CompartmentSyndrome and Lower-Limb Fasciotomies inthe CombatEnvironment

Kevin L. Kirk, DOa,*, Roman Hayda, MDb,c

the risks of fasciotomy in false-positive cases.The incidence of compartment syndrome and limbs at risk in combat casualties

requiring evacuation is estimated to be 15%.1 In recent United States conflicts,severe extremity trauma caused by blast injuries has been a common presentation re-sulting in more than 71% of the total number of extremity injuries and accountsfor 86% of those requiring fasciotomy.14 Exploding ordnance causes significant

vice San Antonio Militaryersity, School of Graduate

dicine, Brown University,

SAAntonio Military MedicalFoot Ankle Clin N Am 15 (2010) 4161a LTC Kevin L. Kirk, DO, Chief, Integrated Orthopedic Surgery SerMedical Center, San Antonio, Texas; Assistant Professor, Baylor UnivStudies, Houston, Texasb Department of Orthopedic Surgery, Warren Alpert School of MeProvidence, RI, USAc Orthopedic Trauma, Rhode Island Hospital, Providence, RI 02905, U* Corresponding author. Integrated Orthopedic Surgery Service, SanCenter, San Antonio, TX, USAE-mail address: kevin.l.kirk@us.army.mil (K.L. Kirk).The battlefield surgeon is faced with challenges in the management of leg and footcompartment syndrome because the conditions pathophysiology, diagnostic modal-ities, and treatment methods all involve controversy. Blast injury, high-velocitygunshot wounds, and blunt trauma associated with combat operations cause injuriesthat may induce compartment syndrome. If untreated, muscle and nerve necrosis mayoccur. Subsequent myoneural fibrosis, contracture, infection, amputation, andsystemic complications are all possible. However, compartment syndrome and itssequelae can be prevented or mitigated by prompt intervention to maintain adequatetissue oxygenation. At present, recommendations for a low threshold for fasciotomyare maintained to avoid missing the diagnosis; however, this exposes casualties to

KEYWORDS

Compartment syndrome Lower-limb fasciotomies Battlefield surgery Combat injuriesdoi:10.1016/j.fcl.2009.11.003 foot.theclinics.com1083-7515/10/$ see front matter. Published by Elsevier Inc.

acumen is of prime importance in evaluating these complex injuries. Onemust not only

Kirk & Hayda42account for what is seen at the time of presentation but also predict how the injury willevolve during the course of evacuation when evaluation is difficult and surgery cannotbe performed. To minimize the incidence of false-negative initial evaluations of the warcasualty, prophylactic fasciotomies may be required before any clinical sign ofcompartment syndrome. Prophylactic fasciotomy is performed before aeromedicalevacuation when compartment syndrome is likely to develop in a delayed fashion.The authors purpose is to provide insight into the unique challenges encounteredby the military surgeon managing combat injuries at risk for compartment syndromeof the leg and foot.

PATHOPHYSIOLOGY

Compartment syndrome occurs when circulation to tissues within a fascial compart-ment is compromised by increased pressure within that space. The resultant ischemiawill ultimately cause necrosis in a time-dependent fashion.57 It is most commonlyobserved in the extremities, particularly the leg, but has also been observed in manyother locations, including the buttocks, thigh, brachium and arm, and the abdomen.Cellular anoxia is the final common pathway of all compartment syndromes. However,the interrelation between increased compartment pressure, blood pressure, and lossof tissue perfusion leading to cell death are incompletely understood. This incompleteunderstanding leads to diagnostic and treatment challenges.Many theories have been proposed to account for the sequence of events leading

from tissue injury to the ischemic sequelae of compartment syndrome. Experimentalstudies have demonstrated that tissue perfusion progressively decreases as tissuecompression increases.5 Burton8 proposed the concept of critical closing pressurethat states that perfusion within a compartment ceases when intra-compartmentalpressure equals diastolic pressure. Blood flow may cease at levels below the meanarterial pressure secondary to passive capillary collapse when local tissue pressureincreases above intracapillary pressure.Another accepted theory is that of local venous hypertension. A local increase insoft-tissue injury, vascular injury, and burns. Eighty-two percent of fractures that occuron the battlefield are open.2 All of these injury factors place extremities at risk forcompartment syndrome.The battlefield imposes restrictions not typically encountered in the civilian environ-

ment. Surgical treatment in a combat environment is performed under austereconditions with limited resources, and at times, high volume. Initial care is focused onlife- and limb-saving procedures, stabilizing patients and their injured extremities toprepare them for evacuation to a higher level of care. Evacuation of patients to fixedfacilities in Germany and ultimately back to the United States for definitive care mayoccur as soon as 12 to 24 hours from injury. Flights on current aircraft from Afghanistanand Iraq to Germany last from 5 to 9 hours. An additional 1 to 2 hours is required forground transportation and aircraft loading and unloading. In the aggregate this maydelay surgical access of undergoing medevac for up to 12 hours.1 Distracting injuries,analgesics, sedation, and the restricted interior space of the aircraft make evaluationand treatment of compartment syndrome extremely difficult during transport.In the combat zone, the diagnosis of compartment syndrome is even more heavily

weighted toward clinical evaluation than in the civilian setting. In this environment,compartmental pressure measurements may be used if available. However, thesefrequently do not enter into the treatment algorithm. The surgeons clinical diagnosticvenous pressure will reduce the arterio-venous (A-V) gradient and in turn decrease

and local blood pressure. Nerves demonstrate functional abnormalities (paresthesias

