OPERATIVE INTERVENTION 

CS requires immediate operative intervention. Once intra-compartmental pressure reaches a critical threshold, only surgical treatment can interrupt the cascade of events leading to ischemia and tissue necrosis. This should be accomplished as soon as possible, as irreversible tissue necrosis occurs within a few hours. Delayed or incomplete compartment release has been associated with increased mortality and need for amputation in military casualties.6  Therapeutic fasciotomy is performed for established compartment syndrome while prophylactic fasciotomy is performed for limbs at risk of developing CS.8-10  The decision to proceed with prophylactic fasciotomy is based on the pattern of extremity injury, the patient’s physiological profile, and operational considerations. We recommend that any limb at risk of CS in an austere location, particularly when AE is anticipated or after extremity vascular repair, should undergo prophylactic fasciotomy when they reach a fixed surgical facility. This avoids missed compartment syndrome or delayed compartment release, especially during times of high battle rhythm. The difficulties associated with monitoring a patient’s physical exam during lengthy periods of transport must be considered in the decision to perform prophylactic fasciotomy, along with the inability to intervene during AE.  High altitude (including normal AE aircraft cabin pressure), in and of itself, is not a contributor to compartment syndrome.17,18 

 

DELAYED EVACUATION

Occasionally, casualties present with a compartment syndrome of prolonged duration (> 12 hours) due to delayed evacuation. This situation is associated with markedly increased risk of complications, including death and infection.12  These casualties may be best treated with appropriate resuscitation, urine alkalization, mannitol use, and intensive support.19  Such conservative care has led to better outcomes than fasciotomy in casualties with closed injuries with mechanically crushed muscle (see Figure 1).12  Therefore, compartment syndromes with greater than 12 hours of warm ischemia with nonviable muscle should not routinely undergo fasciotomy.19  The role of amputation is currently unclear in this situation.

 

FASCIOTOMY 

Once the decision is made to perform compartment release, a complete fasciotomy must be performed.14,20  This involves releasing all compartments in the affected anatomic region over their full length. In the calf/leg, the anterior, lateral, superficial posterior and deep compartments must be released through full length incisions. Although a one-incision approach is possible in expert hands, we feel that a two incision technique should remain the standard of care in combat.21,22 A frequent error by inexperienced surgeons is not releasing the deep posterior compartment of the calf/leg. In the forearm, the superficial and deep volar compartments must be released through an incision that extends from the lacertus fibrosus to the carpal tunnel. The dorsal compartment, when involved, is released through a separate incision. Incomplete fasciotomy can be secondary to failure to release a specific compartment or to short fascial incisions. The most commonly missed compartment syndromes are the anterior and deep posterior compartments of the calf/leg.7 The most common incompletely released compartments are also in the calf/leg.7 Incomplete fasciotomy is associated with worse outcomes; fortunately, improved surgical education has been shown to decrease the rate of fasciotomy requiring revision.7,23 There is no reported experience with fasciotomy performed by non-surgeons in austere locations. We would caution that attempting this procedure outside of an operating room setting is fraught with pitfalls, including uncontrollable bleeding and iatrogenic neurovascular injury. Wound vacuum dressings or laced vessel loops are both acceptable methods of initially covering the surgical wounds.

 

The common reasons for incomplete calf fasciotomy are:

 

Passive stretch pain (e.g., ankle dorsiflexion), palpation of muscles for tenseness and pulse quality combined with an index of suspicion makes up the mainstay for clinical evaluation. Pressure monitoring by manometer does not reliably diagnose CS in theater, so the diagnosis remains a clinical, not a technological diagnosis. Since there is currently no sensitive or specific technique for establishing the diagnosis of compartment syndrome, a fasciotomy should be considered in a patient with significant mechanism of injury and clinical findings suspicious for compartment syndrome.

 

TREATMENT OF FOOT CS

Fasciotomy for treatment of CS of the foot remains controversial. While surgical release is generally supported in the literature, the sequelae of foot fasciotomy can, in many instances, result in more severe sequelae (infection, skin grafting, difficulty with shoe wear) than result from compartment syndrome itself (claw toe deformity). The surgeon must, therefore, carefully weigh the advantages and disadvantages prior to performing foot fasciotomies.