British Journal of PIostic Surgery (2000), 53, 690-693 �9 2000 The British Association of Plastic Surgeons doi: 10.1054/bjps.2000.3444

B R I T I S H J O U R N A L OF ~ J P L A S T I C S U R G E R Y

Long-term sequelae of fasciotomy wounds

A. M. Fitzgerald, R Gaston*, Y. Wilson, A. Quaba and M. M. McQueen*

Department of Plastic Surgery, St John's Hospital, Howden Road West, Livingston EH54 6PP; and *Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh EH3 9YW,, UK

1

SUMMARY. A retrospective study of patients admitted to an Orthopaedic Trauma Unit over an 8-year period requiring fasciotomies, of either upper or lower limb, to reduce the risk of compartment syndrome was performed. Sixty patients were studied, of which 49 had an underlying fracture. The long-term morbidity of the wounds was studied. Ongoing symptoms such as pain related to the wound occurred in six patients (10%) and altered sensation within the margins of the wound occurred in 46 patients (77%). Examination revealed 24 patients (40%) with dry scaly skin, 20 patients (33%) with pruritus, 18 patients (30%) with discoloured wounds, 15 patients (25%) with swollen limbs, 16 patients (26%) with tethered scars, eight patients (13%) with recurrent ulceration, eight patients (13%) with muscle herniation and four patients (7%) with tethered tendons. The appearance of the scars affected patients such that 14 (23%) kept the wound covered, 17 (28%) changed hobbies and seven (12%) changed occupation. This study reveals a significant mor- bidity associated with fasciotomy wounds. In light of these findings, further consideration should be given to tech- niques that reduce both the symptoms and examination findings mentioned above and the aesthetic insult to the affected limb. �9 2000 The British Association of Plastic Surgeons

Keywords: compartment syndrome, fasciotomy, morbidity.

Compartment syndrome is described as an increase in interstitial pressure within a closed osseo-fascial space resulting in microvascular compromise and myoneural damageJ The diagnosis of compartment syndrome requires the presence of clinical symptoms such as pain, tenseness and swelling and possibly diminished motor and sensory function in the affected limb. Such a diagnosis can be assisted by the use of continuous pressure monitoring.

Delay in diagnosis can result in disastrous conse- quences such as Volkmann's ischaemic contracture, neu- rological sequelae and an increased incidence of infection and possibly amputation. To relieve the increased pressure in endangered compartments, a fasciotomy is performed in order to divide the fascia that separates the compart- ments of the affected limb.

A number of fasciotomy techniques have been reported to allow access to the four compartments of the lower limb. Kelly and Whitesides described a single lateral inci- sion technique with added fibulectomy. 2 However, Matsen and Krugmire suggested the single lateral incision approach be performed without the fibulectomy, in order to preserve the fibula for possible future osseous recon- struction. 3 Jacob recommended the double incision tech- nique with incisions placed on both the medial and the lateral sides of the lower limb. 4 It is a modification of this double incision technique that is recommended by the joint working committee of the British Association of Plastic Surgeons and the British Orthopaedic Association)

Likewise, several fasciotomy techniques in the fore- arm have been reported by which the volar and dorsal compartments can be released. They all use two incisions of varying design, one on the volar surface and the other on the dorsal aspect. 6-9

To date, the outcome assessment of compartment syn- drome has concentrated on the incidence of resulting com- plications such as contracture and nerve damage rather than on the fasciotomy wound itself. The aim of this study was to assess the long-term outcome and morbidity of fas- ciotomy wounds of both the upper and the lower limbs.

Patients and methods

A retrospective review was performed on 164 consecu- tive adult patients, who required fasciotomy of either the upper or the lower limb and were admitted to the Orthopaedic Trauma Unit of Edinburgh Royal Infirmary between January 1988 and December 1995. All patients were prospectively recorded. The patients were revie- wed 25-117 months following their injury with a mean follow-up of 59 months.

Patients who suffered post-ischaemic acute compart- ment syndrome were excluded as vascular surgeons undertook their management. All 164 patients were con- tacted at their last known address to which 60 patients (37%) replied and were included in this study. Thirty- four patients attended a clinic review for both a clinical examination and completion of a questionnaire, and 26 patients who lived outside south-east Scotland completed the questionnaire over the telephone. The same question- naire was used for all 60 patients. All clinical examina- tions were performed by two of the authors (PG and YW) who had not been involved at any stage in the original fasciotomy procedures.

The diagnosis of acute compartment syndrome, in all cases, was made on the basis of both clinical signs and

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Long-term sequelae of fasciotomy wounds 691

symptoms, such as resting pain, stretch pain or swelling, and compartmental pressure monitoring.