Compartment Syndrome and Fasciotomies in Combat 43and hypoesthesia) within 30 minutes of ischemic onset. Irreversible functional loss willoccur after 12 to 24 hours of total ischemia.5 Muscle shows functional changes after 2to 4 hours of ischemia with irreversible loss of function beginning at 4 to 12 hours.5

Regardless of which theory predominates as the pathoetiology of compartmentsyndrome, the result is ischemic necrosis of compartmental tissue in the absence ofprompt intervention. Compartment syndromes lasting longer than 8 to 12 hours arelikely to produce chronic functional deficits, such as contractures, sensory aberrations,and motor weakness. Clinically, a precise pressure threshold and duration do not existabove which significant damage is irreversible and below which recovery is assured.A complex relationship exists between the energy released at the time of injury and

the development of foot compartment syndrome. Themagnitude of the tissue damagesustained with battlefield injuries, such as blasts and high-velocity gunshot wounds,place these casualties at risk for compartment syndrome. Currently, the number of fas-ciotomies performed for compartment syndrome during the conflicts in Afghanistanand Iraq have not been determined. Studies are ongoing to determine how many ofthese procedures are performed or what their clinical outcomes are. The battlefieldexperience to date seems to reinforce previous studies on compartment syndrome;namely, that the initial energy transferred at the time of injury plays a crucial role indetermining the timing and development of foot and leg compartment syndrome.

ANATOMYFoot

The osteofascial spaces of the foot are not well understood and there is considerabledisagreement regarding the anatomic features of the plantar aspect of the foot. Earlyinjection studies were performed in attempt to describe the spread of infectionsthrough potential spaces in the foot. Grodinsky9 described four potential fascialspaces within the foot. He demonstrated a communication between the central andthe medial and lateral compartment, and with the posterior compartment of the calf.In a similar study, Kamel and Sakla10 confirmed these previous findings but demon-

strated that the medial and lateral proved to be closed spaces. Other descriptions ofthe compartments and fascial spaces in the foot are available and the exact number ofcompartments described differs greatly among authors.1113

In 1990, Manoli and Weber14 performed a gelatin-injection study on unembalmedcadaveric legs, describing the presence of nine foot compartments rather than fourcapillary blood flow. Modulation of the local vascular resistance can counteract someof the reduction in the A-V gradient. However, this compensation becomes ineffectivewith increasing tissue pressure. As local tissue pressure rises, the A-V gradient dimin-ishes eventually causing capillary blood flow to cease.5 Compartment syndromeoccurs when the diminished local A-V gradient prevents sufficient blood flow tomeet the metabolic demands of the tissue. This theory explains how myoneuralischemia can occur in the presence of blood flow. As ischemia continues, irreparabledamage to tissue ensues and myoneural necrosis occurs. Some deployed surgeonshave postulated that decreased atmospheric pressure as occurs during flight mayexacerbate muscle edema in the injured limb causing compartment syndrome. Alter-natively, the lower oxygen tension may cause relative tissue anoxia to already injuredtissues leading to compartment syndrome.Development of compartment syndrome depends on many factors, including the

duration of the pressure elevation, the metabolic rate of the tissues, vascular tone,as previously thought. Three compartments run the entire length of the foot (medial,

Kirk & Hayda44lateral, and superficial). Five compartments are contained within the forefoot (adductorand four interossei). A description of a new separate compartment, the calcanealcompartment, containing the quadratus plantae muscle and lateral plantar nervewas made. In addition, a communication of the calcaneal compartment with thedeep posterior compartment of the leg through the retinaculum behind themedial mal-leolus via the neurovascular and tendinous structures was suggested. They postu-lated that the claw-toe deformities sometimes seen after calcaneus fracture arecaused by a compartment syndrome of the quadratus plantae in the calcanealcompartment. They emphasized the need to release this separate compartmentwhen performing foot fasciotomies.Guyton and colleagues15 refuted prior injection studies as inaccurate and invalid

because of flawed experimental design. Using CT guidance, they injected fluid intoisolated compartments and monitored the resulting interstitial pressures. Based ontheir findings they felt it impractical to subdivide the foot into more than four compart-ments based on the location of a variety of fascial planes.Ling and Kumar16 used cadaveric dissection to determine the myofascial anatomy

of the foot. They questioned the need to separately release the quadratus plantae. Theauthors did identify five structures in the plantar aspect of the foot that may playa major role in compartment syndrome in the hindfoot or midfoot. They five structuresare the plantar aponeurosis, the medial vertical fascial septum, the intermediatevertical fascial septum, and the lateral vertical fascial septum. These structureswere highlighted because of their low compliance and need to be incised if associatedcompartments are to be adequately decompressed.Recently, a 10-compartment model was proposed based upon MRI in normal feet.

