Leg Fasciotomy: Step-by-Step Guide

Introduction to Leg Fasciotomy

A leg fasciotomy is an emergency surgical procedure performed to relieve dangerously high pressure in muscle compartments. When compartment syndrome develops, immediate fasciotomy can mean the difference between saving a limb and permanent disability. This guide details the step-by-step surgical technique, post-operative care, and consequences of delayed treatment.

Surgical Technique for Four-Compartment Leg Fasciotomy

Preoperative Preparation

• Spinal Anesthesia is administered
• Tourniquet applied (for visualization, not ischemia)
• Sterile prep of entire leg

Medial Incision: Releasing Posterior Compartments

1. Incision Placement
   • 3 cm posterior to tibial border
2. Dissection Technique
   • Blunt dissection through subcutaneous fat
   • Protect saphenous vein and nerve
3. Fascial Release
   • Open posterior compartment fascia
   • Confirm release by digital palpation along entire length
4. Deep Compartment Access
   • Reflect gastrocnemius and soleus posteriorly
   • Incise intermuscular septum longitudinally
   • Verify complete deep compartment release

Lateral Incision: Releasing Anterior and Lateral Compartments

1. Incision Placement
   • Midway between tibial crest and fibula
2. Nerve Protection
   • Identify and protect superficial peroneal nerve
   • Note variable anatomical course
3. Compartment Release
   • Longitudinal incision through anterior compartment fascia
   • Separate incision or septum opening for lateral compartment
   • Confirm complete release by palpation

Muscle Viability Assessment (The “Four Cs”)

After decompression, assess tissue viability:

1. Color – Healthy muscle appears pink/red
2. Contractility – Responds to stimulation
3. Consistency – Necrotic muscle feels mushy (removable with curette)
4. Capacity to Bleed – Viable tissue bleeds when incised

Critical Step:

• Use artery forceps to spread muscle fibers and check for central necrosis
• Excise all non-viable tissue to prevent infection

Wound Management and Postoperative Care

Initial Dressing

• Leave wounds open
• Apply absorbent or vacuum-assisted closure (VAC) dressing

48-Hour Follow-Up

• Return to OR for:
  • Reassessment of muscle viability
  • Further debridement if needed
  • Possible delayed primary closure

Definitive Wound Closure Options

1. Gradual Secondary Closure (serial operations)
2. Split-Thickness Skin Grafting
3. Vacuum-Assisted Closure for gradual healing

Consequences of Delayed Treatment

When compartment syndrome is missed for 24-48+ hours:

• Muscle necrosis is typically irreversible
• High infection risk with late fasciotomy
• Poor functional outcomes likely
• Amputation or arthrodesis may become necessary

Key Surgical Considerations

✅ Complete fascial release is mandatory – partial decompression fails
✅ Preserve neurovascular structures during dissection
✅ Adequate debridement prevents infection
✅ Early follow-up surgery improves outcomes

For Further Reading:

• AAOS Compartment Syndrome Guidelines
• Wikipedia: Fasciotomy

Other Ortho Topics: Orthopaedics Surgery