There were 54 male patients with an average age of 27.7 years (range: 14-88 years) and six female patients with an average age of 54.8 years (range: 32-83 years). There were 17 patients who sustained contact sport injuries, nine patients who were car occupants, eight pedestrians, eight patients who fell more than 3 feet, eight crush injuries, five patients who fell less than 3 feet, four motorcyclists and one patient with a non-contact sports injury.

Forty-five patients sustained trauma to the lower limb and 15 patients to the upper limb. The type of fasciotomy performed in all cases is given in Table 1.

Forty-nine out of the 60 patients sustained a fracture, of which eight were open. These included 18 tibial frac- tures, 13 combined tibial and fibular fractures, eight distal radius fractures, six combined radius and ulnar fractures, three femoral fractures and one patient with multiple frac- tures of the metatarsals.

The tibial diaphyseal fractures were classified accord- ing to the Tscherne and Gustilo classifications] ~ The closed tibial fractures were classified as Tscherne Type C1 in 16 patients, C2 in seven patients, C3 in one patient and CO in one patient. The eight open tibial fractures were classified as four Gustilo Type 1, two Type 2, one Type 3A and one Type 3B.

Nineteen patients had additional injuries, including five patients with long bone fractures elsewhere in the limb with acute compartment syndrome. Fourteen patients sustained multisystem injury.

The fasciotomy wounds were left open with subse- quent debridement if necessary at 48 h. The wounds were closed in 30 cases by partial direct closure and partial split skin grafting of the wound, in 18 cases by direct clo- sure, in six patients by skin stretching followed by imme- diate skin closure, in five patients by complete skin grafting of the wound and in one patient the wound was left to heal by secondary intention.

Table 1 Type of fasciotomy performed in the lower and upper limbs

Lower limb Double incision release,

four compartments, lower leg Release quadriceps compartment Release interosseous compartment

of the feet Release of anterior and lateral

compartments, lower leg only Release of deep and superficial

posterior compartments only

Upper limb Release volar compartment,

forearm only Release volar compartment

of forearm and carpal tunnel decompression

Release volar and dorsal compartments of forearm

35 4

3

2

1

Results

Thirty-nine patients (65%) required only one operation to close their wounds, 13 patients (22%) required two oper- ations, six patients (10%) required three operations and in two patients (3%) four operations were performed prior to wound closure.

Thirty-three patients (54%) suffered continued pain in the affected limb, which was localised to the fasciotomy wound in six cases (10%). Twenty-four patients (40%) complained of pain in a joint either immediately above or below the fasciotomy wound and in three cases (5%) the pain was localised to the fracture site. Rest pain was pre- sent in twelve cases (20%).

Altered sensation within the limbs prior to fasciotomy was reported in 26 cases (43%) but following fasciotomy this rose to 57 cases (95%) at the time of review. Out of these 57 patients, the area of diminished sensation was localised to within the limits of the fasciotomy wounds in 46 patients (84%). The area of diminished sensation was limited to those wounds closed by split skin graft in 36 patients (60%) and to directly closed wounds in ten patients (17%). The remaining 11 patients (18%) had altered sensation in the same areas that had abnormal sensation prior to surgery. The areas of diminished sensa- tion occurred in four patients over the dorsum of the foot, three patients surrounding the ankle, two patients in the toes and in one patient each over the dorsum of the hand and in the thumb.

Twenty-four patients (40%) had wounds that were found to consist of dry scaly skin, 20 patients (33%) com- plained of pruritus within the limits of the healed wound, 18 patients (30%) that their wounds were discoloured, 15 patients (25%) that their affected limbs were swollen and eight patients (13%) that they suffered recurrent ulcera- tion of their wounds. Examination of the wounds also revealed that 16 patients (26%) had tethered scars, four patients (7%) tethering of tendons of the anterior com- partment and eight patients (13%) muscle herniation.

Fourteen patients (23%) were so concerned by the appearance of their wounds that they always kept the operated limb covered by clothing. Seven patients (12%) declared that they had changed occupation, and 17 patients (28%) changed their hobbies, because of the fasciotomy and its subsequent appearance.

Discussion

This study of 60 patients requiring open fasciotomy of a traumatised limb has revealed a marked morbidity in terms of continued pain, altered sensation and poor cos- metic result as perceived by the patients aswel l as on- going wound morbidity.

A traumatised limb suffering from an acute compart- ment syndrome requires an early and correctly performed fasciotomy in order to prevent Volkmann's ischaemic contracture and long-term nerve damage.13

Much of the literature assesses final outcome of fas- ciotomy in terms of the prevention of subsequent con- tracture although no study has closely questioned patients as to their opinion of the subsequent wounds, which are substantial, and of the aesthetic insult to their bodies.

692 British Journal of Plastic Surgery

Rorabeck studied a series of 18 patients requiring four compartment fasciotomies of the lower limb using the double incision technique. 14 The results were rated as acceptable, unacceptable or amputation. Thirteen patients (72%) were said to be acceptable, which was regarded as a leg with normal function, no residual neurological sequelae and in which no further reconstructive surgery was required. Four patients (22%) were rated as unac- ceptable as they had persistent neurological sequelae requiring either further reconstructive surgery or an orthosis, and one patient (6%) required an amputation.