The authors highlighted inclusion of the skin as a separate compartment. Needle-insertion sites and trajectories for measurement of pressures in uninjured feet weredefined. The practical application including the skin as a separate compartment isquestionable as the skin is always released in all anatomic sites surgically treatedfor compartment syndromes.17

Although controversies continue to exist regarding the exact anatomy of thecompartments of the foot, it is important for the combat surgeon to release at leastfive compartments when a foot compartment syndrome is to be surgically treated.18

The medial compartment contains the abductor hallucis and flexor hallucis brevismuscles and flexor hallucis longus, peroneus longus, and posterior tibial tendons.This compartment is bound by the inferior surface of the first metatarsal shaft dorsally,extension of the plantar aponeurosis medially, and the intermuscular septum laterally.The boundaries of the central compartment are the plantar aponeurosis inferiorly, theintermuscular septum medially and laterally, and the tarsometatarsal joints dorsally.From plantar to dorsal, this compartment contains the flexor digitorum brevis muscle,flexor digitorum longus tendons, lumbrical muscles, quadratus plantae, adductor hal-lucis muscle, and the peroneal and posterior tibial tendons. The lateral compartment isbordered by the fifth metatarsal shaft dorsally, the intermuscular septummedially, andthe edge of the plantar aponeurosis laterally. It contains the abductor, short flexor, andopponens muscle of the fifth toe. The interosseous compartment is bounded by theinterosseous fascia and the metatarsals and contains the seven interossei (Fig. 1).

Leg

The leg is divided into four osteofascial compartments. The anterior compartmentcontains the anterior tibialis, long toe extensors, supplied by the deep peroneal nerveand the anterior tibial artery. The lateral compartment contains the peroneus longus

and brevis supplied by the superficial peroneal nerve and peroneal artery. The

Compartment Syndrome and Fasciotomies in Combat 45Fig. 1. Cross section through the forefoot demonstrating the compartments of the foot.superficial posterior compartment contains the gastrocnemius and soleus musclessupplied by the tibial nerve and the posterior tibial artery. The deep posterior compart-ment contains the popliteus, tibialis posterior, flexor hallucis longus, and flexor digito-rum longus. All of these muscles are innervated by the tibial nerve.Matsen and Clawson19 described a deep compartment syndrome of the leg causing

complications in the foot after observing this condition in a case series of 14 subjects.This condition is characterized by pain, weakness of toe flexion, painful passive toeextension, plantar hypoesthesia, and tension in the fascial boundaries of the compart-ment. If untreated, the deep compartment syndrome can lead to claw toes, posteriortibial neuropathy, and weakness or contracture of the long toe flexors and tibialisposterior. The authors noted that the association of deep posterior compartmentsyndrome with open fractures demonstrated that the associated fascial defect doesnot necessarily provide adequate decompression of its contents. It has been sug-gested that the posterior tibial muscle has its own separate compartment from theremainder of the deep posterior compartment.20 This suggestion was refuted in ananatomic study, indicating that the posterior tibialis muscle is decompressed withrelease of the deep posterior compartment (Fig. 2).21

DIAGNOSIS

Explosions can cause fractures, soft-tissue damage, and vascular injury all of whichplace theextremity at risk for compartment syndrome.However, itmust be rememberedthat compartment syndrome can occur in the absence of fracture and with open frac-tures. In civilian blunt trauma the most common sites of extremity compartmentsyndrome in the absence of fracture are the leg (53%62%), forearm (24%26%), thigh

(From Shereff MJ. Compartment syndromes of the foot. In: Instructional course lectures,The American Academy of Orthopaedic Surgeons, vol. 39. Park Ridge (IL): The AmericanAcademy of Orthopaedic Surgeons; 1990. p. 12732.)

Kirk & Hayda46(4%15%), foot (4%5%) and hand (2%4%).1,22 Traditionally the development ofcompartment syndrome is assessed on clinical grounds using criteria of patients painout or proportion, pain on passive stretch, paresthesias, poikilothermia, paralysis, andlack of pulse. Because these subjective symptoms rely on responsive and cooperativepatients, compartmental pressure measurements may be made to provide objective

SuperficialPosterior Cmpt.

Gastrocnemius M.

Tibialis Posterior

Posterior MedialIncision

AnterolateralIncision

G. Saphenous V.Tibia

Anterior Tibial Artery, Vein, Peroneal Nerve

Tibialis AnteriorAnteriorCmpt.EHLEDL

FHL in theDeep Posterior

Cmpt.

Peroneus Brevisand Longus inLateral Cmpt.

Fig. 2. Cross section of the leg compartments sectioned through mid calf. (From Emergencywar surgery. 3rd United States revision. Borden Institute; 2004. p. 22.12. Available at: http://www.bordeninstitute.army.mil/other_pub/ews.html.)data in the assessment of the limb, particularly in patients who are obtunded. Recentefforts have also attempted to establish noninvasive methods of diagnosis.23,24

All clinical signs have inherent drawbacks in making the diagnosis. Pain is an unre-liable and variable predictor. It can range from being very mild to severe and isalready present in patients who have suffered acute trauma.7 The pain of the obviousinjury can mask that of an impending compartment syndrome and cannot alone bedepended upon to make the diagnosis.25 Mubarak and colleagues26 found thatpain in response to passive stretching of the affected muscle compartment wasalso an unreliable sign and suggested that the presence of hypoesthesia wasmore dependable. However, Rorabeck and Macnab27 found hypoesthesia to bethe last clinical finding to develop as the syndrome progressed. Palpable compart-mental tumescence is a crude indication of increased compartmental pressure.25

