Editing Compartment syndrome (section)

== Specific compartments ==

=== Arm ===

** Can get just anterior compartment after failed injections into ACF or both compartments in venous occlusion (lying on arm while overdosed) or crush injuries
** Anterior compartment (deltoid/biceps)
*** Incise medial arm from just distal to deltoid, over biceps, can go across ACF into forearm
** Posterior compartment (triceps)
*** Incise posteriorly over triceps in midline to about 3cm proximal to elbow, or by extending anterior incision proximally to rotator cuff

=== '''Forearm''' ===

** All three compartments can be compromised after burns or extensive long bone trauma with vascular reconstruction
** '''Volar''' - wrist and hand flexors - most commonly affected
*** Contains FDP, FPL and pronator quadratus, all supplied by anterior interosseous artery
*** ''AIA is especially vulnerable to occlusion by compartment pressures''
*** Subcutaneous street drug injection, extravasation of IVF, or insect bites
*** Technique:
**** Incise at lateral part of elbow, descending medially in a curved manner for the proximal half of forearm, then curving laterally down to just above wrist along the ulnar side of FCU tendon (this incision also decompresses lateral compartment). Incorporate the palm by crossing the wrist flexor crease then incising in line with the radial border of the ring finger - basically to line up with carpal tunnel decompression. This incision also endorsed in Valentine's.
**** Large veins crossing incision path often require ligation
**** Elevate the flap along its entire length by developing the plane between fascia and muscle
**** Separate FCU and FDS, including the ulnar neurovascular bundle with the FDS
**** In most cases, the dorsal compartment muscles will be adequately decompressed by the full length volar decompression
** '''Dorsal''' - extensors
*** 6-8cm incision in line from the lateral epicondyle to the radial styloid allows release
** '''Lateral''' - brachioradialis and ECRL and ECRB
*** See above
**

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=== Hand/foot ===

** Rare
** Try to avoid incising palm/sole
**

=== Buttock ===

** The three major muscles each have their own fascial compartment
** No universal technique
** Longitudinal incision most frequently described

=== Thigh - rare ===

** Occurs with crush injury, venous outflow obstruction, or extensive trauma (explosions/high-velocity rifle)
** Likely to involve all three compartments when it occurs
** Anterior - sartorius, quad femoris, femoral nerve
*** Almost always get pain with passive motion
*** Technique:
**** Incise from GT posterolaterally to just above the lateral epicondyle
**** Expose iliotibial band and incise longitudinally along the length of the skin incision, which decompresses the anterior compartment
** Medial - gracilis, adductor, obturator nerve
*** Medial incision which stays posterior to Hunter's canal and opens the fascia over the gracilis and adductor muscles
*** Decompression is rarely necessary, but can be done through a medial incision over the adductor group
** Posterior - biceps femoris, semitendinosus, semimembranosus, sciatic nerve
*** Technique:
**** Same incision as above
**** Then reflect vastus lateral medially to expose the lateral intermuscular septum, which is incised over the length of the skin incision to release the posterior compartment
**

=== Calf - '''most common location for compartment syndrome''' ===

** Four-compartment fasciotomy is generally done with two incisions
** Anterior - tibialis anterior, EHL, EDL, part of peroneus tertius, deep peroneal nerve (check sensation first dorsal webspace and ability to extend big toe)
*** Anterior compartment syndrome occurs after a period of increased physical activity, before the anterior calf tightened and became extremely painful. Needs urgent decompression by an incision from tibial tuberosity to just above the ankle in the midpoint of the anterior compartment mass.
** Lateral - peroneus longus and brevis, superficial peroneal nerve
** Superficial posterior - soleus, gastrocnemius, plantaris
*** Technique:
**** Be wary of injury to SPN - branches from common peroneal nerve at or below the proximal fibular head
** Deep posterior - FHL, TP, FDL, popliteus. Peroneal artery, posterior tibial artery, deep peroneal nerve.

=== '''Four-compartment decompression (double-incision technique):''' ===

*** Use a generous incision - 12-20cm - on both sides
*** Lateral/anterior: 
**** Incise between fibular shaft and crest of tibia (about 4cm lateral to crest of tibia), right over the intermuscular septum between the anterior and lateral compartments. 
**** Raise skin flaps medially and laterally to expose the fascia of the anterior and lateral compartments
**** Clearly identify the intermuscular septum so you can be sure they are both decompressed
**** Open both anterior and lateral compartments with separate, parallel, 12-20cm fascial incisions using Metz scissors (elevate scissors off muscle to avoid injury to nerves, and terminate incisions 5cm distal to fibular heads to avoid the nerves there)
*** Posterior compartments:
**** Incise 1-2cm posterior to tibia, avoiding GSV and nerve
**** Decompress superficial posterior compartment with a longitudinal incision along gastrocnemius fascia
**** To decompress the deep posterior compartment, divide the attachments of the soleus muscle to the tibia or push them away bluntly, exposing the fascia overlying tibialis posterior and the flexor muscles of the foot, then incise the fascia longitudinally, avoiding injury to the posterior tibial artery. Need to see the posterior tibial neurovascular bundle to be assured of having decompressed the deep compartment.
** Single-incision technique
*** Single incision over fibula down to lateral malleolus
*** Most surgeons now favour double-incision technique
** Selective decompression:
*** If opening the lateral, anterior and superficial posterior compartments normalises the pressure in the deep posterior compartment, no further decompression is required
**

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=== Post-op management ===

* Goals:
** Prevent further muscle injury or necrosis until muscle swelling subsides sufficiently to permit closure
* Dress open wounds with dry gauze and a soft wrap and elevate
* If questionable viability, saline gauze with daily review and debridement
* Consider VAC if extensive drainage, but not preferable right afterwards
* Posterior splint of leg recommended to prevent foot drop
* Some fasciotomy incisions can be closed in 5-7 days, but avoid closing too soon
* Closure:
** Delayed primary closure - only for cases with minimal/non-existent muscle swelling, and don't generally do it early post-op
** Closure by secondary intention - only if medically or nutritionally ill-suited for other options
** Gradual dermal apposition
** STSG
** Myocutaneous flap coverage - for coverage of neurovascular structures or exposed bone in a limb that remains functional

=== Complications: ===

* Early:
** Death - 11-15%
** Major amputations - 5-21%
** Wound complications - 4-38%
** Renal failure - mainly if significant myonecrosis
** Neurological defects 7-36%
* Late:
** Impaired sensation at margins of wound 77%
** Tethered tendons 7%
** Recurrent ulcerations at fasciotomy site 13%
** Chronic venous insufficiency 47%
** Late amputation 7%
** Volkmann contracture (for missed compartment syndrome) - ischaemic muscle and nerve replaced by fibrosis

[[Category:Skin, soft tissue and wounds]]