Compartment S y n d ro m e a n d L o w e rLimb Fasciotomies in the Combat E n v i ro n m e n t

Kevin L. Kirk,
KEYWORDS  Compartment syndrome  Lower-limb fasciotomies  Battlefield surgery  Combat injuries
DO
a,

*, Roman Hayda,

MD

b,c

The battlefield surgeon is faced with challenges in the management of leg and foot compartment syndrome because the conditions pathophysiology, diagnostic modalities, and treatment methods all involve controversy. Blast injury, high-velocity gunshot wounds, and blunt trauma associated with combat operations cause injuries that may induce compartment syndrome. If untreated, muscle and nerve necrosis may occur. Subsequent myoneural fibrosis, contracture, infection, amputation, and systemic complications are all possible. However, compartment syndrome and its sequelae can be prevented or mitigated by prompt intervention to maintain adequate tissue oxygenation. At present, recommendations for a low threshold for fasciotomy are maintained to avoid missing the diagnosis; however, this exposes casualties to the risks of fasciotomy in false-positive cases. The incidence of compartment syndrome and limbs at risk in combat casualties requiring evacuation is estimated to be 15%.1 In recent United States conflicts, severe extremity trauma caused by blast injuries has been a common presentation resulting in more than 71% of the total number of extremity injuries and accounts for 86% of those requiring fasciotomy.14 Exploding ordnance causes significant

LTC Kevin L. Kirk, DO, Chief, Integrated Orthopedic Surgery Service San Antonio Military Medical Center, San Antonio, Texas; Assistant Professor, Baylor University, School of Graduate Studies, Houston, Texas b Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA c Orthopedic Trauma, Rhode Island Hospital, Providence, RI 02905, USA * Corresponding author. Integrated Orthopedic Surgery Service, San Antonio Military Medical Center, San Antonio, TX, USA E-mail address: kevin.l.kirk@us.army.mil (K.L. Kirk). Foot Ankle Clin N Am 15 (2010) 4161 doi:10.1016/j.fcl.2009.11.003 1083-7515/10/$ see front matter. Published by Elsevier Inc. foot.theclinics.com

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soft-tissue injury, vascular injury, and burns. Eighty-two percent of fractures that occur on the battlefield are open.2 All of these injury factors place extremities at risk for compartment syndrome. The battlefield imposes restrictions not typically encountered in the civilian environment. Surgical treatment in a combat environment is performed under austere conditions with limited resources, and at times, high volume. Initial care is focused on life- and limb-saving procedures, stabilizing patients and their injured extremities to prepare them for evacuation to a higher level of care. Evacuation of patients to fixed facilities in Germany and ultimately back to the United States for definitive care may occur as soon as 12 to 24 hours from injury. Flights on current aircraft from Afghanistan and Iraq to Germany last from 5 to 9 hours. An additional 1 to 2 hours is required for ground transportation and aircraft loading and unloading. In the aggregate this may delay surgical access of undergoing medevac for up to 12 hours.1 Distracting injuries, analgesics, sedation, and the restricted interior space of the aircraft make evaluation and treatment of compartment syndrome extremely difficult during transport. In the combat zone, the diagnosis of compartment syndrome is even more heavily weighted toward clinical evaluation than in the civilian setting. In this environment, compartmental pressure measurements may be used if available. However, these frequently do not enter into the treatment algorithm. The surgeons clinical diagnostic acumen is of prime importance in evaluating these complex injuries. One must not only account for what is seen at the time of presentation but also predict how the injury will evolve during the course of evacuation when evaluation is difficult and surgery cannot be performed. To minimize the incidence of false-negative initial evaluations of the war casualty, prophylactic fasciotomies may be required before any clinical sign of compartment syndrome. Prophylactic fasciotomy is performed before aeromedical evacuation when compartment syndrome is likely to develop in a delayed fashion. The authors purpose is to provide insight into the unique challenges encountered by the military surgeon managing combat injuries at risk for compartment syndrome of the leg and foot.
PATHOPHYSIOLOGY

Compartment syndrome occurs when circulation to tissues within a fascial compartment is compromised by increased pressure within that space. The resultant ischemia will ultimately cause necrosis in a time-dependent fashion.57 It is most commonly observed in the extremities, particularly the leg, but has also been observed in many other locations, including the buttocks, thigh, brachium and arm, and the abdomen. Cellular anoxia is the final common pathway of all compartment syndromes. However, the interrelation between increased compartment pressure, blood pressure, and loss of tissue perfusion leading to cell death are incompletely understood. This incomplete understanding leads to diagnostic and treatment challenges. Many theories have been proposed to account for the sequence of events leading from tissue injury to the ischemic sequelae of compartment syndrome. Experimental studies have demonstrated that tissue perfusion progressively decreases as tissue compression increases.5 Burton8 proposed the concept of critical closing pressure that states that perfusion within a compartment ceases when intra-compartmental pressure equals diastolic pressure. Blood flow may cease at levels below the mean arterial pressure secondary to passive capillary collapse when local tissue pressure increases above intracapillary pressure. Another accepted theory is that of local venous hypertension. A local increase in venous pressure will reduce the arterio-venous (A-V) gradient and in turn decrease