Because only a small part of the deep posterior compartment is sufficiently palpablebeneath the skin,19 this sign is of little value in diagnosing involvement of thiscompartment. Frank motor weakness is very difficult to elicit in patients after trauma,and demonstrable weakness may also be caused by several other reasons. Pain inconjunction with increasing pressure to the point of tenseness or firmness is themost important clinical indicator in conscious patients. It is important to realizethat lack of pulse and paralysis are late findings and generally reflect progressiontoward irreversible damage.26

Ulmer28 performed a comprehensive search of the literature to assess if clinicalfindings are predictive of the diagnosis of compartment syndrome. He found theclinical signs have a sensitivity of 13% to 19% and a positive predictive valueof only 11% to 15%. He concluded that there was a paucity of data from which

Compartment Syndrome and Fasciotomies in Combat 47to determine the value of clinical findings in the diagnosis of compartmentsyndrome. However, the probability of compartment syndrome increases markedlyif three or more clinical findings are simultaneously present. Clinical findings havemore utility in their absence to exclude the diagnosis than their presence has toconfirm it.Direct intra-compartmental pressure measurement has been established as valu-

able tool to diagnose compartment syndrome. Measurement can be performed witha manometer device as described by Whitesides and colleagues,29 but a handheldpressure measurement device is more commonly used. Alternatively, an appropriatelycalibrated arterial line may be used. A side-ported needle, or slit catheter, is most reli-able when used in conjunction with a hand-held device or arterial line; a straight needlemay record falsely elevated pressures.30

A variety of thresholds have been suggested for diagnosis of compartmentsyndrome and performance of fascial release. The use of these values is predi-cated on the accurate placement of the needle in the compartment. The thresholdmust be set low enough to prevent the long-term sequelae of a missed compart-ment syndrome but must be balanced against the potential morbidity of additionalsurgery, wound, infection, neuroma complications, and weakness of an unneces-sary fascial release. Threshold values range from an absolute pressure of 30mmHg to a (diastolic pressure)(measured compartment pressure) (Dp) lessthan or equal to 20 to 30 mm Hg.31 A Dp less than 20 to 30 mm Hg is generallyaccepted as an indicator of loss of adequate perfusion to the compartment and anindication for urgent fasciotomy.31

This threshold has been brought into question, although it is widely used as a diag-nostic criterion. Prayson and colleagues32 described 19 subjects with lower-extremityfractures and elevated pressures within accepted thresholds for fasciotomy. Elevensubjects had a Dp less than 20 mm Hg and five more within 30 mm Hg. None of thesesubjects underwent fasciotomy. At 1 year none developed clinical sequelae ofcompartment syndrome. These pressures were measured under anesthesia. A sepa-rate study found that diastolic blood pressures measured under anesthesia may besignificantly depressed complicating the use of pressure measurements as a diag-nostic tool.33 Continuous monitoring has been used successfully in some centersbut is not practical in the combat environment.34

Other methods have been developed to assist in the diagnosis of compartmentsyndrome. These methods include tonometry, near infrared spectrometry (NIRS),and laser flowmetry, At the time of this writing, none have established clinical efficacyalthough NIRS is showing some promise.35 In an innovative project in a swine model,investigators used an ultrafiltration device to remove a small amount of fluid in limbsdeveloping compartment syndrome. The ultrafiltrate demonstrated elevated levelsof creatine kinase and lactate dehydrogenase that may serve as a diagnosis tool.The limbs demonstrated less tissue necrosis suggesting a possible treatment effect.36

The investigators also noted that fascia has a low compliance, so a small amount offluid may lead to significant pressure changes and subsequent loss of perfusion.36

In the combat environment, the diagnosis of compartment syndrome is made onclinical grounds. Initially, a high index of suspicion is required to make the diag-nosis. It is important to remember that the syndrome can occur in conjunctionwith apparently minor injuries regardless of the etiology, degree of fracture commi-nution, or open fracture grade. Above all, compartment syndrome remains a clinicaldiagnosis supported by the objective examination findings.18 The reliance on clin-ical examination with a low threshold for fascial release may result in unwarranted

fasciotomies but it avoids the grave consequences of a missed diagnosis.

Kirk & Hayda48Foot

In the foot, the clinical signs of foot compartment syndrome are difficult to distinguishfrom the pain associated with the associated injury. Fracture and soft-tissue injury maymask pressure or ischemic pain that allow unambiguous testing of passive stretch ofmuscles suspect for compartment syndrome.37 Most patients who have foot compart-ment syndrome describe clinical symptoms of severe, relentless, burning paininvolving the entire foot. Myerson38 reported the most common symptom for clinicaldiagnosis was pain in the foot. However, many of these patients sustained crushinjuries, confounding use of pain in diagnosis. In addition, loss of pinprick sensationand objective motor deficit were difficult to document and were found to be unreliableindicators. Vascular examination was particularly unreliable for diagnosis, as dorsalispedis and posterior tibial pulses and satisfactory capillary refill were documented infeet with compartmental ischemia. Nevertheless, a thorough vascular examinationshould be performed.Fakhouri and Manoli39 stated that the only way of diagnosing compartment

syndrome reliably is direct tissue pressure measurement. However, this is not prac-tical in a combat environment and fails to account for the possible evolution of theinjury during transport.Evidence of blast or crushing mechanisms of injury should raise a high level of suspi-

cion for development of compartment syndrome. The presence of associated openinjuries does not eliminate the potential for compartment syndrome developing.35,40,41

Open injuries do not necessarily decompress compartments. Fascial defects may notbe sufficient to accommodate increased volume of compartmental contents.5,7,35

The presence of tense swelling and severe unremitting pain associated with foottrauma suggests that there is a need for decompression. In the combat environment,these cases should either be decompressed before entering the evacuation chain or atleast be observed in borderline cases.

