A fasciotomy is a surgical procedure involving an incision into the fascia, which is the tough, fibrous connective tissue that encases muscles and other soft tissues in the body. This operation is most often performed as an emergency treatment to relieve dangerously high pressure that has built up within a muscle compartment. The procedure is intended to restore blood flow and prevent irreversible damage to the muscles and nerves within the affected area. While sometimes used for chronic conditions, a fasciotomy is typically an urgent intervention to address a limb-threatening medical situation.
Understanding the Fascia and Compartment Syndrome
The fascia is a continuous sheath of connective tissue, primarily made of collagen, that wraps around and supports nearly every structure in the body, including muscles, nerves, and blood vessels. In the arms and legs, the deep fascia divides muscles into distinct groups called fascial compartments. This compartmentalization allows muscles to function independently and provides a protected pathway for neurovascular structures.
Compartment Syndrome (CS) is the primary medical scenario that necessitates an emergency fasciotomy. This condition occurs when swelling or bleeding within one of these rigid fascial compartments causes the internal pressure to rise significantly. The fascia, being non-elastic, cannot expand quickly enough to accommodate the increased volume.
The elevated pressure within the tight compartment acts like a tourniquet, compressing the veins and small arteries that supply the muscles and nerves. When the pressure exceeds a certain threshold, it compromises blood flow, leading to a state of oxygen deprivation, known as ischemia. If this pressure is not relieved promptly, the lack of oxygen causes muscle and nerve tissue to die, a process that can begin within hours.
Untreated acute compartment syndrome can lead to permanent nerve damage, muscle necrosis, and potentially the need for limb amputation. A fasciotomy is the only effective treatment to immediately decrease the compartment pressure and restore circulation. This procedure is most common in the lower leg and the forearm, which contain multiple distinct fascial compartments.
The Surgical Procedure
The fasciotomy is typically performed in an operating room under general anesthesia, though local or regional anesthesia may be used. The surgeon’s goal is to open the fascia to release the pressure. This is accomplished by making one or two long incisions in the skin over the affected muscle compartments.
For a common site like the lower leg, a double-incision technique is often used, involving a lengthy cut on the inner side and another on the outer side of the calf. Once the skin is incised, the surgeon carefully cuts through the deep fascia along the length of the compartment, which allows the muscle tissue to bulge out and immediately decompress. The procedure may take up to two hours, depending on the complexity of the underlying trauma.
After the fascia is cut, the underlying muscle is inspected for viability, with dead or non-viable tissue removed in a process called debridement. The skin incision is generally left open temporarily because the underlying muscle remains significantly swollen, and closing the skin immediately would risk the return of compartment syndrome. The open wound is covered with a sterile dressing or a specialized wound vacuum device to manage the fluid and promote healing.
Post-Surgical Care and Outlook
The primary concern immediately following surgery is allowing the swelling to subside completely, which typically takes between three to seven days. During this time, the affected limb is often kept elevated to help reduce the edema.
Once the swelling has resolved and the muscle tissue is confirmed to be healthy, the surgeon plans for definitive wound closure. This second procedure involves either delayed primary closure, where the skin edges are pulled back together and stitched, or the use of a split-thickness skin graft. Skin grafting is necessary in about half of cases, particularly if the initial incision was very wide or the skin cannot be closed without tension.
Patients usually require a hospital stay for observation and wound care, especially for acute cases. Physical therapy is a major part of the recovery process to help restore range of motion, flexibility, and strength to the affected limb.
Potential complications include infection of the open wound, nerve damage resulting in persistent numbness or weakness, and the formation of noticeable scarring. While a fasciotomy is often a limb-saving procedure, long-term outcomes can vary, with some patients experiencing a residual functional deficit, such as chronic pain or reduced exercise tolerance. When performed promptly, however, the surgery is highly successful at preventing the catastrophic consequences of untreated acute compartment syndrome.