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capillary blood flow. Modulation of the local vascular resistance can counteract some of the reduction in the A-V gradient. However, this compensation becomes ineffective with increasing tissue pressure. As local tissue pressure rises, the A-V gradient diminishes eventually causing capillary blood flow to cease.5 Compartment syndrome occurs when the diminished local A-V gradient prevents sufficient blood flow to meet the metabolic demands of the tissue. This theory explains how myoneural ischemia can occur in the presence of blood flow. As ischemia continues, irreparable damage to tissue ensues and myoneural necrosis occurs. Some deployed surgeons have postulated that decreased atmospheric pressure as occurs during flight may exacerbate muscle edema in the injured limb causing compartment syndrome. Alternatively, the lower oxygen tension may cause relative tissue anoxia to already injured tissues leading to compartment syndrome. Development of compartment syndrome depends on many factors, including the duration of the pressure elevation, the metabolic rate of the tissues, vascular tone, and local blood pressure. Nerves demonstrate functional abnormalities (paresthesias and hypoesthesia) within 30 minutes of ischemic onset. Irreversible functional loss will occur after 12 to 24 hours of total ischemia.5 Muscle shows functional changes after 2 to 4 hours of ischemia with irreversible loss of function beginning at 4 to 12 hours.5 Regardless of which theory predominates as the pathoetiology of compartment syndrome, the result is ischemic necrosis of compartmental tissue in the absence of prompt intervention. Compartment syndromes lasting longer than 8 to 12 hours are likely to produce chronic functional deficits, such as contractures, sensory aberrations, and motor weakness. Clinically, a precise pressure threshold and duration do not exist above which significant damage is irreversible and below which recovery is assured. A complex relationship exists between the energy released at the time of injury and the development of foot compartment syndrome. The magnitude of the tissue damage sustained with battlefield injuries, such as blasts and high-velocity gunshot wounds, place these casualties at risk for compartment syndrome. Currently, the number of fasciotomies performed for compartment syndrome during the conflicts in Afghanistan and Iraq have not been determined. Studies are ongoing to determine how many of these procedures are performed or what their clinical outcomes are. The battlefield experience to date seems to reinforce previous studies on compartment syndrome; namely, that the initial energy transferred at the time of injury plays a crucial role in determining the timing and development of foot and leg compartment syndrome.
ANATOMY Foot

The osteofascial spaces of the foot are not well understood and there is considerable disagreement regarding the anatomic features of the plantar aspect of the foot. Early injection studies were performed in attempt to describe the spread of infections through potential spaces in the foot. Grodinsky9 described four potential fascial spaces within the foot. He demonstrated a communication between the central and the medial and lateral compartment, and with the posterior compartment of the calf. In a similar study, Kamel and Sakla10 confirmed these previous findings but demonstrated that the medial and lateral proved to be closed spaces. Other descriptions of the compartments and fascial spaces in the foot are available and the exact number of compartments described differs greatly among authors.1113 In 1990, Manoli and Weber14 performed a gelatin-injection study on unembalmed cadaveric legs, describing the presence of nine foot compartments rather than four as previously thought. Three compartments run the entire length of the foot (medial,

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lateral, and superficial). Five compartments are contained within the forefoot (adductor and four interossei). A description of a new separate compartment, the calcaneal compartment, containing the quadratus plantae muscle and lateral plantar nerve was made. In addition, a communication of the calcaneal compartment with the deep posterior compartment of the leg through the retinaculum behind the medial malleolus via the neurovascular and tendinous structures was suggested. They postulated that the claw-toe deformities sometimes seen after calcaneus fracture are caused by a compartment syndrome of the quadratus plantae in the calcaneal compartment. They emphasized the need to release this separate compartment when performing foot fasciotomies. Guyton and colleagues15 refuted prior injection studies as inaccurate and invalid because of flawed experimental design. Using CT guidance, they injected fluid into isolated compartments and monitored the resulting interstitial pressures. Based on their findings they felt it impractical to subdivide the foot into more than four compartments based on the location of a variety of fascial planes. Ling and Kumar16 used cadaveric dissection to determine the myofascial anatomy of the foot. They questioned the need to separately release the quadratus plantae. The authors did identify five structures in the plantar aspect of the foot that may play a major role in compartment syndrome in the hindfoot or midfoot. They five structures are the plantar aponeurosis, the medial vertical fascial septum, the intermediate vertical fascial septum, and the lateral vertical fascial septum. These structures were highlighted because of their low compliance and need to be incised if associated compartments are to be adequately decompressed. Recently, a 10-compartment model was proposed based upon MRI in normal feet. The authors highlighted inclusion of the skin as a separate compartment. Needleinsertion sites and trajectories for measurement of pressures in uninjured feet were defined. The practical application including the skin as a separate compartment is questionable as the skin is always released in all anatomic sites surgically treated for compartment syndromes.17 Although controversies continue to exist regarding the exact anatomy of the compartments of the foot, it is important for the combat surgeon to release at least five compartments when a foot compartment syndrome is to be surgically treated.18 The medial compartment contains the abductor hallucis and flexor hallucis brevis muscles and flexor hallucis longus, peroneus longus, and posterior tibial tendons. This compartment is bound by the inferior surface of the first metatarsal shaft dorsally, extension of the plantar aponeurosis medially, and the intermuscular septum laterally. The boundaries of the central compartment are the plantar aponeurosis inferiorly, the intermuscular septum medially and laterally, and the tarsometatarsal joints dorsally. From plantar to dorsal, this compartment contains the flexor digitorum brevis muscle, flexor digitorum longus tendons, lumbrical muscles, quadratus plantae, adductor hallucis muscle, and the peroneal and posterior tibial tendons. The lateral compartment is bordered by the fifth metatarsal shaft dorsally, the intermuscular septum medially, and the edge of the plantar aponeurosis laterally. It contains the abductor, short flexor, and opponens muscle of the fifth toe. The interosseous compartment is bounded by the interosseous fascia and the metatarsals and contains the seven interossei (Fig. 1).
Leg

