Fasciotomy: Lower Extremity

Fasciotomy: Lower Extremity

David Ray Velez, MD

Table of Contents

Buttock Fasciotomy
Thigh Fasciotomy
Calf Fasciotomy
Foot Fasciotomy

See Also:
*See Compartment Syndrome
*See Fasciotomy

Buttock Fasciotomy

Buttock Compartments (x3)

  • Gluteus Maximus
  • Gluteus Medius and Gluteus Minimus
  • Tensor Fascia Lata

Buttock Fasciotomy Technique

  • Technique is Not Well Standardized
  • Incision: Longitudinal Incision Over the Lateral Hip
  • Releases All Three Muscle Compartments

Buttock Fasciotomy 1

Thigh Fasciotomy

Thigh Compartments (x3)

  • Anterior (Quadriceps and Sartorius)
  • Posterior (Hamstring)
  • Medial/Adductor

Thigh Fasciotomy Technique

  • Incision: Longitudinal Skin Incision Over the Lateral Thigh
    • Alternative: Can Make Two Separate Anterior/Posterior Incisions for Each Compartment Separately
  • Release the Anterior and Posterior Compartments
  • May Also Consider a Separate Medial/Adductor Incision
    • Generally Omitted as the Medial Compartment Rarely Develops Compartment Syndrome

Thigh Compartments

Thigh Fasciotomy

Calf Fasciotomy

The Most Commonly Performed Fasciotomy in Trauma

Calf Compartments (x4)

  • Anterior
    • Muscles: Tibialis Anterior, Extensor Hallucis Longus, and Extensor Digitorum Longus
    • Vascular: Anterior Tibial Artery
    • Nerve: Deep Peroneal Nerve (Dorsiflexion and First Webspace Sensation)
  • Lateral
    • Muscles: Peroneus Brevis and Peroneus Longus
    • Nerve: Superficial Peroneal Nerve (Eversion and Lateral Foot Sensation)
  • Deep Posterior
    • Muscles: Tibialis Posterior, Flexor Hallucis Longus, and Flexor Digitorum Longus
    • Vascular: Posterior Tibial Artery and Peroneal Artery
    • Nerve: Tibial Nerve (Plantar Flexion)
  • Superficial Posterior
    • Muscles: Gastrocnemius and Soleus
    • Nerve: Sural Nerve

The Anterior Compartment is the Most Commonly Affected Compartment and Generally the First to Be Affected (First Web Space Numbness is an Early Finding)

Calf Fasciotomy: Double-Incision Technique

  • Most Common Approach – Easier to Access Deep Posterior Compartment
  • Anterolateral Incision:
    • 15-20 cm Vertical Incision Midway Between Tibia and Fibula
    • Incise the Anterior Fascia Longitudinally – Just Anterior to the Intermuscular Septum
    • Incise the Lateral Fascia Longitudinally – Just Posterior to the Intermuscular Septum
    • Incise the Intermuscular Septum Transversely to Create an “H”
    • *Protect Superficial Peroneal Nerve (Around the Neck of the Fibula) – Most Common Nerve Injured
  • Posteromedial Incision:
    • 15-20 cm Vertical Incision 1-2 cm Posterior to Posterior Border of Tibia
      • Take Care to Avoid Saphenous Vein Injury
    • Incise the Superficial Posterior Fascia Just Under the Skin Incision
    • Detach the Soleus from the Tibia to Release the Deep Posterior Compartment

Calf Fasciotomy: Single-Incision Technique

  • Single Lateral Incision: 15-18 cm Vertical Incision Just Anterior to Fibula
  • Directly Incise the Anterior and Lateral Compartments – Similar to the Anterolateral Incision of the Double-Incision Technique
    • Incise the Anterior Fascia Longitudinally – Just Anterior to the Intermuscular Septum
    • Incise the Lateral Fascia Longitudinally – Just Posterior to the Intermuscular Septum
    • Incise the Intermuscular Septum Transversely to Create an “H”
    • *Protect Superficial Peroneal Nerve (Around the Neck of the Fibula) – Most Common Nerve Injured
  • Raise a Small Posterior Flap to Access and Incise the Superficial Posterior Compartment
  • Reflect the Soleus from Fibula Through the Posterior Flap to Release the Deep Posterior Compartment

Calf Compartments

Calf Fasciotomy

Foot Fasciotomy

Foot Compartments (x4-9, Debated)

  • Interosseous – May Be x4 Separate Compartments
  • Medial
  • Lateral
  • Central – May Be x3 Separate Compartments (Superficial, Middle, and Deep)

Foot Fasciotomy Technique

  • Dual Dorsal Incisions:
  • Medial Incision: Along Medial Margin of Second Metatarsal
    • Releases the 1st/2nd Interosseous, Medial, and Deep Central Compartments
  • Lateral Incision: Along Lateral Margin of Fourth Metatarsal
    • Releases the 3rd/4th Interosseous, Lateral, Superficial Central, and Middle Central Compartments
  • May Consider Adding a Medial Incision to Release the Calcaneal Compartment

Foot Fasciotomy

Foot Fasciotomy – Calcaneal Compartment Release

Foot Fasciotomy – Depth 2

References

  1. Diaz Dilernia F, Zaidenberg EE, Gamsie S, Taype Zamboni DE, Carabelli GS, Barla JD, Sancineto CF. Gluteal Compartment Syndrome Secondary to Pelvic Trauma. Case Rep Orthop. 2016;2016:2780295. (License: CC BY-4.0)
  2. Raza H, Mahapatra A. Acute compartment syndrome in orthopedics: causes, diagnosis, and management. Adv Orthop. 2015;2015:543412. (License: CC BY-3.0)