Acute Compartment Syndrome & Fasciotomy

Objectives

This guideline covers the diagnosis of acute compartment syndrome and procedural guidance for the treatment, which is urgent surgical fasciotomy of the affected limb(s).

Scope

This guideline covers all echelons of deployed surgical care (i.e. R2 and higher).

Audience

The target audience is deployed surgical teams.

Initial Assessment & Management

Diagnosis

In the deployed setting this is a clinical diagnosis. The decision to perform fasciotomy must be made in the context of the resource limitations on the surgical team and the evacuation timelines to the next surgical facility.

Failure to perform this procedure on a patient with compartment syndrome will lead to functional loss or amputation

The Awake patient

Severe unremitting pain out of proportion to the injury is the hallmark clinical finding. Severe pain on passive stretch of the muscles running in the compartment can add weight to the diagnosis but is not always reliable. Do not wait for signs of vascular compromise (pallor, pulselessness, cold extremity, distal weakness and numbness), pulse may continue to be palpable in compartment syndrome. Numbness in the first web space (deep peroneal nerve) is described as being indicative of compartment syndrome of the anterior compartment of the leg but this sign is not to be relied upon in isolation. Common causes of acute compartment syndrome in the deployed setting are severe trauma and/or ischaemia from vascular trauma or tourniquet use.

Unconscious Patients

The decision to perform fasciotomies in these patients is made primarily on injury pattern and mechanism of injury. Examination finding of a firm compartment is unreliable. Using the anaesthetic equipment to create a compartment pressure monitor is described in the literature but should not form part of routine deployed surgical care. The guiding principle in unconscious patients is that if the treating team are concerned about compartment syndrome then fasciotomy should be performed without delay.

All Patients

Any patient with limb ischaemia (tourniquet, vascular injury, etc) longer than 6 hours should undergo fasciotomy of compartments distal to the point of ischaemia. The 6-hour limit is based on convention rather than strong evidence so deviation may be made based on clinical judgement and fasciotomy after significantly shorter ischaemic time is supported. The longer the evacuation timeliness from the surgical facility, the lower the threshold should be for performing fasciotomy, both in terms of ischaemic time and diagnostic confidence.

Non-surgical management

in awake patients where the likely cause is due to tight dressings or a plaster cast, the immediate management is to release the compressing layers down to skin. The patient is then monitored carefully. If their pain resolves significantly upon releasing the layers then a non-operative management plan may be considered. Alternative methods of controlling unstable extremity fractures will need to be performed such as external fixation or traction.

Delayed Presentation Beyond 8 Hours

The management of patients with missed or delayed presentation of acute compartment syndrome is controversial. This is because the muscles and nerves in the compartment are likely to be irreversibly damaged after 8 hours. In this context, creating large surgical wounds that may become infected may commit the patient to amputation. Late fasciotomy for delayed presentation or missed diagnosis of compartment syndrome is associated with a high amputation rate. The literature does not provide clear guidance for what is defined as “late” nor what is the best way to manage these patients. Therefore the senior clinical decision-makers present must use their judgement in this situation, taking into account all of the contextual factors of the deployed setting.

Advanced Assessment & Management

Fasciotomy - Surgical Guidelines

Equipment Required

Surgical Instruments (see Fig 1):

• 10 Blade
• McIndoe scissors
• Forceps, toothed, large & small (Gillies & Lanes)
• Diathermy
• Mayo scissors

For the Dressing

• Non-adherent base layer
• Velband
• Crepe
• POP if necessary to stabilise limb 

Patient Position

Supine/Crucifix, arm boards to be used. All dressings/splints should be removed for prep. The limb should be socially washed prior to prep. Betadine and water in a bowl with large swabs can be used for this social wash.

Prep and Drape

Prep beyond joints above and below limb for fasciotomy. Limb to be elevated for circumferential preparation. U-drapes to be fashioned from universal drapes and applied above proximal joint, a cut off drape or glove to cover extremity beyond distal joint.

Surgical Approaches

In all cases, the length of the fasciotomy incisions must be the full length of the affected compartment.

All necrotic tissue must be excised according to the principles described in the wound excision CGO.

Closure

Do not close fasciotomy wounds in the forward (Role 2) deployed setting unless there are strong contextual reasons to do so (see Prolonged Field Care below). 

Do not use sloops to partially close fasciotomy wounds. Standard dressing with a non-adherent layer then velband and crepe is acceptable.

If available, negative pressure dressings can be used but are not essential in this setting. Fasciotomy patients with negative pressure dressings must be monitored closely as these dressings can, rarely, induce secondary compartment syndrome due to their mode of action. In these cases, the vacuum must be immediately released and not reintroduced for at least 48 hours.

Post-Operative Management

Analgesia

Post-op bloods (Hb, renal function if available)

Antibiotics (1.2 g Co-Amoxiclav IV TDS) until definitive closure

Plan for return to theatre for relook and/or closure within 48-72 hours, ideally at Role 3

Evacuate via stretcher

Prolonged Casualty Care

Wound Care

If the dressings adequately control wound exudate and post-op bleeding then they should be left undisturbed until second look in theatre in 48-72 hours. Excessive bleeding might require a return to theatre to identify the source.

Further Surgery

If second-look surgery is required, the timing will be driven by operational context but should be no longer than 72 hours after initial surgery. If the wounds are found to be healthy at second look then closure may be considered. If direct closure of both wounds is not possible, consider closing one side and re-dressing the other. In cases where the wounds cannot be closed, the options are 1. allowing the wound to heal by secondary intention or 2. repatriation to Role 4 for definitive surgical management.

Paediatric Considerations

Within the context of deployed surgical care, there are no practical differences between adults and children in terms of the management of acute compartment syndrome.

Note, however, that compartment syndrome is comparatively rare in children and that children externalise pain differently to adults so the diagnosis may be more challenging than in adults.