The leg is divided into four osteofascial compartments. The anterior compartment contains the anterior tibialis, long toe extensors, supplied by the deep peroneal nerve and the anterior tibial artery. The lateral compartment contains the peroneus longus and brevis supplied by the superficial peroneal nerve and peroneal artery. The

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Fig. 1. Cross section through the forefoot demonstrating the compartments of the foot. (From Shereff MJ. Compartment syndromes of the foot. In: Instructional course lectures, The American Academy of Orthopaedic Surgeons, vol. 39. Park Ridge (IL): The American Academy of Orthopaedic Surgeons; 1990. p. 12732.)

superficial posterior compartment contains the gastrocnemius and soleus muscles supplied by the tibial nerve and the posterior tibial artery. The deep posterior compartment contains the popliteus, tibialis posterior, flexor hallucis longus, and flexor digitorum longus. All of these muscles are innervated by the tibial nerve. Matsen and Clawson19 described a deep compartment syndrome of the leg causing complications in the foot after observing this condition in a case series of 14 subjects. This condition is characterized by pain, weakness of toe flexion, painful passive toe extension, plantar hypoesthesia, and tension in the fascial boundaries of the compartment. If untreated, the deep compartment syndrome can lead to claw toes, posterior tibial neuropathy, and weakness or contracture of the long toe flexors and tibialis posterior. The authors noted that the association of deep posterior compartment syndrome with open fractures demonstrated that the associated fascial defect does not necessarily provide adequate decompression of its contents. It has been suggested that the posterior tibial muscle has its own separate compartment from the remainder of the deep posterior compartment.20 This suggestion was refuted in an anatomic study, indicating that the posterior tibialis muscle is decompressed with release of the deep posterior compartment (Fig. 2).21
DIAGNOSIS

Explosions can cause fractures, soft-tissue damage, and vascular injury all of which place the extremity at risk for compartment syndrome. However, it must be remembered that compartment syndrome can occur in the absence of fracture and with open fractures. In civilian blunt trauma the most common sites of extremity compartment syndrome in the absence of fracture are the leg (53%62%), forearm (24%26%), thigh

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EDL Anterolateral Incision Peroneus Brevis and Longus in Lateral Cmpt. Tibialis Posterior FHL in the Deep Posterior Cmpt.

EHL

Anterior Cmpt.

Tibialis Anterior

Anterior Tibial Artery, Vein, Peroneal Nerve Tibia G. Saphenous V. Posterior Medial Incision

Gastrocnemius M.

Superficial Posterior Cmpt.

Fig. 2. Cross section of the leg compartments sectioned through mid calf. (From Emergency war surgery. 3rd United States revision. Borden Institute; 2004. p. 22.12. Available at: http:// www.bordeninstitute.army.mil/other_pub/ews.html.)

(4%15%), foot (4%5%) and hand (2%4%).1,22 Traditionally the development of compartment syndrome is assessed on clinical grounds using criteria of patients pain out or proportion, pain on passive stretch, paresthesias, poikilothermia, paralysis, and lack of pulse. Because these subjective symptoms rely on responsive and cooperative patients, compartmental pressure measurements may be made to provide objective data in the assessment of the limb, particularly in patients who are obtunded. Recent efforts have also attempted to establish noninvasive methods of diagnosis.23,24 All clinical signs have inherent drawbacks in making the diagnosis. Pain is an unreliable and variable predictor. It can range from being very mild to severe and is already present in patients who have suffered acute trauma.7 The pain of the obvious injury can mask that of an impending compartment syndrome and cannot alone be depended upon to make the diagnosis.25 Mubarak and colleagues26 found that pain in response to passive stretching of the affected muscle compartment was also an unreliable sign and suggested that the presence of hypoesthesia was more dependable. However, Rorabeck and Macnab27 found hypoesthesia to be the last clinical finding to develop as the syndrome progressed. Palpable compartmental tumescence is a crude indication of increased compartmental pressure.25 Because only a small part of the deep posterior compartment is sufficiently palpable beneath the skin,19 this sign is of little value in diagnosing involvement of this compartment. Frank motor weakness is very difficult to elicit in patients after trauma, and demonstrable weakness may also be caused by several other reasons. Pain in conjunction with increasing pressure to the point of tenseness or firmness is the most important clinical indicator in conscious patients. It is important to realize that lack of pulse and paralysis are late findings and generally reflect progression toward irreversible damage.26 Ulmer28 performed a comprehensive search of the literature to assess if clinical findings are predictive of the diagnosis of compartment syndrome. He found the clinical signs have a sensitivity of 13% to 19% and a positive predictive value of only 11% to 15%. He concluded that there was a paucity of data from which

