Fasciotomy - Surgical Procedure

What is Fasciotomy?

Fasciotomy is a surgical procedure where the fascia is cut to relieve the compartmental pressure in patients with compartment syndrome of the limbs. Fascia is a tough limiting inelastic fibrous membrane that surrounds muscles, nerves and blood vessels and binds them into compartments.

Compartment syndrome is a painful condition with an increase in the pressure of the compartment (muscles, nerves and blood vessels which are covered by fascia) of upper or lower limbs. It leads to a compromise in the blood supply to the muscles and nerves in the compartment and hence reduces the function. The symptoms and signs of compartment syndrome are a disproportionate pain, paresthesia, pain on passive stretching of the muscles, paralysis of muscles, progressive tension in the compartment and pulses are present.

Why is the Fasciotomy Performed?

Fasciotomy is performed to treat a painful condition called compartmental syndrome. Certain conditions like fractures or injury to muscles can increase the pressure within the compartment resulting in compartmental syndrome. The condition compromises blood supply to the muscles, affects the function of nerves in the compartment and injures tissues. The symptoms and signs of compartment syndrome are disproportionate pain, tingling and numbness, pain on passive stretching of the muscles and paralysis of muscles.

Surgical incision or splitting of the fascia reduces the pressure and hence further damage to the structures in the compartment.

What are the Indications of Fasciotomy?

Fasciotomy is performed for the following conditions:

Acute Compartment Syndrome: Fasciotomy helps to salvage the limb in acute cases.

The following are a few causes of acute compartment syndrome:

• Fracture of the limb bones
• Constricting bandages
• Casts of the limbs
• A crush injury
• A snake bite

Chronic Compartment Syndrome: Chronic compartment syndrome is seen among the athletes due to an increase in the muscle mass. It is not an emergency but fasciotomy is necessary if all other conservative measures fail.

A compartment pressure of more than 30mm of Hg is generally considered as an indication for fasciotomy.

What are the Contraindications of Fasciotomy?

Fasciotomy is contraindicated if the diagnosis of the compartment syndrome is made late.

What are the Tests done before Fasciotomy?

The doctor will first confirm the presence of a compartment syndrome through a complete medical history and a physical examination. Acute compartment syndrome is a medical emergency and you may be taken for an operation without any tests. Tests like x-ray or measurement of compartment pressure may be used to confirm the diagnosis of chronic compartment syndrome. Once the surgery is finalized, you will need to undergo certain tests to confirm that you are fit for the surgery. Tests done before fasciotomy may include the following:

• Blood tests including full blood count, liver and kidney function tests, blood glucose estimation, bleeding and clotting times, viral serology to include hepatitis B, hepatitis C and HIV, and blood grz
• Urine tests to rule out diabetes, kidney disease or urinary infection
• Chest x-ray and electrocardiogram (ECG) to rule out lung or heart disease that may impact the type of anesthesia or the choice of anesthetic agent used for the surgery

What are the Preparations required before Fasciotomy?

Before a planned fasciotomy surgery, you will be advised the following:

• Certain medications such as aspirin, anticoagulants or NSAIDs that you may be taking regularly should be stopped at least 2 weeks prior to the surgery as they increase the risk of bleeding
• You will have to get admitted to the hospital on the evening before the surgery. You will not permitted to eat or drink anything after 10PM. Intravenous fluid may be occasionally required to keep you well hydrated. Sedation may be required for good overnight sleep before the surgery
• Certain medications may be prescribed the night before surgery to reduce airway secretions before and during surgery and to keep you calm

What is the Procedure followed for a Fasciotomy Procedure?

Shift to the Operating room - The ambience in the operating room can sometimes be very daunting and a small amount of sedation can help overcome your anxiety. When you are shifted to the operating table, you will see the operating light console and at the head end will be the anesthesia machine. There may also be monitors to check oxygen levels, ECG and other vital parameters. A constant beeping sound may be present from the monitors, which may sometimes be irritating.

Anesthesia before surgery - The fasciotomy surgery is usually performed under general anesthesia due to which you will be asleep during the procedure. Regional anesthesia is also sometimes used, where an anesthetic is injected to numb the entire limb where the surgery is being carried out.

