Fasciotomy for Acute Compartment Syndrome of the Leg

Overview

Compartment syndrome is an elevation of interstitial pressure in a closed osteofascial compartment that causes microvascular compromise (Campbell). It arises from a vicious cycle of tissue swelling, rising compartment pressure, falling perfusion pressure and local hypoxia (AO). Experimental evidence suggests significant muscle necrosis can occur when intracompartmental pressure exceeds 30 mm Hg for more than 8 hours, and higher pressures cause damage faster (Campbell). The anterior and deep posterior compartments of the leg and the volar forearm are most commonly involved (Campbell).

Between 2.8% and 4.3% of patients with tibial fractures need fasciotomy for acute compartment syndrome (Campbell).
Young age (young men with thick, noncompliant fascia) is the most important risk factor; more than two-thirds of cases are associated with a fracture, most often tibial diaphyseal fractures (Rockwood, AO).
Other risk factors: open fractures (2.2-3.8 times higher risk), crush injuries, gunshot or penetrating injury, vascular injury with ischemia-reperfusion, blunt soft-tissue injury and anticoagulation (Campbell, AO).
Early treatment is essential: good results in 68% when fasciotomy is done within 12 hours versus 8% after 12 hours (Campbell).

Diagnosis

Clinical findings (Campbell, AO)

Pain out of proportion to the injury is the most important sign; pain with passive stretch of muscles in the compartment, a tense compartment, paresthesia or hypesthesia and weakness (Campbell).
Motor weakness is a late finding; pulses are usually present because compartment pressure rarely exceeds systolic pressure (AO).
In unconscious patients, unexplained tachycardia or a rising lactate may be a sign once other causes are excluded; increasing patient-controlled analgesia requirements should alert the team (AO).
Clinical findings have low sensitivity and positive predictive value but high specificity and negative predictive value; absence of findings is more useful to exclude the diagnosis than their presence is to confirm it (Campbell).

Pressure measurement

Measure intracompartmental pressure (ICP) when the examination is unreliable: multiple injuries, altered consciousness, children, regional or epidural anesthesia, nerve injury (Campbell).
Perfusion pressure (delta P) = diastolic blood pressure - ICP. A delta P below 30 mm Hg indicates hypoxia and anaerobic metabolism (AO). Example: 78 - 51 = 27 mm Hg (AO).
AAOS guidance cited by Campbell uses a delta P cutoff of less than 30 mm Hg.
Pressure measurements can be erroneous in 30-35% of patients and should not be the sole determinant; combining examination and pressure raises positive predictive value to 69% (Campbell).
A single reading of delta P 30 mm Hg or less, without its trend, gave a false-positive rate of 35%; fasciotomy should not be based on a single measurement except in extreme cases (Rockwood).
Edinburgh protocol (Rockwood): continuous anterior compartment monitoring; fasciotomy when delta P stays at 30 mm Hg or less for more than 2 hours. If delta P is below 30 but rising while ICP falls, continued observation is safe. Rockwood recommends continuous monitoring in all at-risk patients, which in practice means almost all tibial fractures.
Measure the anterior compartment; measure the deep posterior compartment if symptoms are unexplained by anterior pressures. Deep posterior measurements are known to be unreliable (Rockwood, AO).

Diagnostic algorithm (Campbell, after Bourne and Rorabeck)

Unequivocal clinical findings: fasciotomy.
Unreliable patient or polytrauma, or inconclusive findings: measure pressure.
Pressure criterion met: fasciotomy. Not met: continuous monitoring and serial examination, with fasciotomy if the criterion is reached.

Initial Management (Campbell, AO, Rockwood)

Split the cast and underlying padding and release constrictive dressings; this lowers compartment pressure by 50-85% (Campbell).
Place the limb at the level of the heart; elevation reduces arterial inflow and increases ischemia (Campbell, AO).
Correct hypotension and give oxygen to maximize perfusion and saturation (Rockwood).
If symptoms do not resolve within 30-60 minutes and readings remain equivocal, perform fasciotomy without delay (Campbell).
Avoid excessive traction, a misplaced thigh bar and excessive leg elevation (90-90) during tibial fracture fixation in at-risk patients (Rockwood).
Treat rhabdomyolysis with rapid fluid resuscitation in intensive care to prevent renal failure (Campbell).
In major arterial disruption or circumferential full-thickness burns, perform fasciotomy at the initial surgery (Campbell); after arterial repair, prophylactic distal fasciotomy is recommended (AO).

Principles of Fasciotomy

Skin incisions must extend over the full length of the affected compartment; limited or subcutaneous fasciotomy has no place in acute compartment syndrome (Rockwood). Percutaneous fasciotomy is not indicated in trauma because intact skin can itself maintain the syndrome (AO).
Release all four compartments of the leg even if pressure is high in only one or two (AO, Rockwood). Selective release protocols exist but require pressure checks every 2 hours and rapid access to theatre; four-compartment release is safer for most patients (Campbell).
Increasing limb diameter by 2 cm with fasciotomy increases compartment volume by about 44% (AO).
Fibulectomy-fasciotomy is unnecessarily destructive, risks the common peroneal nerve and is contraindicated in trauma (Rockwood, AO).
The double-incision technique is generally safer and more effective, because the soft tissues of the injured leg are rarely undistorted; all fascial incisions are superficial and it is faster. Both techniques lower pressure equally (Campbell, Rockwood).
Perform fasciotomy before fracture stabilization to avoid delaying decompression; then stabilize the fracture, which protects the soft tissues. Reamed nailing does not increase compartment pressure (Rockwood).