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to determine the value of clinical findings in the diagnosis of compartment syndrome. However, the probability of compartment syndrome increases markedly if three or more clinical findings are simultaneously present. Clinical findings have more utility in their absence to exclude the diagnosis than their presence has to confirm it. Direct intra-compartmental pressure measurement has been established as valuable tool to diagnose compartment syndrome. Measurement can be performed with a manometer device as described by Whitesides and colleagues,29 but a handheld pressure measurement device is more commonly used. Alternatively, an appropriately calibrated arterial line may be used. A side-ported needle, or slit catheter, is most reliable when used in conjunction with a hand-held device or arterial line; a straight needle may record falsely elevated pressures.30 A variety of thresholds have been suggested for diagnosis of compartment syndrome and performance of fascial release. The use of these values is predicated on the accurate placement of the needle in the compartment. The threshold must be set low enough to prevent the long-term sequelae of a missed compartment syndrome but must be balanced against the potential morbidity of additional surgery, wound, infection, neuroma complications, and weakness of an unnecessary fascial release. Threshold values range from an absolute pressure of 30 mmHg to a (diastolic pressure)(measured compartment pressure) (Dp) less than or equal to 20 to 30 mm Hg.31 A Dp less than 20 to 30 mm Hg is generally accepted as an indicator of loss of adequate perfusion to the compartment and an indication for urgent fasciotomy.31 This threshold has been brought into question, although it is widely used as a diagnostic criterion. Prayson and colleagues32 described 19 subjects with lower-extremity fractures and elevated pressures within accepted thresholds for fasciotomy. Eleven subjects had a Dp less than 20 mm Hg and five more within 30 mm Hg. None of these subjects underwent fasciotomy. At 1 year none developed clinical sequelae of compartment syndrome. These pressures were measured under anesthesia. A separate study found that diastolic blood pressures measured under anesthesia may be significantly depressed complicating the use of pressure measurements as a diagnostic tool.33 Continuous monitoring has been used successfully in some centers but is not practical in the combat environment.34 Other methods have been developed to assist in the diagnosis of compartment syndrome. These methods include tonometry, near infrared spectrometry (NIRS), and laser flowmetry, At the time of this writing, none have established clinical efficacy although NIRS is showing some promise.35 In an innovative project in a swine model, investigators used an ultrafiltration device to remove a small amount of fluid in limbs developing compartment syndrome. The ultrafiltrate demonstrated elevated levels of creatine kinase and lactate dehydrogenase that may serve as a diagnosis tool. The limbs demonstrated less tissue necrosis suggesting a possible treatment effect.36 The investigators also noted that fascia has a low compliance, so a small amount of fluid may lead to significant pressure changes and subsequent loss of perfusion.36 In the combat environment, the diagnosis of compartment syndrome is made on clinical grounds. Initially, a high index of suspicion is required to make the diagnosis. It is important to remember that the syndrome can occur in conjunction with apparently minor injuries regardless of the etiology, degree of fracture comminution, or open fracture grade. Above all, compartment syndrome remains a clinical diagnosis supported by the objective examination findings.18 The reliance on clinical examination with a low threshold for fascial release may result in unwarranted fasciotomies but it avoids the grave consequences of a missed diagnosis.

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Foot

In the foot, the clinical signs of foot compartment syndrome are difficult to distinguish from the pain associated with the associated injury. Fracture and soft-tissue injury may mask pressure or ischemic pain that allow unambiguous testing of passive stretch of muscles suspect for compartment syndrome.37 Most patients who have foot compartment syndrome describe clinical symptoms of severe, relentless, burning pain involving the entire foot. Myerson38 reported the most common symptom for clinical diagnosis was pain in the foot. However, many of these patients sustained crush injuries, confounding use of pain in diagnosis. In addition, loss of pinprick sensation and objective motor deficit were difficult to document and were found to be unreliable indicators. Vascular examination was particularly unreliable for diagnosis, as dorsalis pedis and posterior tibial pulses and satisfactory capillary refill were documented in feet with compartmental ischemia. Nevertheless, a thorough vascular examination should be performed. Fakhouri and Manoli39 stated that the only way of diagnosing compartment syndrome reliably is direct tissue pressure measurement. However, this is not practical in a combat environment and fails to account for the possible evolution of the injury during transport. Evidence of blast or crushing mechanisms of injury should raise a high level of suspicion for development of compartment syndrome. The presence of associated open injuries does not eliminate the potential for compartment syndrome developing.35,40,41 Open injuries do not necessarily decompress compartments. Fascial defects may not be sufficient to accommodate increased volume of compartmental contents.5,7,35 The presence of tense swelling and severe unremitting pain associated with foot trauma suggests that there is a need for decompression. In the combat environment, these cases should either be decompressed before entering the evacuation chain or at least be observed in borderline cases.
Leg

Numerous authors have reported the characteristic signs and symptoms of compartment syndrome.23,24,4244 The early clinical signs of compartment syndrome are pain out of proportion, pain with passive stretch of the involved compartment, and a tense swollen compartment. The late clinical signs for diagnosis are paresthesias, lack of pulse, pallor, and paralysis. Although commonly accepted, there is continuing debate regarding the most reliable measures for establishing the diagnosis and determining the need for surgical intervention.
FOOT COMPARTMENT SYNDROME

