Bedside Fasciotomy for Treatment of Compartment Syndrome

A compartment is an area of muscle groups and neurovascular structures enclosed by fascia. The leg consists of 4 compartments: anterior, lateral, superfi cial posterior, and deep posterior. The foot, although occupying less surface area than the leg, contains 9 compartments. The compartments are medial, lateral, 4 interossei, calcaneal, and superfi cial and deep central compartments (1). Compartment syndrome is defi ned as a raised pressure within an enclosed area with the potential to cause irreversible damage to its contents. This ability to permanently damage these structures is what makes compartment syndrome a podiatric surgical emergency. Therefore, it is important to effi ciently identify, diagnose, and treat a compartment syndrome. The authors will discuss the use of a bedside fasciotomy under local anesthetics in select cases in order to avoid delay in compartmental release. Before treating compartment syndrome, one must be able to properly identify the condition. Common causes include but are not limited to trauma, hemorrhage, tight casting, or constrictive bandaging. If a patient presents with a cast or dressing, it is advised to remove the causative agent. Garfi n and Mubarak reported an average reduction of 65% in compartmental pressures after removal of a cast, and then an additional decrease of 10-20% after the dressing was removed (2). The presence of an open fracture does not exclude the diagnosis of compartment syndrome. Although the affected area is open, the adjacent compartments are not necessarily spared. The historical symptoms of a patient with compartment syndrome are pain, pallor, parasthesia, paralysis, and pulselessness. However, these symptoms should not be considered a reliable fi nding. A patient with an early presentation will have pulses and an adequate capillary fi ll time. The vascular defi ciency tends to be a late fi nding of compartment syndrome. Immediate symptoms that should warrant a compartment syndrome are allodynia and palpable tenseness in the involved compartment. Compartment syndrome can only be accurately diagnosed with the use of a Wick’s catheter. There are several different theories reported in the literature that can aid with the interpretation of the results. The fi rst, being the absolute pressure theory presented by Mubarak (3) and Matsen (4), who suggested a fasciotomy be performed when intracompartmental pressures reach or exceed 30 mm Hg (3) and 45mm Hg (4). Then, there is the perfusion theory of Whitesides (5), who revealed the relationship of tissue perfusion and diastolic blood pressure (DBP). He recommended surgical decompression when the tissue pressure is within 20 mm Hg of the DBP. McQueen (6) suggested a differential <30 mm Hg of the diastolic pressure and the intramuscular pressure as a threshold for release as being more reliable.