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Fasciotomy DR. BAYU AGUNG ALAMSYAH
Introduction
Compartment syndrome is a limb and life threatening condition that occurs when perfusion pressure falls below tissue pressure in a closed anatomical compartment .
If left untreated tissue necrosis and sequele, ultimately death
It is found wherever a compartment is present.
What is Compartment Syndrome?
Matsen’s definition 1980
“a compartment syndrome is a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space.”
Causes
Simple cause: THE PRESSURE IS TOO HIGH.
Either – decreased compartment size or increased compartment (fluid) content.
Increased fluid content: Intensive muscle use Burns Intra-arterial injection Infiltrated infusion Haemorrhage
Envenomation
Decreased/limitation compartment size Burns Casts
Tissue Threshold to Ischemia
Muscle 4-8 hrs
Nerve 4-8 hrs
Fat 12 hrs
Skin 24 hrs
Bone 72-96 hrs
Therefore for a viable functional limb the upper threshold is about 6 hrs
Forearm compartments
Superficial Volar Compartment: FCU, FDS, FCR, PT
Deep Volar Compartment: FDP, FPL, FPB, Pronator Quadratus
Dorsal Compartment: ECU, EDQ, EDC, Supinator
Mobile Wad/Lateral Compartment: BR, ECRB, ECRL
The 5 components of a physical examination
Inspection (swelling, trauma, skin changes)
Palpation and passive stretch of muscles in the compartments
Evaluation of sensory function
Evaluation of motor function
Evaluation of perfusion
6P’s + Poikilothermia
Pain
Parasthesia
Palor
Paralysis
Pulselessness
Puffiness
Poikilotermia
NS
Mercury manometer, a 20-mL syringe, intravenous extension tubing, and an 18gauge needle. Movement of the air-saline column after injection of a “small amount of saline” into the tissue is the point at which the compartment pressure is read on the manometer.
After flushing, the hand-held monitor is placed at the level of the compartment to be measured for a “0” reading. The compartment pressure is read off the monitor after allowing for a decrease in the original value over 15 to 20 seconds.
The forearm muscle are very susceptible to ischemia and development compartment syndrome.
Relieve by performing longitudinal incission along the mid medial and mid lateral lines of forearm, extending from just above the elbow down to the wrist
The incision is made through skin and subcutaneous fat to expose the deep fascia which is the incised
Particular care must be taken to protect the ulnar nerve at the elbow
Fasciotomy of the Volar and Lateral Compartments of the Forearm (Volar-Ulnar Approach)
A transverse incision starting distal to the antecubital crease on the radial side of the forearm is extended to the ulnar side of the forearm and then turned 90°.
The longitudinal component of the incision is extended down the ulnar side of the forearm until it reaches the wrist, where it curves medially to the mid-aspect of the volar wrist.
The incision is now extended and curved into the thenar crease of the palm.
By dividing the underlying fascia at the transverse origin of the incision distal to the antecubital crease, the muscles of the lateral (mobile wad) compartment are decompressed.
Fasciotomy of the Volar and Lateral Compartments of the Forearm (Volar-Ulnar Approach) The fascia underlying the longitudinal and wrist components of the skin incision is opened, thereby decompressing the superficial flexor muscles of the forearm and the carpal tunnel. The space between the FCU and FDS muscles (flexing the fingers will help differentiate these muscles) is separated with retractors, and the ulnar nerve and artery are visualized lying on the deep flexor compartment. The deep flexor compartment is opened longitudinally after retracting the ulnar artery and nerve laterally and ligating any small arterial branches in the area where the fasciotomy is to be performed. Ideally, the fascia over each deep volar muscle should be incised. If there is continued tightness at the level of the wrist, the tunnels of the median and ulnar nerves should be divided.
Fasciotomy of the Dorsal Compartment of the Forearm
Pressures in the dorsal compartment of the forearm often return to the normal range following decompression of the volar and lateral compartments.
Therefore, the pressure in the dorsal compartment is reassessed at this time to avoid an unnecessary skin incision and fasciotomy.
After the forearm is pronated, a longitudinal skin incision from 2 cm lateral to and 2 cm distal to the lateral epicondyle of the humerus to the mid-aspect of the posterior wrist is made.
A longitudinal fasciotomy to decompress the superficial muscles of the dorsal compartment is made between the extensor carpi radialis brevis and extensor digitorum communis muscles (extending the fingers will help differentiate these muscles).