This study set out to investigate the actual morbidity of the fasciotomy wounds and the effect on the daily lifestyle of the patients involved. The findings reveal that the majority of patients (95%) suffered continued altered sensation within the affected limb postoperatively. However, this altered sensation was restricted to within the limits of the fasciotomy wound in 77% of patients. Furthermore, altered sensation was more marked in those whose wounds were split skin grafted rather than those where the wound was directly closed.

Continuing pain existed in 55% of patients in the affected limbs. However, only 10% of patients had pain that could be solely attributed to their fasciotomy wounds. Much of the perceived pain is, in actual fact, attributable to stiff joints on either side of either the underlying fracture or the fasciotomy wound that have been relatively immobile for long periods of time.

No patient in this study developed subsequent contrac- ture or required amputation.

The fasciotomy wounds were a considerable source of continuing morbidity in that eczematous changes (40%), pruritus (33%), discolouration (30%) and recurrent ulcer- ation (13%) were all found to be present.

No previous study has investigated the impact of fas- ciotomy on the everyday lives of patients but the results of this study indicate that the appearance of and contin- ued symptoms in the affected limbs cause a notable pro- portion of patients to alter their activities of daily living. Fourteen patients (23%) were so upset by the cosmetic appearance of their wounds that they kept the wounds covered at all times. The wounds also affected the profes- sional and social activities of the patients, requiring seven patients (12%) to change occupation and 17 patients (28%) to change hobbies.

However, it is acknowledged that only 37% of the original patients were examined in this study. Mitigating against this low follow-up is the fact that the length of follow-up was at least 2 years in all cases (and in some cases nearly 10 years) in a population largely made up of young male adults who are well known as a group to be highly transient in nature. We therefore suggest that the results presented are representative of the total population of patients undergoing fasciotomy.

In light of these findings, perhaps increased considera- tion should be given to revisional surgery of the fasciotomy wounds, such as direct closure, rubber-band closure, serial excision or tissue expansion. Moreover, in order to reduce wound morbidity, such as decreased sensation, eczematous change, pruritus, discolouration and recurrent ulceration, every effort should be made to close the fasciotomy wound directly rather than by split skin graft closure.

It may be time to re-evaluate the role of less invasive fasciotomy techniques, which may not only diminish wound problems, as revealed by this study, but also reduce the number of operations that a patient is subjected to in order to close the subsequent wound. Subcutaneous fas- ciotomy has previously been described by Due and Nordstrand. 15 They performed a blind fasciotomy of the anterior compartment of the lower limb in 133 service- men suffering from chronic anterior compartment syn- drome. This was performed via a single incision under local anaesthesia. They stated that there was 'no appre- ciable loss of sensibility in the leg, and no troublesome bleeding'. However, they did report two minor wound infections and one muscle hernia in an incomplete fas- ciotomy. Despite their relatively low complication rate, there is a theoretical risk that blind release of the deep fascia may result in division of neurovascular structures, especially in fractured limbs where local anatomy may be distorted, as well as inadequate access resulting in incomplete division of the investing fascia. In addition, subcutaneous fasciotomy may result in a non-compliant skin envelope, which may result in increased compart- mental pressures. ~6 However, modern-day pressure moni- toting techniques should alert the surgeon to continued high compartmental pressures, which would then require division of the skin envelope as well. A possible step for- ward in the treatment of compartment syndrome, to reduce the morbidity of fasciotomy wounds, could be the endoscopic release of the deep fascia along with contin- ued pressure monitoring.

In conclusion, this retrospective review of patients requiting fasciotomy revealed that patients sustained wounds associated with marked morbidity and of such an appearance that their lifestyles were altered. This study suggests that fasciotomy wound closure should be reap- praised and techniques sought that reduce the size and subsequent morbidity of such wounds.

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The Authors

Aidan Fitzgerald MPhil, FRCS, Specialist Registrar in Plastic Surgery Yvonne Wilson FRCS(Plast), Consultant Plastic Surgeon Awf Quaba FRCS(Plast), Consultant Plastic Surgeon

Department of Plastic Surgery, St John's Hospital, Howden Road West, Livingston EH54 6PP, UK.

Paul Gaston FRCS, Specialist Registrar in Orthopaedic Surgery Margaret McQueen MD, FRCSEd(Orth), Consultant Orthopaedic Surgeon

Department of Orthopaedic Surgery, Edinburgh Royal Infirmary, Lauriston Place, Edinburgh EH3 9YW, UK.

Correspondence to Mr Aidan Fitzgerald MPhil, FRCS.

Paper received 7 September 1999. Accepted 17 July 2000.