Leg

Numerous authors have reported the characteristic signs and symptoms of compart-ment syndrome.23,24,4244 The early clinical signs of compartment syndrome are painout of proportion, pain with passive stretch of the involved compartment, and a tenseswollen compartment. The late clinical signs for diagnosis are paresthesias, lack ofpulse, pallor, and paralysis. Although commonly accepted, there is continuing debateregarding the most reliable measures for establishing the diagnosis and determiningthe need for surgical intervention.

FOOT COMPARTMENT SYNDROME

Although the compartment syndrome of the leg is well recognized, compartmentsyndrome of the foot has received much less attention.4554 Compartment syndromeof the foot was treated cursorily until 1987, whenMyerson55 elaborated on the presen-tation, diagnosis, and treatment. Since then other authors have addressed this topic indetail.56,57 The incidence of foot compartment syndrome has been estimated to occurin approximately 4.7% to 17% of calcaneal fractures.37 A recent prospective multi-center trial suggested a substantially lower incidence (1%).58

Untreated compartment syndrome of the foot may lead to a painful, dysfunctionalextremity characterized by sensory disturbances, stiffness, forefoot contracture,and clawing of the toes. Claw-toe deformities are caused by the damaged intrinsicshort flexors and extensors unable to counteract the intact extrinsic toe flexors and

extensors. This inability causes unopposed flexion at the distal interphalangeal joint

Compartment Syndrome and Fasciotomies in Combat 49and hyperextension of the metatarsal phalangeal joint. The most severe consequenceof missed foot compartment syndrome is extensive tissue necrosis leading toamputation.50

Manoli and Weber14 postulated that the claw-toe deformity following a calcaneusfracture appears to be secondary to a late contracture of the quadratus plantaemusclein the calcaneal compartment. Myerson and Manoli50 postulated that the increasedpressure in this situation is secondary to hemorrhage from the large bleeding cancel-lous surfaces of the fracture. Calcaneal compartment pressures rise as the hematomafills this deep compartment.Andermahr and colleagues46 postulated that bleeding from the medial calcaneal

artery into the quadratus plantae muscle is the main causative factor in developmentof foot compartment syndrome. As pressure rises, the quadratus plantae musclebecomes ischemic within the foot compartment. If untreated, the quadratus plantaeshortens, fibroses, and tethers the flexor digitorum longus tendon, which leads tothe flexion component of the claw-toe deformity. The second and third toes are pref-erentially affected because the quadratus plantae has more mass medially.51

There is a modest amount of level IV clinical data from the civilian setting with whichto help guide judgments on the performance of foot fasciotomies. Myerson38 retro-spectively looked at 14 compartment syndromes in 12 subjects with calcaneal frac-tures. Of those with crush injuries, 41% developed compartment syndromecompared with 17% of those with non-crush injuries.Mittelmier and colleagues45 reported on 12 subjects with 16 fractures who had

elevated absolute tissue pressures greater than 30 mm Hg within the central plantarmuscle compartment. The maximum values of tissue pressure were observed duringthe first 2 days after injury. These values decreased gradually over 3 to 5 days after theprimary injury. On follow up at 18 months, 7 of the 12 subjects with elevated footcompartment pressures developed plantar contractures or claw-toe deformity. Threeof the 12 subjects in this series had no observable direct concomitant soft-tissuecontusion, but they developed claw toes and plantar contracture.Fakhouri andManoli39 reported on 12 cases of compartment syndrome of the foot in

10 subjects. All sustained high-energy injuries resulting in various hindfoot and fore-foot fractures or fracture/dislocations. Decompressive fasciotomies were performedon this cohort of subjects between 3 and 13 hours after the initial presentation. Allwere evaluated at least 12 months after injury to determine if they had developedsequelae of foot compartment syndrome or complications from the fasciotomies. Allwounds were well healed with no evidence of infection or wound complications. Eightof the 10 subjects had complaints of some degree of pain, discomfort, or stiffness,especially with ambulation. Two subjects developed nerve paresthesias (one medialplantar nerve, one lateral plantar nerve distribution). There was no evidence ofischemic contracture, such as claw-toe deformity or any significant intrinsic muscleatrophy.Another case series by Manoli and colleagues59 reported on eight subjects with

concurrent compartment syndromes of the foot and leg. Of five subjects in whichearly (within a few hours of the injury) fasciotomies of the leg and foot were per-formed, no residual symptoms were identified. In contrast, all three subjects whohad delayed fasciotomies performed experienced complications, such as nervedysfunction with clawing of the toes and even a case of above-knee amputation.However, the amputation was attributed to a concomitant open fracture of the femurrather than the severe foot injury. This study highlighted the importance of expedi-tiously identifying and treating concurrent compartment syndrome of the leg and

