Surgical approaches to fascial compartments

Compartment Syndrome - Under Pressure!

• Pathophysiology: ↑ Intracompartmental pressure → ↓ tissue perfusion → ischemic necrosis. Most common in leg (anterior compartment) & forearm.
• Etiology: Trauma (fractures, crush), burns, reperfusion injury.
• Clinical: Pain out of proportion to injury, paresthesias, tense/swollen compartment.
  • 📌 6 Ps (late signs): Pain, Pallor, Paresthesia, Pulselessness, Paralysis, Poikilothermia.
• Diagnosis: Clinical suspicion is key. Compartment pressure measurement (e.g., Stryker needle).
  • ⚠️ Fasciotomy indicated if diastolic BP - compartment pressure (ΔP) < 20-30 mmHg or absolute pressure > 30-40 mmHg.

⭐ Irreversible nerve and muscle damage begins after 4-6 hours of ischemia.

Leg Fasciotomy - The Four‑Poster Bed

• Indication: Acute compartment syndrome of the lower leg, typically post-trauma.
• Goal: Decompress all four fascial compartments to restore perfusion.
• Technique: Utilizes two main skin incisions to access all four compartments.

• Anterolateral Incision

  • Location: Midway between the tibial crest and the fibula.
  • Releases: Anterior and Lateral compartments.
  • Procedure: Incise the fascia over the anterior compartment, then identify the intermuscular septum and incise the fascia over the lateral compartment.

• Posteromedial Incision

  • Location: ~2 cm posterior to the posteromedial border of the tibia.
  • Releases: Superficial Posterior and Deep Posterior compartments.

⭐ High-Yield: The superficial peroneal nerve is at high risk during the anterolateral incision, especially in the distal third of the leg. The saphenous nerve is at risk with the posteromedial incision.

Arm & Thigh Approaches - Limb Service

• Arm Compartment Decompression

  • Single Lateral Incision: Preferred for both anterior and posterior compartments.
    • Landmark: Mid-lateral line between biceps and triceps.
    • Anterior Release: Incise the lateral intermuscular septum; protect the musculocutaneous nerve.
    • Posterior Release: Retract triceps posteriorly; protect the radial nerve and profunda brachii artery in the spiral groove.

• Thigh Compartment Decompression

  • Anterior & Lateral Compartments: Single anterolateral incision.
    • Landmark: Line from ASIS to the lateral patella.
    • Incise the fascia lata to decompress.
  • Posterior & Medial Compartments: Separate posteromedial incision.
    • ⚠️ Risk: Protect the femoral artery/vein and saphenous nerve medially.

⭐ During thigh fasciotomy via a lateral approach, the vastus lateralis must be retracted anteriorly to safely release the posterior compartment by incising the lateral intermuscular septum.

High‑Yield Points - ⚡ Biggest Takeaways

• Compartment syndrome is a surgical emergency requiring immediate fasciotomy to prevent irreversible muscle and nerve damage.
• Decompression is indicated when compartment pressures exceed 30 mmHg or when the diastolic pressure gradient (ΔP) is less than 20-30 mmHg.
• A two-incision approach is standard for the leg to safely release all four compartments.
• The forearm typically requires both a volar (Henry) approach and a separate dorsal incision.
• Be cautious of iatrogenic nerve injury, especially the superficial peroneal nerve in the leg.
• Wounds are initially left open for delayed primary closure or skin grafting.