Although the compartment syndrome of the leg is well recognized, compartment syndrome of the foot has received much less attention.4554 Compartment syndrome of the foot was treated cursorily until 1987, when Myerson55 elaborated on the presentation, diagnosis, and treatment. Since then other authors have addressed this topic in detail.56,57 The incidence of foot compartment syndrome has been estimated to occur in approximately 4.7% to 17% of calcaneal fractures.37 A recent prospective multicenter trial suggested a substantially lower incidence (1%).58 Untreated compartment syndrome of the foot may lead to a painful, dysfunctional extremity characterized by sensory disturbances, stiffness, forefoot contracture, and clawing of the toes. Claw-toe deformities are caused by the damaged intrinsic short flexors and extensors unable to counteract the intact extrinsic toe flexors and extensors. This inability causes unopposed flexion at the distal interphalangeal joint

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and hyperextension of the metatarsal phalangeal joint. The most severe consequence of missed foot compartment syndrome is extensive tissue necrosis leading to amputation.50 Manoli and Weber14 postulated that the claw-toe deformity following a calcaneus fracture appears to be secondary to a late contracture of the quadratus plantae muscle in the calcaneal compartment. Myerson and Manoli50 postulated that the increased pressure in this situation is secondary to hemorrhage from the large bleeding cancellous surfaces of the fracture. Calcaneal compartment pressures rise as the hematoma fills this deep compartment. Andermahr and colleagues46 postulated that bleeding from the medial calcaneal artery into the quadratus plantae muscle is the main causative factor in development of foot compartment syndrome. As pressure rises, the quadratus plantae muscle becomes ischemic within the foot compartment. If untreated, the quadratus plantae shortens, fibroses, and tethers the flexor digitorum longus tendon, which leads to the flexion component of the claw-toe deformity. The second and third toes are preferentially affected because the quadratus plantae has more mass medially.51 There is a modest amount of level IV clinical data from the civilian setting with which to help guide judgments on the performance of foot fasciotomies. Myerson38 retrospectively looked at 14 compartment syndromes in 12 subjects with calcaneal fractures. Of those with crush injuries, 41% developed compartment syndrome compared with 17% of those with non-crush injuries. Mittelmier and colleagues45 reported on 12 subjects with 16 fractures who had elevated absolute tissue pressures greater than 30 mm Hg within the central plantar muscle compartment. The maximum values of tissue pressure were observed during the first 2 days after injury. These values decreased gradually over 3 to 5 days after the primary injury. On follow up at 18 months, 7 of the 12 subjects with elevated foot compartment pressures developed plantar contractures or claw-toe deformity. Three of the 12 subjects in this series had no observable direct concomitant soft-tissue contusion, but they developed claw toes and plantar contracture. Fakhouri and Manoli39 reported on 12 cases of compartment syndrome of the foot in 10 subjects. All sustained high-energy injuries resulting in various hindfoot and forefoot fractures or fracture/dislocations. Decompressive fasciotomies were performed on this cohort of subjects between 3 and 13 hours after the initial presentation. All were evaluated at least 12 months after injury to determine if they had developed sequelae of foot compartment syndrome or complications from the fasciotomies. All wounds were well healed with no evidence of infection or wound complications. Eight of the 10 subjects had complaints of some degree of pain, discomfort, or stiffness, especially with ambulation. Two subjects developed nerve paresthesias (one medial plantar nerve, one lateral plantar nerve distribution). There was no evidence of ischemic contracture, such as claw-toe deformity or any significant intrinsic muscle atrophy. Another case series by Manoli and colleagues59 reported on eight subjects with concurrent compartment syndromes of the foot and leg. Of five subjects in which early (within a few hours of the injury) fasciotomies of the leg and foot were performed, no residual symptoms were identified. In contrast, all three subjects who had delayed fasciotomies performed experienced complications, such as nerve dysfunction with clawing of the toes and even a case of above-knee amputation. However, the amputation was attributed to a concomitant open fracture of the femur rather than the severe foot injury. This study highlighted the importance of expeditiously identifying and treating concurrent compartment syndrome of the leg and foot.14,40

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From these series, the consistent message is that constant vigilance by the treating physician is crucial, especially in light of the significant morbidity of a missed foot compartment syndrome. Foot compartment syndrome can develop as late as 36 hours after the time of injury or quickly depending on the energy transferred at the time of injury.37 The late sequelae of foot compartment syndrome are unpredictable. The resulting muscle imbalances and varying degrees of deformity are likely influenced by muscle injury of the trauma, from the effects of the compartment syndrome and the postinjury rehabilitation.14 The combat surgeon must weigh the risks and benefits of performing a foot fasciotomy.
TREATMENT

The importance of early detection and prompt treatment of compartment syndromes of the foot and leg cannot be overemphasized. Treatment for this syndrome is an emergency surgical procedure because treatment delays may contribute to irreversible muscle and nerve injury. Prolonged ischemia from sustained compartment pressures result in significant muscle infarction. Fibroblasts replace the infarcted muscle. This process can occur over 6 to 12 months. Additionally, this necrotic muscle often adheres to surrounding tissues that fix the muscle position and reduce mobility further. It is thought that the limited muscle excursion and the longitudinal contraction during fibrotic proliferation results in the loss of joint motion and subsequent contracture.37 Once the diagnosis of acute compartment syndrome has been made, the goal of relieving pressure in the affected compartments must be met. Fasciotomy is the definitive treatment for acute compartment syndrome.18 The fascial defect caused by either an open or closed injury is not adequate to fully decompress the compartment and compartment syndrome may still occur.7 Regardless of the extremity involved, skin incisions must be generous and the fascial releases of the affected compartments complete. Skin closure is not performed at the time of fasciotomy. This allows further swelling of the soft tissues to be accommodated as the full extent of the inflammatory response reaches is realized. Although the integument is more expansile than the investing fascia it still can critically restrict swelling. There have been reports of recurrence of compartment syndrome from the skin constricting the limb despite adequate fascial release. Incisions should be placed in line with approaches for definitive care in mind. They should be long enough to achieve decompression but no longer. They must never be of insufficient length to decompress the limb. Delayed primary closure or coverage of even the most generous incisions can subsequently be achieved.
Surgical Releases Foot

