A fasciotomy is an emergency surgical procedure where a tough, unyielding band of connective tissue called fascia is cut to relieve internal pressure. Fascia is the fibrous tissue that wraps around and organizes groups of muscles, nerves, and blood vessels into distinct compartments throughout the body, particularly in the limbs. The procedure involves making an incision to open this tissue layer, allowing the muscle tissue underneath to swell outward and immediately decompress the area, preventing serious tissue damage.
Understanding Compartment Syndrome
The primary reason a fasciotomy is necessary is to treat acute compartment syndrome (ACS). This condition occurs when bleeding or swelling within one of the body’s muscle compartments creates an excessive pressure buildup. Because the surrounding fascia is a strong, inflexible sheath, it cannot expand quickly enough to accommodate the increased volume.
This high pressure within the enclosed space compresses the blood vessels and nerves, restricting blood flow to the muscles and depriving them of oxygen and nutrients. The lack of adequate circulation can quickly lead to ischemia, or tissue death, which is why ACS is considered a medical emergency. If left untreated, consequences can include permanent nerve damage, irreversible muscle death, and potentially the need for limb amputation.
Acute compartment syndrome is most often triggered by severe trauma, such as a fractured bone, a crush injury, or a severe burn. Approximately 75% of acute cases are associated with a broken arm or leg, particularly a fracture of the tibia. Other causes include prolonged compression of a limb during unconsciousness or reperfusion injury after blood flow is restored to an area that had been blocked.
Steps of the Surgical Procedure
A fasciotomy is typically performed under general anesthesia, given the urgent nature and the extent of the necessary incisions. The surgeon makes a large incision through the skin and subcutaneous tissue over the affected muscle compartment, most commonly in the forearm or lower leg. In the leg, two separate longitudinal incisions, each 15 to 20 centimeters long, are often required to access and decompress all four muscle compartments.
The next step involves carefully cutting the deep fascia that surrounds the muscle groups. This fascial incision is extended along the entire length of the muscle compartment to fully release the restrictive pressure. Once the fascia is cut, the underlying muscle tissue immediately bulges out of the incision.
After the pressure is successfully released, the surgeon examines the exposed muscle tissue for any signs of damage or dead tissue, which is removed in a process called debridement. The wound is left intentionally open and covered with a sterile dressing. Leaving the wound open ensures that the pressure does not build up again and allows the massive swelling to subside over the next several days.
Recovery and Wound Management
The initial open wound requires careful management in the days following the emergency procedure. The open incision is routinely inspected and dressed to protect the exposed tissue from drying out and to monitor for any developing infection. In some cases, a vacuum-assisted closure (VAC) device, which uses negative pressure wound therapy, may be applied to help manage the wound and prepare it for eventual closure.
Definitive wound closure usually occurs several days later, typically when the swelling has completely resolved. Early primary closure, or stitching the wound shut immediately, is avoided because it risks reintroducing pressure and causing a recurrence of compartment syndrome. If the skin edges can be brought together without tension after the swelling subsides, a delayed primary closure using stitches or staples is performed.
However, the incision is often too wide to be closed directly, requiring a skin graft to cover the exposed tissue. A split-thickness skin graft is commonly used, where a thin layer of skin is taken from another part of the body, such as the thigh, and placed over the fasciotomy wound. Following wound closure, physical therapy is necessary to help the patient regain full range of motion, strength, and function in the affected limb.