VOL. 73-B, NO. 2, MARCH 1991, pp. 287-290
           
Copyright 1991 by The British Editorial Society of Bone and Joint Surgery
       
ACUTE COMPARTMENT SYNDROME. EFFECT OF DERMOTOMY
  ON FASCIAL DECOMPRESSION IN THE LEG
        
By Cohen, M. S., Garfin, S. R., Hargens, A. R., 
     Mubarak, S. J.
              
     From the University of California, San Diego

     The authors wish to thank Kathy Edwards for typing and
preparing the manuscript.

     No benefits in any form have been received or will be
received from a commercial party related directly or indirectly
to the subject of this article.

     ABSTRACT: Prompt surgical decompression is the only means of
preventing the late sequelae of ischaemic contracture in post-traumatic
compartment syndromes. However, controversy exists regarding the length of
dermotomy required for adequate decompression in the lower extremity. This
study investigated the skin envelope as a potential contributing factor. 

     Wide fascial releases were performed through limited 8 cm incisions in
eight cases of post-traumatic lower extremity compartment syndrome. In nine
of 29 compartments the pressure remained greater than 30 mmHg. Lengthening
the skin incisions to an average of 16 cm decreased intracompartmental
pressures significantly.

     This study documents the skin envelope as a contributing factor in
acute compartment syndromes of the leg. The use of generous skin incisions
is supported and the need for intra-operative compartment pressure
measurements in the treatment of this condition is emphasised.
                                                       END OF ABSTRACT

     Prompt fascial release is the recognised treatment for acute
compartment syndromes. However, controversy exists regarding the length of
dermotomy required for adequate decompression in the lower extremity. Some
authors have favoured limited incisions, claiming low morbidity as an
advantage (Patman, Poulos and Shires 1964; Rosato et al 1966; Gaspar et al
1968; Bate 1972; Gaspard, Cohen and Gaspar 1972; Patman, Thompson and
Persson 1973; Gaspard and Kohl 1975; Patman 1975; Hoopes and Maxwell 1979).
Others have stated that long skin incisions are required to decompress
affected compartments adequately (Mubarak and Owen 1977; Matsen, Winquist
and Krugmire 1980; DeLee and Stiehl 1981; Rollins, Bernhard and Towne 1981;
Hyde, Peck and Powell 1983; Mubarak and Hargens 1983; Bess 1984; Rorabeck
1984; Blick et al 1986; Noble and Banks 1986). Several instances in which
the skin continued to cause compression after fasciotomy through short
incisions have been reported (Gaspard et al 1972; Gaspard and Kohl 1975),
but measurements of intracompartmental pressure were not recorded in these
cases.

     This study was undertaken to determine the effect of the length of the
skin incision in post-traumatic compartment syndromes of the lower
extremity treated by fascial decompression. Intracompartmental pressures
were measured using a wick catheter, which is known to give reliable and
reproducible measurements (Mubarak et al 1976, 1978; Koman, Hardaker and
Goldner 1981; Russell, Apyan and Burns 1985).

                        Materials and Methods

     Eight patients with lower extremity compartment syndromes were
studied; their ages ranged from 19 to 64 years (mean 34). All had suspected
compartment syndromes following lower extremity trauma. Pressure
measurements were made using a wick catheter (Cutter Biomedical, San
Diego). The indications for pressure measurements were painful swelling of
the limb and a palpably tense compartment, usually with distal
hypo-aesthesia (Mubarak et al 1978; Mubarak 1984). An intracompartmental
pressure greater than 30 mmHg was recorded in all patients. We and others
have chosen this pressure as an indication for decompressive fasciotomy
(Mubarak and Owen 1977; Mubarak et al 1978; Saffle, Zeluff and Warden
1980; Koman et al 1981; Hyde et al 1983; Bess 1984; Rorabeck 1984; Russell
et al 1985; Blick et al 1986; Gershuni et al 1987; Siverhus and Amis 1988;
Vitale et al 1988).