Several authors have described techniques for fasciotomy of the foot compartments from plantar only,60,61 medial only,12,60 dorsal only,56 plantar and lateral,54 and medial plantar and dorsal.35 The choice of fasciotomy is governed by surgeon preference, other planned procedures, and preexisting soft-tissue injuries. Consideration should be made to perform a medial-only foot compartment release because this incision can adequately decompress all the compartments without unduly interfering with future surgical procedures. However, this technique and the anatomy of the medial aspect of the foot may be less familiar to some surgeons risking iatrogenic neurovascular damage. A failure to account for further surgical procedures along the staged surgical care by other surgeons unfamiliar with the initial injury pattern may jeopardize the ultimate functional outcome of the war casualty.

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Myerson40 investigated, in a cadaveric model, the ease and rate of decompression by way of a double incision dorsal approach compared with a medial longitudinal approach. In both methods, the intra-compartmental pressures were satisfactorily decompressed. However, it took longer after effective fasciotomies for pressures to normalize with the dorsal approach (11 minutes vs 1 minute, P<.01). The dorsal approach was simpler to perform and may be the preferred approach when metatarsal or tarsometatarsal fractures are present and for surgeons unfamiliar with the anatomy of the plantar surface of the foot. Nevertheless, the medial approach provides excellent access to all the compartments of the foot without jeopardizing surgical approaches to the calcaneus or mid and forefoot. Based upon available information, the War Surgery Manual18 recommends either a release through two dorsal incisions or a single medial approach. The dorsal approach uses two dorsal incisions along the length of the second and fourth metatarsals. Further longitudinal dissection is performed medially and laterally to each metatarsal into the interosseous space, entering the central compartment by piercing the interosseous fascia (Fig. 3). The medial approach follows an incision along the length of the inferior surface of the first metatarsal. The medial incision begins at the medial side of the calcaneus just anterior to the abductor hallucis origin (4 cm from the posterior aspect of the heel and 3 cm superior to the plantar surface), extending distally parallel to the plantar surface for 6 cm.14 Following medial compartment fasciotomy, the abductor hallucis is reflected superiorly to expose the intermuscular septum. Care must be taken at this point to avoid damage to the neurovascular bundle (lateral plantar nerve and vessels) just deep to the fascia. Splitting the intermuscular septum medially to the abductor hallucis executes its release. Caution must also be exercised at the distal end of the incision to prevent injury to the medial plantar nerve. Blunt dissection is performed through the distal septum to avoid injury to these structures. Bulging of the quadratus plantae indicates adequate deep (calcaneal) compartment release. By reflecting the medial compartment superiorly, the superficial compartment is identified just lateral to the medial compartment. The superficial compartment is then opened longitudinally thus releasing the flexor digitorum brevis. This step is followed by inferior retraction of the flexor digitorum brevis with the underlying transverse septum of the hindfoot, which allows exposure of the medial aspect of the lateral septum. Using sharp elevation, the lateral septum is opened from its posterior origin to its anterior limit for the release of the lateral compartment. The lateral compartment is fully released when the abductor digiti quinti and flexor digiti minimi are both visible.50,51,60
Leg

Mubarak and Owen62 popularized the double-incision technique for decompression of the four leg compartments. The anterior and lateral compartments are approached through an anterolateral incision approximately 15 cm in length placed halfway down the leg 2 cm anterior to the fibular shaft. The intramuscular septum is identified and incised and the anterior compartment fascia is released midway between the septum and tibial crest. The lateral compartment fascia is released by incising the fascia in line with the fibular shaft. In the face of a distorted anatomy of a severe fracture, release of the anterior compartment can be confirmed by palpating the lateral face of the tibia and of the lateral compartment, the posterior lateral corner of the fibula. To avoid injury to the superficial peroneal nerve in the distal wound the scissors are directed toward the lateral malleolus to stay posterior to the nerve as it exits the fascia in the distal third of the leg near the septum.

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Fig. 3. (A) Interosseous compartment releases through two dorsal incisions. (From Emergency war surgery. 3rd United States revision. Borden Institute; 2004. p. 26.7. Available at: http://www.bordeninstitute.army.mil/other_pub/ews.html.) (B) Compartments released through medial approach. (From Emergency war surgery. 3rd United States revision. Borden Institute; 2004. p. 26.8. Available at: http://www.bordeninstitute.army.mil/other_pub/ews. html.)

