How to perform a fasciotomy of the thigh
Source
Surgeon:
Ville Vänni (trauma surgeon)
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Summary
Focus: Fasciotomy of the thigh to prevent or treat ischemic tissue injury by releasing pressure in the thigh muscle compartments.
Key elements: Lateral release of the anterior and posterior compartments, selective medial compartment release, wound reassessment, and delayed closure.
Indications and Clinical Context
General
Medical experts: Ville Vänni, trauma surgeon
Names of procedure: Fasciotomy of the thigh, thigh fasciotomy
Goal of Operation
To prevent or treat ischemic tissue injury by releasing pressure in the muscle compartments.
Problem
Increased pressure in the muscle compartments of the thigh caused by trauma or severe disturbance.
Diagnosis
Acute compartment syndrome (ICD-10: T79.6)
Short Pathophysiological Description
Compartment syndrome occurs when the pressure within a closed muscle compartment increases to a point where it exceeds the perfusion pressure, leading to decreased blood flow to the compartment. Compartment syndrome can be caused by trauma, such as fracture, hemorrhage, or burn; prolonged compression of the muscle, such as alcohol-related sleeping on the limb or prolonged compression of the limb; or infection.
If left untreated, the pressure will compromise the blood supply to the muscles and nerves and subsequently lead to ischemia and eventually necrosis. During fasciotomy, the fascia surrounding the muscles is incised, which allows the pressure to be released, restoring blood flow to the affected tissues, preventing further damage, and enabling healing.
Key Anatomical Structures
Compartments of the thigh
Anterior compartment
Posterior compartment
Medial compartment
Fascia lata
Intermuscular septum
Great saphenous vein
Step-by-Step Technique
Patient Positioning, Anesthesia, and Preparation
The patient is in a supine position, with the entire limb exposed.
The position should allow access to all compartments: anterior, posterior, and medial.
General anesthesia is preferred, since patients needing fasciotomy are usually critically ill.
The use of a tourniquet should be avoided, as it further reduces blood flow to tissues that are already ischemic. Additionally, the tourniquet may impair the evaluation of tissue vitality.
Landmarks and Incision Site
The lateral skin incision should provide optimal access to the anterior and posterior muscle compartments for decompression while keeping vital structures safe.
Palpate the greater trochanter and the lateral condyle in the distal femur.
The incision extends in a straight line from the greater trochanter to the lateral condyle. Correct incision location allows access to the anterior and posterior compartments from the same incision.
Lateral Incision
The goal is to properly expose the fascia lata to enable access to the intermuscular septum, from where the anterior and posterior compartments can be decompressed safely.
Incise the skin with a scalpel, perpendicular to the skin, as planned. There are no critical structures directly underneath the skin.
Use a scalpel or diathermy and advance through the subcutis down to the fascia. Coagulate bleeding vessels.
Use retractors to gain better visibility and to expose the fascia lata.
Anterior Compartment Release
The goal is to decompress the muscles in the anterior compartment by opening the fascia and allowing the muscles to expand.
Incise the fascia lata with a scalpel or scissors over the entire length so that the muscle can expand properly.
Sometimes the fascia lata is so unforgiving that, in addition to the longitudinal incision, some transverse relaxing incisions can be made.In the distal part of the thigh, the vastus lateralis muscle can be elevated to gain access to the posterior compartment through the intermuscular septum.
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Posterior Compartment Release
The goal is to decompress the muscles in the posterior compartment by opening the fascia and allowing the muscles to expand.
After releasing the anterior compartment, the posterior compartment can be accessed through the intermuscular septum using a scalpel or scissors.
Expand the incision as far proximally as there is palpable pressure in the posterior compartment.
Landmarks and Medial Incision Site
In most cases, releasing the pressure of the anterior and the posterior compartments is enough, but sometimes there is also pressure in the medial compartment that needs to be addressed. The medial compartment of the thigh contains the gracilis muscle and the adductors.
The medial skin incision should provide optimal access for decompression of the medial muscle compartment.
The landmarks for the medial incision are the pubic bone and the medial condyle of the distal femur.
Plan the incision between these landmarks.
Medial Incision
The goal is to expose the fascia and allow safe access to the medial compartment for decompression.
Incise the skin with a scalpel perpendicular to the skin, as planned.
Advance through the subcutaneous tissue down to the fascia with a scalpel or scissors. Beware of the great saphenous vein in the subcutis. Coagulate bleeding vessels.
Use retractors to gain better visibility and for optimal exposure of the fascia.
Medial Compartment Release
The goal is to decompress the muscles in the medial compartment by opening the fascia and allowing the muscles to expand.
Incise the fascia with a scalpel or scissors.
Depending on the tension in the compartment, extend the incision both proximally and distally.
One incision of the medial fascia is sufficient to decompress the entire compartment. There is no need to explore deeper in between the sartorius and gracilis muscles.
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Piftalls and Complications
Pitfalls
Short Incisions
If the incisions are not extended enough proximally and distally, they may not release all the pressure, leading to potential tissue damage. The fascia should be released over its entire length, and the skin incision should be long enough to allow good visibility and not cause the expanding muscle to be trapped by the skin edges.
Inadequate Achievement of Visibility
Most complications are associated with inadequate visibility, or because the procedure has been attempted with an incision that does not extend far enough proximally and distally, that is, “blindly.” This can lead to complications, such as muscle necrosis in the unopened compartment.
To release the posterior compartment, a large retractor should be used, or the assistant should elevate the lateral vastus muscle to provide excellent visibility.
Careless Tissue Handling
There are no major vascular structures in the lateral part of the thigh. A few major perforant branches may run through the fascia to the skin, but these can be managed by cauterization.
Medially, avoid unnecessary contact with the great saphenous vein. If the vein is in the way or is accidentally severed, it should be ligated. Any long-term detriment to the patient is usually very minor.
Complications
Muscle Necrosis
The greatest problem in fasciotomy is failure to release the symptomatic compartment. The subsequent increase in pressure results in muscle necrosis and partial or total loss of the muscle, causing local functional deficit.
Injury to the Great Saphenous Vein
There is a risk of injury to the great saphenous vein from the medial incision. Unnecessary contact with the vein should be avoided, but in the case of injury or need for better access to the surgical field, the vein or its branches can be ligated.
Aftercare
General Guidelines
Immediately after the operation, highly absorbent dressings and bandage should be used, not too tight. A silicone net or a paraffin gauze can be placed immediately on the wound to make dressing change more comfortable for the patient.
Bedside evaluation of the wound is performed the next day. Evaluation in the operating room for possible wound closure is performed at 48–72 hours post-fasciotomy. Eventually, during closure, only the skin needs to be closed on the medial side. On the lateral side, the fascia should also be closed to offer support for the muscles.
FAQ
What is the goal of fasciotomy of the thigh?
The goal is to prevent or treat ischemic tissue injury by releasing pressure in the muscle compartments.
Which thigh compartments are accessed through the lateral incision?
Correct lateral incision location allows access to the anterior and posterior compartments from the same incision.
When is a medial incision needed?
In most cases, releasing the anterior and posterior compartments is enough, but sometimes pressure in the medial compartment also needs to be addressed.
Why should a tourniquet be avoided?
A tourniquet should be avoided because it further reduces blood flow to tissues that are already ischemic and may impair evaluation of tissue vitality.
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