foot.14,40

Foot

Kirk & Hayda50Several authors have described techniques for fasciotomy of the foot compartmentsfrom plantar only,60,61 medial only,12,60 dorsal only,56 plantar and lateral,54 and medialplantar and dorsal.35 The choice of fasciotomy is governed by surgeon preference,other planned procedures, and preexisting soft-tissue injuries. Consideration shouldbe made to perform a medial-only foot compartment release because this incisioncan adequately decompress all the compartments without unduly interfering withfuture surgical procedures. However, this technique and the anatomy of the medialaspect of the foot may be less familiar to some surgeons risking iatrogenic neurovas-cular damage. A failure to account for further surgical procedures along the stagedsurgical care by other surgeons unfamiliar with the initial injury pattern may jeopardizeFrom these series, the consistent message is that constant vigilance by the treatingphysician is crucial, especially in light of the significant morbidity of a missed footcompartment syndrome. Foot compartment syndrome can develop as late as 36hours after the time of injury or quickly depending on the energy transferred at thetime of injury.37 The late sequelae of foot compartment syndrome are unpredictable.The resulting muscle imbalances and varying degrees of deformity are likely influ-enced by muscle injury of the trauma, from the effects of the compartment syndromeand the postinjury rehabilitation.14 The combat surgeon must weigh the risks andbenefits of performing a foot fasciotomy.

TREATMENT

The importance of early detection and prompt treatment of compartment syndromesof the foot and leg cannot be overemphasized. Treatment for this syndrome is anemergency surgical procedure because treatment delays may contribute to irrevers-ible muscle and nerve injury. Prolonged ischemia from sustained compartment pres-sures result in significant muscle infarction. Fibroblasts replace the infarcted muscle.This process can occur over 6 to 12 months. Additionally, this necrotic muscle oftenadheres to surrounding tissues that fix the muscle position and reducemobility further.It is thought that the limited muscle excursion and the longitudinal contraction duringfibrotic proliferation results in the loss of joint motion and subsequent contracture.37

Once the diagnosis of acute compartment syndrome has been made, the goal ofrelieving pressure in the affected compartments must be met. Fasciotomy is the defin-itive treatment for acute compartment syndrome.18 The fascial defect caused by eitheran open or closed injury is not adequate to fully decompress the compartment andcompartment syndrome may still occur.7

Regardless of the extremity involved, skin incisions must be generous and thefascial releases of the affected compartments complete. Skin closure is not performedat the time of fasciotomy. This allows further swelling of the soft tissues to be accom-modated as the full extent of the inflammatory response reaches is realized. Althoughthe integument is more expansile than the investing fascia it still can critically restrictswelling. There have been reports of recurrence of compartment syndrome from theskin constricting the limb despite adequate fascial release. Incisions should be placedin line with approaches for definitive care in mind. They should be long enough toachieve decompression but no longer. They must never be of insufficient length todecompress the limb. Delayed primary closure or coverage of even the most generousincisions can subsequently be achieved.

Surgical Releasesthe ultimate functional outcome of the war casualty.

Compartment Syndrome and Fasciotomies in Combat 51Myerson40 investigated, in a cadaveric model, the ease and rate of decompressionby way of a double incision dorsal approach compared with a medial longitudinalapproach. In both methods, the intra-compartmental pressures were satisfactorily de-compressed. However, it took longer after effective fasciotomies for pressures tonormalize with the dorsal approach (11 minutes vs 1 minute, P

Kirk & Hayda52Aposteromedial incision ismade 2 cm from the palpable posterior edge of the tibia torelease the posterior compartments. The superficial compartment is released and thenthe soleus attachment is released, exposing the deep posterior compartment. Thefascia is then inciseddistally andproximally under thebelly of the soleusmuscle (Fig. 4).Others have advocated release of all four compartments through a single lateral

incision. Although this may avoid a medial incision with its attendant risk of exposingthe tibia, this approach is less familiar to most surgeons and may not be adequate forthe high-energy injuries seen on the battlefield.43

Wound Closure Techniques

In the trauma setting fasciotomy wounds are not closed at the time of fasciotomy. Fas-ciotomy wounds are often large and may not be closeable because of tissue swelling,

Fig. 3. (A) Interosseous compartment releases through two dorsal incisions. (From Emer-gency war surgery. 3rd United States revision. Borden Institute; 2004. p. 26.7. Availableat: http://www.bordeninstitute.army.mil/other_pub/ews.html.) (B) Compartments releasedthrough medial approach. (From Emergency war surgery. 3rd United States revision. BordenInstitute; 2004. p. 26.8. Available at: http://www.bordeninstitute.army.mil/other_pub/ews.html.)

Compartment Syndrome and Fasciotomies in Combat 53skin retraction, or tissue loss caused by the open injury. Split-thickness skin grafts(STSG) may be required when patients and the wound are stable. However, skin graftsare insensate and cosmetically unappealing. From the time of fasciotomy, woundmanagement focuses on swelling control, allowing recovery of injured tissues andminimizing skin retraction, if possible. Absorbent dressings are usually applied alongwith a supportive splint. This step allows for egress of fluids from edematous muscleduring the staged evacuation to the United States for definitive care. Several tech-niques have been described to minimize skin retraction, possibly obviating the needfor STSG.6366

The vessel-loop or shoelace technique is commonly performed.64 It involves usingvessel loops interlaced over the wound through staples placed at the skin edges.Although it uses equipment readily available, it suffers from several drawbacks. Thethin vessel loops frequently do not have adequate tensile forces to allow minimalskin retraction in battlefield injuries because of the significant soft-tissue swellingcaused by blasts. It is common for such swelling to cause the vessel loops to break,eliminating any effect they may exert. Dressing changes are made more difficult andcarry with them the potential of having the staples dislodged from the skin. Equaldistribution of force across the wound edges is not ensured with this technique(Fig. 5).Subatmosphericwounddressings have beenused successfully to provide fasciotomy

and open-wound control. This technique seals the wound from the outside environmentwhile allowing for removal of exudates. Studies have shown improved capillary circula-tionwith use of these devices (Fig. 6).67 The downside of this technique is that it requiresa machine to provide suction and may be difficult to apply around external fixators.