Fasciotomy of the Hand
Two 4-cm longitudinal incisions are made on the dorsum of the hand over the metacarpal bones of the index and ring fingers.
Fascial incisions are then made along both sides of these metacarpals, thereby releasing the 4 dorsal interosseous muscles.
The first palmar interosseous and adductor compartments are opened by blunt dissection along the ulnar aspect of the index metacarpal bone.
The second and third palmar interosseous compartments are released by dissection along the radial aspect of the ring and small metacarpal bones.
A longitudinal incision is then made along the radial side of the first metacarpal bone to release the thenar compartment.
A longitudinal incision is made along the ulnar aspect of the fifth metacarpal bone to release the hypothenar compartment.
Reference
Dente CJ, Wyrzykowski AD, Feliciano DV.Fasciotomy. Curr Probl Surg. 2009 Oct;46(10):779-839.
Brodie L, Robert KB, ickson D, Farey N, et al. Emergency Management of Severe Burns. 17th Ed. Australiaand New Zaeland Burln Association. 2013.
Asensio JA, Trunkey DD, eds. Current therapy of trauma and surgical critical care. Philadelphia: Mosby Elsevier; 2007
Hansen JT. Netter’s Clinical Anatomy, 2nd Ed. Philadelphia: Saunders Elsevier. 2010.
Moore KL, Dalley AF. Clinically oriented anatomy, 5th Ed. Philadelphia: Lippincott William & Wilkins. 2006
Netter FH. Atlas of Human Anatomy. 6th Ed. Philadelhia: Elsevier. 2014
Salter RB. Textbook of disorders and injuries of the musculoskeletal system, 3rd Ed. USA: Lippincott William & Wilkins. 1999
Fitzgerald AM, Gaston P, Wilson Y, Quaba A, McQueen MM. Long-term sequelae of fasciotomy wounds. Br J Plast Surg 2000;53:690-3.
Rowland S. Fasciotomy: the treatment of compartment syndrome. In: Green DP, ed. Operative hand surgery. vol. 1, 2 edn. New York: Churchill Livingstone; 1988: 678-679
Jagminas L. Compartment Pressure Measurement. Medscape reference (online) Available at http://emedicine.medscape.com/article/140002.
Irawan H. Sindrom Kompartemen. Medika. 2014. Downloaded from https://www.researchgate.net/publication/323111001
Introduction
Compartment syndrome is a limb and life threatening condition that occurs when perfusion pressure falls below tissue pressure in a closed anatomical compartment .
If left untreated tissue necrosis and sequele, ultimately death
It is found wherever a compartment is present.
What is Compartment Syndrome?
Matsen’s definition 1980
“a compartment syndrome is a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space.”
Causes
Simple cause: THE PRESSURE IS TOO HIGH.
Either – decreased compartment size or increased compartment (fluid) content.
Increased fluid content: Intensive muscle use Burns Intra-arterial injection Infiltrated infusion Haemorrhage
Envenomation
Decreased/limitation compartment size Burns Casts
Tissue Threshold to Ischemia
Muscle 4-8 hrs
Nerve 4-8 hrs
Fat 12 hrs
Skin 24 hrs
Bone 72-96 hrs
Therefore for a viable functional limb the upper threshold is about 6 hrs
Forearm compartments
Superficial Volar Compartment: FCU, FDS, FCR, PT
Deep Volar Compartment: FDP, FPL, FPB, Pronator Quadratus
Dorsal Compartment: ECU, EDQ, EDC, Supinator
Mobile Wad/Lateral Compartment: BR, ECRB, ECRL
The 5 components of a physical examination
Inspection (swelling, trauma, skin changes)
Palpation and passive stretch of muscles in the compartments
Evaluation of sensory function
Evaluation of motor function
Evaluation of perfusion
6P’s + Poikilothermia
Pain
Parasthesia
Palor
Paralysis
Pulselessness
Puffiness
Poikilotermia
NS
Mercury manometer, a 20-mL syringe, intravenous extension tubing, and an 18gauge needle. Movement of the air-saline column after injection of a “small amount of saline” into the tissue is the point at which the compartment pressure is read on the manometer.
After flushing, the hand-held monitor is placed at the level of the compartment to be measured for a “0” reading. The compartment pressure is read off the monitor after allowing for a decrease in the original value over 15 to 20 seconds.
The forearm muscle are very susceptible to ischemia and development compartment syndrome.