A posteromedial incision is made 2 cm from the palpable posterior edge of the tibia to release the posterior compartments. The superficial compartment is released and then the soleus attachment is released, exposing the deep posterior compartment. The fascia is then incised distally and proximally under the belly of the soleus muscle (Fig. 4). Others have advocated release of all four compartments through a single lateral incision. Although this may avoid a medial incision with its attendant risk of exposing the tibia, this approach is less familiar to most surgeons and may not be adequate for the high-energy injuries seen on the battlefield.43
Wound Closure Techniques

In the trauma setting fasciotomy wounds are not closed at the time of fasciotomy. Fasciotomy wounds are often large and may not be closeable because of tissue swelling,

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Fig. 4. Medial and lateral incisions of the leg for four compartment fasciotomy of the leg. (From Emergency war surgery. 3rd United States revision. Borden Institute; 2004. p. 22.13. Available at: http://www.bordeninstitute.army.mil/other_pub.ews.html.)

skin retraction, or tissue loss caused by the open injury. Split-thickness skin grafts (STSG) may be required when patients and the wound are stable. However, skin grafts are insensate and cosmetically unappealing. From the time of fasciotomy, wound management focuses on swelling control, allowing recovery of injured tissues and minimizing skin retraction, if possible. Absorbent dressings are usually applied along with a supportive splint. This step allows for egress of fluids from edematous muscle during the staged evacuation to the United States for definitive care. Several techniques have been described to minimize skin retraction, possibly obviating the need for STSG.6366 The vessel-loop or shoelace technique is commonly performed.64 It involves using vessel loops interlaced over the wound through staples placed at the skin edges. Although it uses equipment readily available, it suffers from several drawbacks. The thin vessel loops frequently do not have adequate tensile forces to allow minimal skin retraction in battlefield injuries because of the significant soft-tissue swelling caused by blasts. It is common for such swelling to cause the vessel loops to break, eliminating any effect they may exert. Dressing changes are made more difficult and carry with them the potential of having the staples dislodged from the skin. Equal distribution of force across the wound edges is not ensured with this technique (Fig. 5). Subatmospheric wound dressings have been used successfully to provide fasciotomy and open-wound control. This technique seals the wound from the outside environment while allowing for removal of exudates. Studies have shown improved capillary circulation with use of these devices (Fig. 6).67 The downside of this technique is that it requires a machine to provide suction and may be difficult to apply around external fixators.

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Fig. 5. Vessel-loop technique for temporary closure of fasciotomy incisions.

Janzing and Broos66 reported on a comparison of three different techniques for closure of civilian fasciotomy wounds in 15 subjects. The mean time to wound closure for all groups was 9 days. They found that skin traction with vessel loops or prepositioned intracutaneous sutures provided good skin apposition without the necessity for skin grafting. The major advantage was that the material required was readily available in most operating rooms. However, they pointed out the potential risk for high compartment pressures during a prolonged time in the postoperative period requiring close monitoring of limb perfusion. Singh and colleagues63 described their experience caring for war casualties in Iraq using a dynamic wound-closure device for closure of fasciotomy incisions. Eleven consecutive subjects who had undergone two incision fasciotomies for compartment syndrome were studied. Ten of the 11 subjects (91%) had their wounds closed in a delayed primary fashion after application of the wound-closure device. They found that the subjects benefited from the use of the device and avoided the need to create

Fig. 6. Subatmospheric wound-dressing therapy for temporary wound control.

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Fig. 7. Dynamic wound-closure device for delayed primary closure of fasciotomy wounds.

additional wounds in multiple-injury patients. However, long-term follow up of this small group was limited because of the rapid evacuation of soldiers to the United States and the expedient discharge from the hospital of host-nation soldiers (Fig. 7, Dynamic Wound Closure Device [DWC, Canica, Almonte, ON, Canada]).

COMPLICATIONS OF FASCIOTOMIES Delayed Fasciotomy

Despite the pre-deployment training of all surgeons in the diagnosis and treatment of compartment syndrome, there have been cases where the diagnosis of compartment syndrome was made following the initial surgical stabilization and evacuation. In a retrospective study, Ritenour and colleagues1 highlighted the dynamic nature of compartment syndrome and the challenges of diagnosis and treatment. Their analysis included 336 subjects receiving 671 fasciotomies for combat injuries treated at the medical center in Germany that receives all evacuated war casualties from Iraq and Afghanistan. The authors compared subjects who required revision of a previously performed fasciotomy or delayed fasciotomy to those who received the procedure before evacuation to Germany. The revision and delayed group had substantially higher Injury Severity Score (26.4 vs 14.5); more subjects with burn injuries and with more severe burns; and tended to require systemic support (ventilation, fluids, and vasopressors) during evacuation. This group had a higher mortality and amputation rate compared with those who had complete fasciotomies in theater, and also required more muscle excision. The most common revision procedures were extension of skin and fascial incisions and opening new compartments, particularly in the leg. This retrospective study does not provide information on the status of the limb before evacuation to assess the evolution of compartment syndrome. It is also not clear which delayed and revision fasciotomies were performed in fractured limbs. Nonetheless, this study highlights the need to maintain a high index of suspicion and to perform prophylactic fasciotomy in patients who have severe injuries. Some surgeons have questioned the practice of performing delayed fasciotomies because of the increased morbidity in the face of little to no functional benefit.67,68 Finkelstein and coauthors68 reviewed the cases of five subjects who underwent a delayed