Fig. 4. Medial and lateral incisions of the leg for four compartment fasciotomy of the leg.(From Emergency war surgery. 3rd United States revision. Borden Institute; 2004. p. 22.13.Available at: http://www.bordeninstitute.army.mil/other_pub.ews.html.)

Kirk & Hayda54Janzing and Broos66 reported on a comparison of three different techniques forclosure of civilian fasciotomy wounds in 15 subjects. The mean time to wound closurefor all groups was 9 days. They found that skin traction with vessel loops or preposi-tioned intracutaneous sutures provided good skin apposition without the necessity forskin grafting. The major advantage was that the material required was readily availablein most operating rooms. However, they pointed out the potential risk for highcompartment pressures during a prolonged time in the postoperative period requiringclose monitoring of limb perfusion.Singh and colleagues63 described their experience caring for war casualties in Iraq

using a dynamic wound-closure device for closure of fasciotomy incisions. Elevenconsecutive subjects who had undergone two incision fasciotomies for compartmentsyndrome were studied. Ten of the 11 subjects (91%) had their wounds closed in a de-

Fig. 5. Vessel-loop technique for temporary closure of fasciotomy incisions.layed primary fashion after application of the wound-closure device. They found thatthe subjects benefited from the use of the device and avoided the need to create

Fig. 6. Subatmospheric wound-dressing therapy for temporary wound control.

COMPLICATIONS OF FASCIOTOMIES

Compartment Syndrome and Fasciotomies in Combat 55Delayed Fasciotomy

Despite the pre-deployment training of all surgeons in the diagnosis and treatmentof compartment syndrome, there have been cases where the diagnosis of compart-ment syndrome was made following the initial surgical stabilization and evacuation.In a retrospective study, Ritenour and colleagues1 highlighted the dynamic nature ofadditional wounds in multiple-injury patients. However, long-term follow up of thissmall group was limited because of the rapid evacuation of soldiers to the UnitedStates and the expedient discharge from the hospital of host-nation soldiers (Fig. 7,Dynamic Wound Closure Device [DWC, Canica, Almonte, ON, Canada]).

Fig. 7. Dynamic wound-closure device for delayed primary closure of fasciotomy wounds.compartment syndrome and the challenges of diagnosis and treatment. Their analysisincluded 336 subjects receiving 671 fasciotomies for combat injuries treated at themedical center in Germany that receives all evacuated war casualties from Iraq andAfghanistan. The authors compared subjects who required revision of a previouslyperformed fasciotomy or delayed fasciotomy to those who received the procedurebefore evacuation to Germany. The revision and delayed group had substantially high-er Injury Severity Score (26.4 vs 14.5); more subjects with burn injuries and with moresevere burns; and tended to require systemic support (ventilation, fluids, and vaso-pressors) during evacuation. This group had a higher mortality and amputation ratecompared with those who had complete fasciotomies in theater, and also requiredmore muscle excision. The most common revision procedures were extension ofskin and fascial incisions and opening new compartments, particularly in the leg.This retrospective study does not provide information on the status of the limb beforeevacuation to assess the evolution of compartment syndrome. It is also not clearwhich delayed and revision fasciotomies were performed in fractured limbs. Nonethe-less, this study highlights the need tomaintain a high index of suspicion and to performprophylactic fasciotomy in patients who have severe injuries.Some surgeons have questioned the practice of performing delayed fasciotomies

because of the increased morbidity in the face of little to no functional benefit.67,68 Fin-kelstein and coauthors68 reviewed the cases of five subjects who underwent a delayed

Fasciotomy Wound Morbidity

Kirk & Hayda56Fasciotomy itself has its own morbidity by exposure of susceptible muscle and deeptissues to infection. Additionally there is potential for nerve injury and alteration inmuscle mechanics. Injuries and initial combat-surgery interventions occur in austereenvironments that place the casualty at increased risk for wound colonization andinfection. The potential limb-saving benefit of fasciotomy must outweigh the potentialinfectious complication of open-leg wounds in casualties already at risk for loss of limbor life. Rush and colleagues70 reported on a retrospective series of 127 lower-extremity fasciotomies performed for compartment syndrome after acute ischemiaand revascularization in subjects with either vascular trauma or arterial occlusivedisease. Superficial infections occurred in five subjects and all resolved with localwound care. However, spread of infection from the foot to the fasciotomy site contrib-uted to amputation in two subjects. In their series, no limb loss was attributed toprimary open fasciotomy. They concluded that the morbidity and mortality of fasciot-omy were the result of refractory ischemia caused by associated injuries or underlyingmedical problems, but not from open fasciotomy wound complications.Leg and foot fasciotomy have been used as an adjunctive technique to optimize

limb salvage after revascularization for ischemia. Limb salvage and good functionalresults were achieved in 10 out of 11 subjects who underwent fasciotomy of thefoot when compartment syndrome after revascularizations was unrelieved with stan-dard leg fasciotomy.71

