensive patients with intracompartment pressures ≥ 20 mm Hg, in uncooperative or unconscious patients with intracompartment pressures ≥ 30 mm Hg, or in normotensive patients with positive clinical findings, who have compartment pressures ≥ 30 mm Hg, and whose duration of increased pressure is unknown or thought to be longer than 8 h, as suggested in 1.

After all compartments are decompressed, the wounds are typically left open with a sterile dressing applied. Delayed primary closure or skin grafting is performed 3-5 days later once swelling subsides. This procedure is essential for preventing tissue necrosis, nerve damage, and contractures that can result from untreated compartment syndrome, which can lead to increased morbidity, mortality, and limb loss, as noted in 1. The benefits of fasciotomy decrease, and the disadvantages increase considerably the later fasciotomy is performed, highlighting the importance of early diagnosis and treatment, as emphasized in 1.

Key steps in the procedure include:

• Making two incisions, a volar and a dorsal incision, to release the superficial and deep volar compartments and the dorsal compartment
• Identifying and protecting the median nerve and superficial radial nerve
• Releasing the superficial and deep volar compartments and the dorsal compartment
• Leaving the wounds open with a sterile dressing applied
• Performing delayed primary closure or skin grafting 3-5 days later once swelling subsides.

From the Research

Forearm Fasciotomy Steps

The steps for forearm fasciotomy are not explicitly outlined in the provided studies. However, the studies discuss different approaches and techniques for forearm fasciotomy:

• A lateral S-shaped approach for fasciotomies of the 3 forearm compartments in the case of acute forearm compartment syndrome is presented in 2.
• An endoscopic single approach forearm fasciotomy technique is described in 3 for chronic exertional compartment syndrome.
• The incidence and risk factors associated with the need for fasciotomy in forearm fractures are analyzed in 4.
• A comparison of the likelihood of acute compartment syndrome in the leg versus the forearm in patients who undergo fasciotomy is made in 5.

Key Considerations

When performing a forearm fasciotomy, the following factors should be considered:

• The approach and technique used, such as a lateral S-shaped approach or an endoscopic single approach 2, 3.
• The risk factors associated with the need for fasciotomy, such as invasive procedures, high-energy injuries, and substance use 4.
• The likelihood and severity of acute compartment syndrome, which can be comparable in the leg and the forearm 5.
• The importance of wound management and the potential for long-term complications 2.