Technique 53.3: Double-Incision Fasciotomy (Mubarak and Hargens) (Campbell)

Make a 20- to 25-cm anterolateral incision centered halfway between the fibular shaft and the tibial crest. Use subcutaneous dissection for wide exposure of the fascial compartments.
Make a small transverse fascial incision to expose the lateral intermuscular septum and identify the superficial peroneal nerve just posterior to the septum.
With Metzenbaum scissors, release the anterior compartment proximally and distally in line with the tibialis anterior.
Release the lateral compartment proximally and distally in line with the fibular shaft.
Make a second longitudinal incision 2 cm posterior to the posterior margin of the tibia, with wide subcutaneous dissection to identify the fascial planes.
Retract the saphenous vein and nerve anteriorly.
Make a transverse incision to identify the septum between the deep and superficial posterior compartments. Release the fascia over the gastrocnemius-soleus complex for the length of the compartment (superficial posterior).
Make another fascial incision over the flexor digitorum longus and release the entire deep posterior compartment. Proximally, if the soleus bridge extends more than halfway down the tibia, release this extended origin.
After posterior release, identify the tibialis posterior muscle compartment; if tension is evident, release it over the extent of the muscle belly.
Pack the wound open or apply a negative pressure device, and apply a posterior plaster splint with the foot plantigrade.

Anatomic pearls (Rockwood)

The superficial peroneal nerve usually pierces the fascia about 10 cm above the lateral malleolus; its course varies (about three-quarters remain in the lateral compartment, one-quarter pass to the anterior compartment).
Place the medial incision about 1-2 cm posterior to the medial tibial border, leaving an adequate skin bridge, and anterior to the posterior tibial artery to preserve perforators for local fasciocutaneous flaps.
The deep posterior compartment is most easily identified in the distal third of the leg; it may be necessary to elevate the superficial muscles from the tibia for a short distance to release it fully.
Inspect every muscle group for viability and debride necrotic muscle carefully.

Technique 53.2: Single-Incision Fasciotomy (Davey et al.) (Campbell)

Useful when the soft tissues are not extensively distorted.

Make a single lateral longitudinal incision in line with the fibula, from just distal to the fibular head to 3-4 cm proximal to the lateral malleolus.
Undermine the skin anteriorly, protecting the superficial peroneal nerve.
Perform longitudinal fasciotomy of the anterior and lateral compartments.
Undermine the skin posteriorly and release the superficial posterior compartment.
Distally identify the interval between the superficial posterior and lateral compartments and develop it proximally by detaching the soleus from the fibula.
Dissect the flexor hallucis longus subperiosteally from the fibula.
Retract the muscle and peroneal vessels posteriorly.
Identify the fascial attachment of the tibialis posterior to the fibula and incise it longitudinally.
Close only the skin over a suction drain or negative pressure device.

Prepare and drape from the iliac crest to the knee.
Make a lateral incision from just distal to the intertrochanteric line to the lateral epicondyle.
Incise the iliotibial band in line with the skin incision.
Reflect the vastus lateralis off the lateral intermuscular septum, coagulating perforating vessels.
Make a 1.5-cm incision in the lateral intermuscular septum and extend it proximally and distally with Metzenbaum scissors (anterior and posterior compartments released).
Measure the medial compartment pressure; if elevated, release the adductor compartment through a separate medial incision.
Pack the wound open and apply a bulky dressing.

Thigh compartment syndrome outcomes are better if decompression is done within 8 hours; a delay of more than 12 hours increases complications (Campbell).

Postoperative Care and Wound Management

Fasciotomy wounds should never be closed primarily because pressure may remain elevated (Rockwood).
Return to theatre at 48-72 hours for debridement of necrotic tissue; IV fluorescein and a Wood light can help assess muscle viability. If there is no necrosis, close the skin loosely or use a negative pressure device; otherwise repeat debridement after another 48-72 hours, then close or skin graft (Campbell).
Delayed primary closure can be achieved gradually with a vessel-loop shoelace technique or commercial devices; split-thickness skin grafting is needed in about 50% of patients (Campbell). Tension-free final closure often requires a skin graft (AO).
Vacuum-assisted closure may reduce edema and the need for skin grafts (Campbell, Rockwood).

Complications and Late Presentation

Delay in diagnosis is the main cause of failure; delaying fasciotomy beyond 6 hours is likely to cause important sequelae (Rockwood).
Missed compartment syndrome leads to muscle necrosis and contracture (Volkmann ischemic contracture), permanent nerve damage, infection, chronic pain, nonunion and amputation; a little over 5% of tibial fracture patients undergoing fasciotomy ultimately require amputation in American registry data (Rockwood, AO).
If surgery is delayed more than 12 hours, infection risk in ischemic muscle rises (Campbell).
In a late, closed crush injury with established total muscle necrosis, surgical exploration offers little except when amputation is required or systemic effects are severe (Rockwood).

References

Bernholt DL, Azar FM. Traumatic disorders. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 53, Techniques 53.1-53.3.
Bernstein B. Soft-tissue injury: pathophysiology, evaluation, and classification. In: Buckley RE, Moran CG, Apivatthakakul T, eds. AO Principles of Fracture Management. 3rd ed. Stuttgart: Thieme; 2017. Chapter 1.5. (Turkish edition: AO Kırık Tedavisinin Prensipleri.)
Acute compartment syndrome. In: Tornetta P III, Ricci WM, Ostrum RF, McKee MD, Ollivere BJ, de Ridder VA, eds. Rockwood and Green's Fractures in Adults. 10th ed. Philadelphia: Wolters Kluwer; 2024. Chapter 17. (Turkish edition: Erişkin Kırıkları.)