Relieve by performing longitudinal incission along the mid medial and mid lateral lines of forearm, extending from just above the elbow down to the wrist
The incision is made through skin and subcutaneous fat to expose the deep fascia which is the incised
Particular care must be taken to protect the ulnar nerve at the elbow
Fasciotomy of the Volar and Lateral Compartments of the Forearm (Volar-Ulnar Approach)
A transverse incision starting distal to the antecubital crease on the radial side of the forearm is extended to the ulnar side of the forearm and then turned 90°.
The longitudinal component of the incision is extended down the ulnar side of the forearm until it reaches the wrist, where it curves medially to the mid-aspect of the volar wrist.
The incision is now extended and curved into the thenar crease of the palm.
By dividing the underlying fascia at the transverse origin of the incision distal to the antecubital crease, the muscles of the lateral (mobile wad) compartment are decompressed.
Fasciotomy of the Volar and Lateral Compartments of the Forearm (Volar-Ulnar Approach) The fascia underlying the longitudinal and wrist components of the skin incision is opened, thereby decompressing the superficial flexor muscles of the forearm and the carpal tunnel. The space between the FCU and FDS muscles (flexing the fingers will help differentiate these muscles) is separated with retractors, and the ulnar nerve and artery are visualized lying on the deep flexor compartment. The deep flexor compartment is opened longitudinally after retracting the ulnar artery and nerve laterally and ligating any small arterial branches in the area where the fasciotomy is to be performed. Ideally, the fascia over each deep volar muscle should be incised. If there is continued tightness at the level of the wrist, the tunnels of the median and ulnar nerves should be divided.
Fasciotomy of the Dorsal Compartment of the Forearm
Pressures in the dorsal compartment of the forearm often return to the normal range following decompression of the volar and lateral compartments.
Therefore, the pressure in the dorsal compartment is reassessed at this time to avoid an unnecessary skin incision and fasciotomy.
After the forearm is pronated, a longitudinal skin incision from 2 cm lateral to and 2 cm distal to the lateral epicondyle of the humerus to the mid-aspect of the posterior wrist is made.
A longitudinal fasciotomy to decompress the superficial muscles of the dorsal compartment is made between the extensor carpi radialis brevis and extensor digitorum communis muscles (extending the fingers will help differentiate these muscles).
Fasciotomy of the Hand
Two 4-cm longitudinal incisions are made on the dorsum of the hand over the metacarpal bones of the index and ring fingers.
Fascial incisions are then made along both sides of these metacarpals, thereby releasing the 4 dorsal interosseous muscles.
The first palmar interosseous and adductor compartments are opened by blunt dissection along the ulnar aspect of the index metacarpal bone.
The second and third palmar interosseous compartments are released by dissection along the radial aspect of the ring and small metacarpal bones.
A longitudinal incision is then made along the radial side of the first metacarpal bone to release the thenar compartment.
A longitudinal incision is made along the ulnar aspect of the fifth metacarpal bone to release the hypothenar compartment.
Reference
Dente CJ, Wyrzykowski AD, Feliciano DV.Fasciotomy. Curr Probl Surg. 2009 Oct;46(10):779-839.
Brodie L, Robert KB, ickson D, Farey N, et al. Emergency Management of Severe Burns. 17th Ed. Australiaand New Zaeland Burln Association. 2013.
Asensio JA, Trunkey DD, eds. Current therapy of trauma and surgical critical care. Philadelphia: Mosby Elsevier; 2007
Hansen JT. Netter’s Clinical Anatomy, 2nd Ed. Philadelphia: Saunders Elsevier. 2010.
Moore KL, Dalley AF. Clinically oriented anatomy, 5th Ed. Philadelphia: Lippincott William & Wilkins. 2006
Netter FH. Atlas of Human Anatomy. 6th Ed. Philadelhia: Elsevier. 2014
Salter RB. Textbook of disorders and injuries of the musculoskeletal system, 3rd Ed. USA: Lippincott William & Wilkins. 1999
Fitzgerald AM, Gaston P, Wilson Y, Quaba A, McQueen MM. Long-term sequelae of fasciotomy wounds. Br J Plast Surg 2000;53:690-3.
Rowland S. Fasciotomy: the treatment of compartment syndrome. In: Green DP, ed. Operative hand surgery. vol. 1, 2 edn. New York: Churchill Livingstone; 1988: 678-679
Jagminas L. Compartment Pressure Measurement. Medscape reference (online) Available at http://emedicine.medscape.com/article/140002.
Irawan H. Sindrom Kompartemen. Medika. 2014. Downloaded from https://www.researchgate.net/publication/323111001
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