     The injuries associated with the compartment syndromes were: closed
proximal fracture of the tibia (with or without fibular fracture) in four
patients; bilateral fibular fractures in one; a low velocity gunshot injury
in one; and closed trauma to the leg without fracture in one patient with
haemophilia.

     Surgical decompression of the leg was performed using the
double-incision technique, which employs an anterolateral and a
posteromedial incision (Dennis 1945; DeBakey and Simeone 1946; Mubarak and
Owen 1977) (Fig. 1). All affected osteofascial compartments were initially
released through 8 cm-long skin incisions. Such incisions were considered
adequate to allow complete proximal and distal fascial release. After the
fasciotomy the compartment pressures were again measured. The pressure was
recorded when equilibrium had been reached, usually five to 10 minutes
after fasciotomy.

     The anterolateral skin incision was then enlarged, in 2 cm increments,
and the pressure was recorded after each extension until the readings
showed no further change. The dermotomy extensions were necessarily
performed without undue delay, to avoid the adverse effects of prolonged
elevation of the intracompartmental pressure.

     The posteromedial incision was enlarged only if the pressure in the
posterior compartment was greater than or near to the critical level of
30 mmHg (25 to 30).

     In all cases the fascial release performed through the limited skin
incisions was adequate and at no time was additional incision of the fascia
required during the extension of the dermotomies.

     The compartment pressures before and after lengthening the skin
incisions were compared using the paired Student's t-test.

                             Results

     The results are given in Table I. Pre-operatively, all patients had
pressure greater than 30 mmHg in at least one compartment (mean 48 mmHg, SD
+/- 12). Following fascial release, through the limited 8 cm incisions, the
compartment pressures decreased to a mean 25 mmHg, SD +/- 11.

___________________________________________________________________________________________________
Table I.
Details of pressure measurements in eight patients with compartment 
syndrome
___________________________________________________________________________________________________
                                       Pressure in mmHg
                                       ____________________________________________________________
                                                 After fasciotomy
     Age/                              Before    through 8-cm   After extension  Final length of
Case Sex  Injury          Compartment* operation skin incision  of skin incision skin incision (cm)
___________________________________________________________________________________________________
1    19/M Closed fibular  ANT          50        37             20 
          fracture        LAT          55        35             20               14
                           SP          45        10    
                           DP          55        17                               8
2    19/M Closed fibular  ANT          46        34             21
          fracture        LAT          40        37             16               16
                           SP          50        22
                           DP          55        22                               8
3    47/F Soft-tissue     ANT          75        35              9   
                          LAT          60        24              4               24
                           SP          20        15              7
                           DP          55        10             20               14
4    64/M Closed proximal  NT          65         5              5
          tibial fracture LAT          55        25             10               12
                           SP          45        18
                           DP          55        21                               8
5    26/F Closed proximal ANT          35        20             15
          tibial/fibular  LAT          35        16             10               12
          fracture         SP          45        26             20   
                           DP          50        28             12               12
6    36/M Closed proximal ANT          65        45             17
          tibial fracture LAT          55        32             12               18
                           SP          30        16                               8
                           DP          35        22
7    28/M Low-velocity    ANT          60        18              7               14
          gunshot         LAT          -         -
                           SP          -         -
                           DP          -         -
8    14/M Closed proximal ANT          50        26              8
          tibial/fibular  LAT          50        36             18               20
          fracture         SP          30        10              6
                           DP          32        25              9               16
___________________________________________________________________________________________________
* fascial compartments: ANT, anterior; LAT, lateral; SP, superficial
  posterior; DP, deep posterior
___________________________________________________________________________________________________

     However, in nine of 29 compartments the pressure remained above
30 mmHg. Four of these compartments were anterior, four lateral, and one
was a deep-posterior compartment.

