- See:
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Compartment Syndrome Menu
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Compartment Syndromes resulting from Tibial Fractures:
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Anterior Compartment
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Lateral Compartment
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Deep Posterior Compartment:
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Superfical Posterior
- Anterolateral Incision: (Two Incision Technique)
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anterior &
lateral compartments are approached thru single longitudinal incision placed halfway down leg 2 cm anterior to fibular shaft,
or alternatively placed halfway between the tibial crest and the fibula;
- incision is therefore placed over anterior intermuscular septum separating anterior & lateral compartments & allowing access to each;
- in an elective chronic syndrome, a small 4-5 cm incision can be used;
- in the acute traumatic syndrome, a 15 cm incision is used;
- transverse incision is made over fascia of anterior &
lateral compartments, which allows clear view of the intermuscular septum;
- attempt to identify the
superficial peroneal nerve near the septum;
- tension is maintained on the fascia w/ a Kocher clamp;
- blunt tipped scissors are used to spread above and below the fascia on both sides of the intermuscular septum, both proximally and distally;
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anterior compartment:
- after identifying septum, small nick is made in fascia of anterior intermuscular septum midway between the septum & tibial crest;
- tension is maintained on the fascia w/ a Kocher clamp;
- blunt tipped scissors are used to spread above and below the fascia both proximally and distally;
- fascia is opened proximally & distally w/ long, blunt-pointed scissors;
- proximally aim for the patella and distally to the center of the ankle inorder to ensure that the fasciotomy stays in anterior compartment;
- distally, avoid straying too medially so as too avoid injury to the dorsalis pedis;
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lateral compartment fasciotomy:
- made in line w/ fibular shaft;
- distally direct scissors toward lateral malleolus inorder to keep instrument posterior to
superficial peroneal nerve;
- superficial peroneal nerve exits from lateral compartment about 10 cm above lateral malleolus and courses into anterior compartment;
- if tip of scissors has strayed from fascia, instrument is left in place and two centimeter incision is made over its tip & fasciotomy is completed;
- once the fascia has been partially transected, tension on the fascia will be lost, which means that the scissors cannot
re-enage the edge of the fascia in a blind fashion;
- Posteromedial Incision: (Two Incision Technique)
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deep and
superficial posterior compartments are approached thru a single 15 cm longitudinal incision in distal part of leg
2 cm posterior to posterior medial palpable edge of the tibia;
- once down to fascia undermine anteriorly to posterior tibial margin, which will avoid
saphenous vein and nerve;
- the saphenous vein should be retracted anteriorly;
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superficial compartment:
- retract saphenous vein & nerve & release fascia over
superfical posterior compartment;
- tension is maintained on the fascia w/ a Kocher clamp;
- blunt tipped scissors are used to spread above and below the fascia both proximally and distally;
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deep posterior compartment:
- the soleus takes origin from the proximal 1/3 of the tibia and fibula and covers the proximal portion of the deep posterior compartment;
- detach soleal bridge and retract it to expose fascia covering
FDL &
tibialis posterior;
- note that the FDL lies just posterior to the tibia, and this fascia needs to be released to decompress the compartment;
- the neurovascular bundle is protected, lying between the tibialis posterior and the soleus;
- in the distal half of the tibia the deep posterior compartment lies just below the subcutaneous tissue;
- again, releasing the fascia over the FDL is required to decompress the deep posterior compartment;
- fascia is opened distally and proximally under the belly of soleus;
- wounds are left open if swelling is too much to allow for primary skin closure;
- skin grafting is rarely needed if full week is allowed for dissipation of edema;
- One Incision Technique:
- performed thru one long incision over
lateral compartment
- make incision in line w/ fibula extending just distal to head of fibula to 3 to 4 cm proximal to the lateral malleolus;
- the incision should be either directly over or slightly posterior to the fibula;
- proximally identify the common peroneal nerve;
- undermine skin anteriorly & avoid injuring superficial peroneal nerve;
- perform longitudinal fasciotomy of anterior and lateral compartments;
- undermine skin posteriorly & perform fasciotomy of
superfical posterior compartment;
- define the interval between the soleus and the FHL;
- identify interval between superficial & lateral components distally & develop this interval proximally by detaching soleus from fibula;
- subperiosteally dissect the
flexor hallucis longus from the fibula;
- retract the muscle and the peroneal vessels posteriorly;
- now identify fascial attachment of the tibialis posterior muscle to fibula and incise this fascia longitudinally;
- exposure of deep fascia for a short distance anterior & posterior to this incision, followed by transverse incision thru fascia at
midpoint, allows easy identification of vertical fascial planes separating compartments;
- release each compartment independently w/ longitudinal incision extending the full length of the compartment;
- after releasing
superfical posterior compartment bluntly dissect posterior to
lateral compartment & release fascia of
deep posterior compartment;
Double-incision fasciotomy of the leg for decompresion in compartment syndromes.
Mubarak SJ, Owen CA.
J Bone Joint Surg 1977; 59A: 184-7.
Pelvic and Lower Extremity Trauma--Symposium: Compartment Syndromes of the Lower Leg.
Bourne-R-B.
Rorabeck-C-H.
Clinical Orthopaedics and Related Research. 1989 Mar. 240. pp 97-104.