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fasciotomy for extremity compartment syndrome at least 35 hours after the injury, when ideally the fasciotomy would have been performed earlier. Of the five subjects, one subject died of septicemia and multiorgan failure and the remaining four required lower-extremity amputation. They concluded that fasciotomies were consistently associated with severe infection and possible death when the recognition of the compartment syndrome was delayed for more than 8 to 10 hours. Furthermore, fasciotomy for early excision of muscle had little advantage over late excision to justify the high risk for local infection and amputation. Williams and colleagues69 demonstrated in a retrospective study of 88 subjects that fasciotomy performed after 12 hours was associated with a fourfold increase in infection compared with those performed before 12 hours. The rates of limb salvage and neurologic sequelae were similar. They advocated that fasciotomy performed early was most effective, but that the similar rates of limb salvage, even with the increased risk for infection, justifies the aggressive use of fasciotomy in extremity trauma regardless of the time of diagnosis. For the combat surgeon these works emphasize the need for close monitoring of the extremity for signs of impending compartment syndrome and the liberal use of prophylactic fasciotomies to prevent the associated morbidity with delayed treatment. If a delayed diagnosis is encountered, even beyond the 8 or 12 hour limit as suggested by some authors, fasciotomy should still be entertained because the precise time of onset of ischemia may be difficult to determine in many cases. Any necrotic tissue found should be completely excised to mitigate the risk for infection.
Fasciotomy Wound Morbidity

Fasciotomy itself has its own morbidity by exposure of susceptible muscle and deep tissues to infection. Additionally there is potential for nerve injury and alteration in muscle mechanics. Injuries and initial combat-surgery interventions occur in austere environments that place the casualty at increased risk for wound colonization and infection. The potential limb-saving benefit of fasciotomy must outweigh the potential infectious complication of open-leg wounds in casualties already at risk for loss of limb or life. Rush and colleagues70 reported on a retrospective series of 127 lowerextremity fasciotomies performed for compartment syndrome after acute ischemia and revascularization in subjects with either vascular trauma or arterial occlusive disease. Superficial infections occurred in five subjects and all resolved with local wound care. However, spread of infection from the foot to the fasciotomy site contributed to amputation in two subjects. In their series, no limb loss was attributed to primary open fasciotomy. They concluded that the morbidity and mortality of fasciotomy were the result of refractory ischemia caused by associated injuries or underlying medical problems, but not from open fasciotomy wound complications. Leg and foot fasciotomy have been used as an adjunctive technique to optimize limb salvage after revascularization for ischemia. Limb salvage and good functional results were achieved in 10 out of 11 subjects who underwent fasciotomy of the foot when compartment syndrome after revascularizations was unrelieved with standard leg fasciotomy.71 Combat surgeons should not withhold fasciotomy when clinically indicated for fear that this effective ancillary procedure will adversely affect limb salvage. It has been the authors experience that even though fasciotomy wounds are frequently colonized, overt clinical signs of wound infection do not occur. Colonization, even that resulting in minor infection, is managed successfully with local measures without adverse

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effects on the eventual outcome. Furthermore, many options exist for the delayed coverage of the wound.
Late Complications

Delayed diagnosis or inadequate release of the compartments can result in long-term problems. The ischemic insult can cause fibrosis of the muscles and result in a painful, dysfunctional foot and leg. Late deficits after foot compartment syndrome includes stiffness and decreased sensation. The lesser toes develop clawing owing to the intrinsic muscle weakness or contracture, which can be very painful. Some physicians argue that isolated, acute, foot compartment syndrome should be observed and a late reconstruction should be performed, if necessary.59,72 Clinically, the diagnosis of deep compartment fibrosis is established by the presence of equinus and cavus with resulting heel varus and claw toes.72 The deformity is caused by the contracture of the tibialis posterior and flexor digitorum longus more frequently than that of the gastrocnemius and soleus. Frink and colleagues73 demonstrated that even with adequate treatment, patients who have compartment syndrome of the leg suffer from long-term impairment, such as reduced muscular strength, reduced range of motion, and pain. Early decisions in treatment of the war casualty can result in significant long-term functional impairments if treatment is withheld or inappropriately performed. Although a prophylactic fasciotomy is not benign, the liberal use of fasciotomy in the combat setting prevents the potentially devastating consequences of a delayed diagnosis of compartment syndrome.
BURN CASUALTIES

Patients with burn injuries comprise 5% of combat casualties.74 These patients often have a high amount of total-body surface area affected. When the limb is involved in a burn, a circumferential eschar limits the ability to accommodate swelling. Resuscitation of these patients also requires large fluid infusion placing them at risk for compartment syndrome.1 At a minimum, an escharotomy that incises the skin but not the fascia is required for accommodation of swelling.75 However, in casualties that require significant resuscitation the relief may not be adequate, necessitating a formal fasciotomy to prevent progression of compartment syndrome.
SUMMARY

Prophylactic and therapeutic treatment of leg compartment syndrome with decompression by double-incision fasciotomy prevents progression of soft-tissue injury in high-energy trauma. This treatment is the standard of care in civilian trauma and combat settings. More controversial is the use of either single- or dual-incision fasciotomy of the foot for prophylactic treatment of foot compartment syndrome. Fasciotomy must be performed in the face of major trauma to the foot with severe swelling and unremitting pain. The role for prophylactic fasciotomy of the foot is unclear and should be considered on a case by case basis. The surgeon must maintain a high degree of vigilance for the development of compartment syndrome in the combat casualty. A careful physical examination is required and pressure measurements serve as an adjunct in making the diagnosis in the deployed setting. Future advances in the understanding of pathophysiology and diagnosis of compartment syndrome may reduce the currently maintained low threshold for fasciotomy to avoid the devastating consequences of a missed diagnosis.

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