     The anterolateral skin incisions were extended in them all and the
posteromedial incisions in three. The final length of the extended
incisions averaged 16 cm +/- 4. The mean final pressure in the
compartments which required extended incisions was 13 mmHg, SD +/- 6. This
was significantly less than the mean pressure recorded in these
compartments before the skin incisions were extended (p < 0.002, Fig. 2).

                             Discussion

     Prompt surgical decompression is the only means of preventing the late
sequelae of ischaemic contracture in post-traumatic compartment syndrome.
In circumferential burns of the limbs, the skin is recognised to be the
primary constricting envelope, and generous escharotomy is the treatment of
choice (Kaplan and White 1961; Pruitt, Dowling and Moncrief 1968; Asch,
Flemma and Pruitt 1969; Justis, Law and MacMillan 1976; Saffle et al 1980).
However, in the traumatised limb, it is the strong fascial compartment
boundaries which are the least responsive to internal pressure gradients,
and all authors agree on the need for wide fascial release. Controversy
exists only with regard to the length of the skin incisions.

     The proponents of limited dermotomy (4 to 8 cm) cite as advantages a
decreased risk of infection, shorter healing time, better scars, and easier
secondary wound closure. Long incisions have been said to cause more
bleeding and to prejudice the distal circulation in the limb by damaging
collateral vessels (Patman et al 1973; Patman 1975).

     Others have recommended long skin incisions (15 to 30 cm) in all
cases, using either a single lateral incision (Matsen and Clawson 1975;
Nghiem and Boland 1980; DeLee and Stiehl 1981; Rollins et al 1981) or a
double-incision technique (Dennis 1945; Mubarak and Owen 1977; Whitesides,
Harada and Morimoto 1977; Hyde et al 1983; Mubarak and Hargens 1983;
Rorabeck 1983; Bess 1984; Blick et al 1986; Noble and Banks 1986). These
authors thought that long incisions were necessary to allow adequate
inspection and decompression of the compartments of the leg. A long
anterolateral incision may also minimise the risk of injury to the
superficial peroneal nerve, and a long posteromedial incision provides
better access to the deep posterior compartment. Long skin incisions are
stated to add little to the morbidity and they eliminate the risk of the
skin acting as an unrecognised compartment envelope. This is especially
important in the hyperaemic period following decompression of an ischaemic
compartment (Matsen and Clawson 1975; Whitesides et al 1977; Matsen et al
1980).

     Sheridan and Matsen (1976) reviewed 46 cases of upper and lower
extremity compartment syndrome treated either by `open' fasciotomy (31
limbs) or `closed' fasciotomy (15 limbs). The size of the dermotomy was
found to influence neither the complication rate nor the late functional
result. However, the two groups were not strictly comparable and
intracompartmental pressures were not measured. Gaspard et al (1972)
described two patients with lower extremity compartment syndromes who
failed to improve clinically, despite adequate fasciotomies through limited
incisions (5 cm). Both responded favourably to wide dermotomies of the
calf.

     Our study confirms that the skin is a potential contributing factor in
compartment syndrome. Though wide fascial releases were carried out in all
patients, nine of 29 compartments remained under pressures greater than
30 mmHg. Lengthening the skin incisions significantly decreased the
pressures.

     Though we cannot predict what would have been the outcome in the limbs
with `limited' dermotomies, this study documents the potential contribution
of the skin envelope in lower extremity compartment syndrome. The use of
generous skin incisions is supported and the need for intra-operative
measurement of the compartment pressures in the treatment of this condition
is emphasised.

                        Article Figure Legends

FIGURE 1: Cross-section at the level of the middle and distal thirds of the
leg to illustrate decompression of the four fascial compartments using the
double-incision technique.  

FIGURE 2: Pressure measurements (mean +/- SEM) in 21 lower extremity
compartments initially treated by fascial decompression through limited 8
cm incisions. Extension of the skin incisions to a mean of 16 cm resulted
in a significant decrease in compartment pressures (p < 0.002).

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