SSSFELICIANO’S MAR [15-05]:Techniques for a Two-incision Four-compartment Fasciotomy of the Leg

MEDICAL ANECDOTAL REPORT
Indexing Title: SSSFELICIANO’S MAR [15-05]
MAR Title: Techniques for a Two-incision Four-compartment Fasciotomy of the Leg
Date of Medical Observation: March 2015
Tag: How to do a two-incision four-compartment fasciotomy of the leg for compartment syndrome
Category: Physical – Reinforcement
NARRATION:
           
My first mortality for this year was that of a 38-year-old male who had multiple gunshot wounds of the lower extremity and back. He had a pneumohemothorax then for which a chest tube was inserted, providing relief for his difficulty of breathing. What we failed to address, however, was a gunshot wound in his thigh, assuming that nothing was wrong since there was presence of pulse in the distal lower extremity, although it was faint. We did a small incision on his anterior thigh to explore the wound and only a small collection of hematoma was released. The next day, the patient was lucky enough to be checked by our service consultant. It was only then that she detected that the patient was already having a compartment syndrome. The patient was directed to the operating room for immediate fasciotomy of the lower extremities. It was my first time to do such a procedure after being shown a video of how it is done. Intra-operatively, the patient had a completely transected femoral artery causing the rhabdomyolysis, further causing the compartment syndrome. We were successful in doing the fasciotomy, but we failed to save the patient. It was too late. Hence, this became a learning experience for me and hopefully the next time I see one, I’d be able to save a patient’s life.
Insight: (Physical, Psychosocial, Professional/Ethical) (Discovery, Stimulus, Reinforcement)
           
As for Leriche, Every surgeon carries within himself a small cemetery, where from time to time, he goes to pray-a place of bitterness and regret, where he must look for an explanation for his failures. So I did.
To perform this procedure, it is essential to identify the landmarks: the fibular head, the tibial tuberosity, and the patella. The tibial tuberosity and the anterior tibial spine serves as a reliable pinpoint between the two incisions. The lateral malleolus and the head of the fibula are used to mark a line that denotes the lateral incision which is made 1 fingerbreadth in front of the fibula. The medial incision is made by identifying the medial aspect of the tibia and the medial malleolus and the incision is made 1 thumb behind  the tibia.
The following depicts the lateral incision of the leg:The lateral incision is made 1 fingerbreadth in front of the fibula from a point 2-3 fingerbreadths below the knee and 2-3 fingerbreadths above the ankle. This incision should be generous and be carried down to the subcutaneous tissue to identify the underlying fascia. Once the underlying fascia has been identified, the intramuscular septum should be sought. Utilizing perforator vessels may be helpful in looking for the intermuscular septum which defines anterior from the lateral compartment of the lower extremity. The fascia is classically opened in an H-shaped incision. The crosspiece of the H is made with a scalpel and once this has been made, scissors are used to open the fascia both cephalad and caudad in the entire length of the extremity. This is done on either side of the septum utilizing curved scissors with the tip turned away from the septum to avoid damage to the nerve structures underneath. The fascia is once again opened completely both in a cephalad and caudad direction of the entire length of the lower extremity. After opening both compartments, identification of the septum and deep peroneal nerve ensures that the anterior and lateral compartments have been entered.
The following depicts the medial incision of the leg: The medial incision is made 1 thumb behind the tibia from a point  about 2-3 fingerbreadths above the ankle and 2-3 fingerbreadths below the knee. The skin is entered and the subcutaneous tissue, taking care to both identify and preserve the saphenous vein and ligate any tributaries that may be present. Once the underlying fascia has been identified, the edge of the tibia is used to help plan the incision. The incision is made just off the edge of the tibia with a scalpel. Scissors are then used with closed tips to open the fascia in both the cephalad and caudad direction to allow entry into the superficial posterior compartment. The fascial incisions are extended the entire length  of the lower extremity to completely open the compartment. This often requires extending the skin incisions to allow complete exposure of the fascia. The next key maneuver is to separate the soleus fibers from the underside of the tibia. This enables entry into the deep posterior compartment. Identification of the posterior  tibial neurovascular bundle assures that the deep posterior compartment has been entered. Once this has been confirmed, the fascia of the deep posterior compartment  is separated further and fully opened the length of the leg. The adequacy of fasciotomy is confirmed and at this junction, both sides are inspected for hemostasis.
ROJoson’s Notes (17jan14):
Sharing of a surgical technique: Techniques for a Two-incision Four-compartment Fasciotomy of the Leg
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