A fasciotomy is a surgical procedure involving an incision through the fascia, a dense connective tissue found throughout the body. This fibrous membrane surrounds and organizes muscle groups, nerves, and blood vessels into distinct bundles called muscle compartments. The sole purpose of this operation is to relieve excessive pressure built up within these compartments, which can quickly compromise the health of the underlying tissues. By cutting this non-elastic sheath, the surgeon allows the swollen muscle to expand, immediately restoring proper blood circulation.
Primary Indications for the Surgery
The majority of fasciotomies are performed as an emergency treatment for Acute Compartment Syndrome (ACS). This syndrome occurs when swelling or bleeding inside a muscle compartment causes a rapid and dangerous rise in internal pressure. Because the fascia cannot stretch, this pressure compresses the blood vessels and nerves, leading to a lack of oxygen and nutrient delivery to the muscle tissue, a state known as ischemia.
If the pressure is not relieved promptly, the tissue will die, making ACS a time-sensitive emergency. The procedure’s goal is the restoration of muscle perfusion, ideally within a six-hour window from the onset of symptoms, to prevent permanent damage. ACS is most commonly triggered by high-energy trauma, such as severe fractures (particularly of the tibia), crush injuries, or extensive burns.
The procedure may also be indicated in less common situations, such as after a blood vessel repair when a sudden rush of blood flow causes massive swelling, or as a prophylactic measure in high-risk scenarios. A fasciotomy can also treat Chronic Exertional Compartment Syndrome. This condition occurs in athletes due to muscle overuse, causing temporary swelling and pain that usually resolves with rest, but may require surgical release if non-operative treatments fail.
How the Fasciotomy Procedure is Performed
The surgical technique focuses on making a long, deep incision through the skin and the underlying fascia to fully open the pressurized compartment. The operation is performed under general or regional anesthesia, and the location depends on the affected area. The lower leg is the most frequent site, where the standard approach is a two-incision, four-compartment fasciotomy, releasing the four separate muscle groups encased there.
The surgeon makes an anterolateral incision to release the anterior and lateral compartments, followed by a posteromedial incision to decompress the superficial and deep posterior compartments. Once the fascia is cut, the underlying muscle often bulges out immediately as the extreme internal pressure is released. The surgeon then inspects the muscle for any dead or damaged tissue, which is removed, ensuring the remaining tissue is healthy.
The most distinguishing feature of a fasciotomy is that the skin incision is often left open after the fascia has been released. This “delayed primary closure” prevents a recurrence of dangerous pressure buildup, as the muscle remains significantly swollen for several days. Temporary dressings are applied to cover the exposed muscle until the swelling subsides enough for the wound edges to be brought closer together.
Recovery and Potential Complications
The recovery phase is complex due to the management of the open surgical wound. In the days following the initial procedure, the patient is often taken back to the operating room for repeated wound checks and debridement to remove any further devitalized tissue. To manage the open wound, specialized tools such as a vacuum-assisted closure (VAC) device, which uses negative pressure to promote healing, may be applied.
The ultimate goal is to close the wound definitively, which typically occurs between five days and three weeks after the initial operation, once the swelling has reduced. If the skin edges cannot be safely stitched together without tension, a split-thickness skin graft is often required to cover the exposed muscle. This involves transplanting a thin layer of skin from another area of the patient’s body over the fasciotomy site.
Despite being a life-preserving operation, a fasciotomy carries risks and long-term complications. These include wound infection, significant scarring, and injury to nearby nerves, such as the superficial peroneal nerve in the leg, which can result in long-term numbness. In severe cases where treatment was delayed or the initial trauma was too extensive, the patient may still face chronic pain, permanent muscle weakness, or the need for amputation.