Combat surgeons should not withhold fasciotomy when clinically indicated for fearthat this effective ancillary procedure will adversely affect limb salvage. It has been theauthors experience that even though fasciotomy wounds are frequently colonized,overt clinical signs of wound infection do not occur. Colonization, even that resultingfasciotomy for extremity compartment syndrome at least 35 hours after the injury,when ideally the fasciotomy would have been performed earlier. Of the five subjects,one subject died of septicemia and multiorgan failure and the remaining four requiredlower-extremity amputation. They concluded that fasciotomies were consistentlyassociated with severe infection and possible death when the recognition of thecompartment syndrome was delayed for more than 8 to 10 hours. Furthermore, fas-ciotomy for early excision of muscle had little advantage over late excision to justifythe high risk for local infection and amputation.Williams and colleagues69 demonstrated in a retrospective study of 88 subjects that

fasciotomy performed after 12 hours was associated with a fourfold increase in infec-tion compared with those performed before 12 hours. The rates of limb salvage andneurologic sequelae were similar. They advocated that fasciotomy performed earlywas most effective, but that the similar rates of limb salvage, even with the increasedrisk for infection, justifies the aggressive use of fasciotomy in extremity trauma regard-less of the time of diagnosis.For the combat surgeon these works emphasize the need for close monitoring

of the extremity for signs of impending compartment syndrome and the liberal useof prophylactic fasciotomies to prevent the associated morbidity with delayedtreatment. If a delayed diagnosis is encountered, even beyond the 8 or 12 hourlimit as suggested by some authors, fasciotomy should still be entertainedbecause the precise time of onset of ischemia may be difficult to determine inmany cases. Any necrotic tissue found should be completely excised to mitigatethe risk for infection.in minor infection, is managed successfully with local measures without adverse

is caused by the contracture of the tibialis posterior and flexor digitorum longusmore frequently than that of the gastrocnemius and soleus. Frink and colleagues73

Patients with burn injuries comprise 5% of combat casualties.74 These patients often

careful physical examination is required and pressure measurements serve as an

Compartment Syndrome and Fasciotomies in Combat 57adjunct in making the diagnosis in the deployed setting. Future advances in the under-standing of pathophysiology and diagnosis of compartment syndromemay reduce thecurrently maintained low threshold for fasciotomy to avoid the devastating conse-have a high amount of total-body surface area affected. When the limb is involved ina burn, a circumferential eschar limits the ability to accommodate swelling. Resusci-tation of these patients also requires large fluid infusion placing them at risk forcompartment syndrome.1 At a minimum, an escharotomy that incises the skin butnot the fascia is required for accommodation of swelling.75 However, in casualtiesthat require significant resuscitation the relief may not be adequate, necessitatinga formal fasciotomy to prevent progression of compartment syndrome.

SUMMARY

Prophylactic and therapeutic treatment of leg compartment syndrome with decom-pression by double-incision fasciotomy prevents progression of soft-tissue injury inhigh-energy trauma. This treatment is the standard of care in civilian trauma andcombat settings. More controversial is the use of either single- or dual-incision fasciot-omy of the foot for prophylactic treatment of foot compartment syndrome. Fasciotomymust be performed in the face of major trauma to the foot with severe swelling andunremitting pain. The role for prophylactic fasciotomy of the foot is unclear and shouldbe considered on a case by case basis. The surgeon must maintain a high degree ofvigilance for the development of compartment syndrome in the combat casualty. Ademonstrated that even with adequate treatment, patients who have compartmentsyndrome of the leg suffer from long-term impairment, such as reduced muscularstrength, reduced range of motion, and pain. Early decisions in treatment of the warcasualty can result in significant long-term functional impairments if treatment is with-held or inappropriately performed. Although a prophylactic fasciotomy is not benign,the liberal use of fasciotomy in the combat setting prevents the potentially devastatingconsequences of a delayed diagnosis of compartment syndrome.

BURN CASUALTIESeffects on the eventual outcome. Furthermore, many options exist for the delayedcoverage of the wound.

Late Complications

Delayed diagnosis or inadequate release of the compartments can result in long-termproblems. The ischemic insult can cause fibrosis of the muscles and result in a painful,dysfunctional foot and leg. Late deficits after foot compartment syndrome includesstiffness and decreased sensation. The lesser toes develop clawing owing to theintrinsic muscle weakness or contracture, which can be very painful. Some physiciansargue that isolated, acute, foot compartment syndrome should be observed and a latereconstruction should be performed, if necessary.59,72

Clinically, the diagnosis of deep compartment fibrosis is established by the pres-ence of equinus and cavus with resulting heel varus and claw toes.72 The deformityquences of a missed diagnosis.

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Compartment Syndrome and Fasciotomies in Combat 61

Compartment Syndrome and Lower-Limb Fasciotomies in the Combat EnvironmentPathophysiologyAnatomyFootLeg

DiagnosisFootLeg

Foot compartment syndromeTreatmentSurgical ReleasesFootLeg

Wound Closure Techniques

Complications of fasciotomiesDelayed FasciotomyFasciotomy Wound MorbidityLate Complications

Burn casualtiesSummaryReferences