During general anesthesia, the anesthetist will inject drugs through an intravenous line and make you inhale some gases through a mask that will put you in deep sleep. Once you are in deep sleep, a tube will be inserted into your mouth and windpipe to administer the anesthesic gases to overcome pain and keep you comfortable during the surgery.

The limb where the fasciotomy is planned is prepared and draped. A skin incision is made, the underlying fascia is identified and an incision is made on the fascia to relieve the pressure. The location of the incisions depend on the part affected.

• Thigh: The thigh has 3 compartments anterior, medial and posterior, separated by the lateral, medial and posterior intermuscular septa. A longitudinal skin incision on the outer aspect of the thigh is required to decompress the anterior and posterior compartments, followed by incision of the underlying fascia. The fascia lata is also incised to decompress the anterior compartment and while the lateral intermuscular septum is incised to decompress the posterior compartment. A 30cm medial skin incision along the course of saphenous vein, along with a longitudinal incision on the fascia is also required to decompress the medial compartment.
• Leg: The leg has 4 compartments anterior, lateral, superficial posterior and deep posterior, formed by the anterior, posterior and transverse intermuscular septa. The skin is incised via one or two longitudinal incisions. The intercompartmental borders are identified, and the relevant fascia over the affected compartment is released. Care should be taken not to damage the great saphenous vein and the saphenous nerve.
• Foot: Foot compartment syndrome is seen in calcaneal fractures and crush injuries of the foot. The foot has 9 compartments. An incision on the inner aspect just below the medial malleolus, the bony prominence of the inner aspect of the foot where it joins the leg, provides access to most foot compartments. An incision just along the inner side of the second metatarsal bone provides access to the first and second interosseous, and medial compartments. An incision just along the outer edge of the fourth metatarsal bones provides access to the third and fourth interosseous compartments, and the lateral, superficial and calcaneal compartments.
• Arm: An arm consists of the two compartments, the anterior (flexor) and posterior (extensor) compartment. They are separated by the medial and lateral intermuscular septa. Compartment syndrome of the arm is relatively rare. During fasciotomy, a longitudinal skin incision is made, the intermuscular septum is identified and the fascia over the affected compartment is incised. Care should be taken not to damage important nerves and blood vessels.
• Forearm: The forearm has 3 compartments, the volar (flexor), dorsal (extensor) and lateral or mobile wad. Skin incisions can be made on the volar and the dorsal aspects before separating the underlying fascia, including the carpal tunnel if necessary.
• Hand: The hand has thenar, hypothenar, adductor and 4 interosseous compartments. Two incisions on the back of the hand on the 2^nd and 4^th metacarpals followed by fascial incisions help to open the interosseous muscles. To open the thenar muscles, a longitudinal incision on the outer side of the first metacarpal is to be made. To open the hypothenar muscles, an incision on the inner aspect of the 5^th metacarpal is required.

The wound is not sutured following the fasciotomy and is covered with a dressing.

What happens after Fasciotomy Surgery?

• If you have received general anesthesia during the surgery, once the surgery is over, you will wake up and the tube down the wind pipe will be removed. You will be asked to open your eyes before the tube is removed. You will be sedated and the voice of the anesthetist may be faint. Once the tube is out, you may have cough and sometimes nausea. There will also be an intravenous line, and may have a nasogastric tube going into your stomach. You will remain on oxygen.
• Once fully awake, you will be shifted on the trolley and taken to the recovery room adjacent to the operation theatre. Your vital signs will be monitored for a few hours and if stable, you will be shifted back to your room
• You will be encouraged to move from your bed early to prevent deep vein thrombosis.
• Oral painkiller and antibiotics will be prescribed.
• The affected limb should be elevated for 1-2 days after the fasciotomy.
• After the tissue swelling reduces, the focus should be laid on the wound care. The wound will be closed by the delayed primary closure, where the edges of the wound are sutured together, or partial thickness skin graft or rarely, rotational or free skin flaps.

What are the Long-term Adverse Effects of Fasciotomy?

Long-term adverse effects of fasciotomy include the following:

• Chronic limb pain
• Altered sensation
• Edema (swelling due to fluid accumulation)
• Contracture
• Muscle herniation, where the muscle may pop out of the fasciotomy incision
• Dry skin
• Pruritus or itching
• Discoloration of skin
• Venous ulceration