0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

A Critical Reappraisal of Indications for Fasciotomy After Extremity Vascular Trauma FREE

Ziad Abouezzi, MD; Zahi Nassoura, MD; Rao R. Ivatury, MD; John M. Porter, MD; William M. Stahl, MD
[+] Author Affiliations

From the Department of Surgery, New York Medical College and Lincoln Medical and Mental Health Center, Bronx, NY.


Arch Surg. 1998;133(5):547-551. doi:10.1001/archsurg.133.5.547.
Text Size: A A A
Published online

Objective  To critically reevaluate the indications for fasciotomy in vascular trauma of the extremities.

Design  Case-control study.

Setting  Level I trauma center.

Materials and Methods  One hundred sixty-three vascular injuries to the extremeties were analyzed. Fasciotomy as an adjunct to vascular repair was performed in 45 limbs (28%), based either on the nature of injury or measured compartment pressure of greater than 35 mm Hg.

Main Outcome Measures  Need for fasciotomy or limb amputation.

Results  Fasciotomy was performed for 29.5% of isolated arterial injuries, 15.2% of isolated venous injuries, and 31.6% of combined arterial and venous injuries, and was not related to venous repair or ligation. Seven delayed fasciotomies were performed either for vascular repair failure (5 patients) or compartment syndrome (2 patients). The highest incidence was for popliteal vessel injury (arterial 57%, combined 61%). Of the 33 lower-extremity fasciotomies, 58% were for popliteal vessel injury. In 51 combined injuries of the lower extremity, only 7 (19%) of 38 patients with injury above the knee required fasciotomy, as compared with 8 (62%) of 13 with injury to the popliteal vessels (P<.001), with or without venous repair. There were 3 amputations, all resulting from vascular repair failure.

Conclusions  The presence of a combined vascular injury or the need for venous ligation does not necessitate routine fasciotomy. The need for fasciotomy may be maximal for injuries to popliteal vessels.

THE ROLE of fasciotomy in the management of vascular trauma remains controversial. Some authors recommend "routine" prophylactic fasciotomy, while others reserve the procedure for selected patients.128 The proponents of prophylactic fasciotomy argue that morbidity and amputation rates can be unacceptably high if the procedure is delayed until the onset of clinical evidence of compartment syndrome.2,6 The opponents of this concept cite the small percentage of patients who need an adjunct fasciotomy following extremity vascular injury.1,711 Furthermore, recent data suggest that fasciotomy is not as innocuous as was previously taught. To redefine the role of fasciotomy in vascular injuries of the extremeties, we retrospectively analyzed our 8-year experience with selective application of fasciotomy.

The records of all patients with upper- or lower-extremity vascular injuries treated surgically between January 1988 and December 1995 at our level I trauma center were reviewed retrospectively. Patients who died within 24 hours of injury were excluded from the study.

All the patients with vascular injuries were treated in the operating room according to standard principles. During the study period, 163 such injuries were identified and treated. Fasciotomy was performed on 45 limbs (33 legs and 12 forearms). The indications for fasciotomy were warm ischemia time greater than 6 hours and clinical evidence of compartment syndrome or elevated compartment pressures (>35 mm Hg). A few patients had prophylactic fasciotomy based on the judgment of the operating surgeon, dictated by the nature, location, and severity of vascular injury. In patients with complex venous injuries who underwent venous ligation because of the extent of injury or hemodynamic instability, clinically evident venous hypertension prompted a fasciotomy. In more stable patients with severe venous injuries, venous stump pressures were measured and guided the need for fasciotomy.12,13

Four-compartment fasciotomy in the legs was performed through an anterolateral and a posteromedial skin incision. Fibulectomy was not employed. Forearm fasciotomy was done either through a volar or a dorsal incision. All fasciotomies were treated postoperatively with wet-and-dry dressing twice daily and were evaluated 5 to 7 days postoperatively by the operating team for possible delayed primary closure or skin grafting.

For the purpose of this study, primary fasciotomy is defined as the procedure done at the initial operation. The fasciotomy is termed delayed when done at a later date for elevated compartment pressures or clinically significant compartment syndrome. The medical records were analyzed for demographics; nature, location, and mechanism of injury; type of vascular repair; and indication for fasciotomy (when performed). Associated fracture and/or nerve injury, the development of compartment syndrome before fasciotomy, and the outcome were recorded. Statistical analysis was performed using the Fisher exact test. P<.05 was considered significant.

A total of 163 extremities were treated for vascular injury during the study period. Of these, 45 fasciotomies (28%) were performed (33 legs and 12 forearms). There were 44 men and 1 woman, with a mean age of 27.7 years (range, 11-46 years). The distribution of vascular injuries in the fasciotomy and no-fasciotomy groups according to mechanism and nature of the injury and the presence or absence of fracture is presented in Table 1. The incidence of fasciotomy according to site of injury and type of repair is described in Table 2. The incidence did not seem to have been influenced by the nature of injuries (arterial vs venous). However, it was the highest in the presence of popliteal vessel injury (arterial, 53%; venous, 67%; combined, 2%). Of the lower-extremity fasciotomies, 57.5% were performed for popliteal vascular trauma. Only 7 (19%) of 38 patients with combined (arterial and venous) injuries proximal to the knee required fasciotomy, while 62% of combined popliteal injuries required such adjunctive treatment (P<.001), with or without venous repair. Fifty-one patients sustained venous injuries, either isolated or combined (Table 3). The surgical management of such injury (ligation vs repair) did not influence the incidence of fasciotomy.

Table Graphic Jump LocationTable 1. Mechanism and Nature of Injury and Associated Fractures
Table Graphic Jump LocationTable 2. Site, Nature, and Treatment of Vascular Injury
Table Graphic Jump LocationTable 3. Venous Repair in Combined Injuries*

Seven of the 45 fasciotomies performed were delayed (ie, not performed at the time of the vascular repair), 5 following failure of vascular repair and 2 for the onset of clinical compartment syndrome. Table 4 summarizes the characteristics of the patients who had a delayed fasciotomy.

Table Graphic Jump LocationTable 4. Characteristics of Patients Who Had Delayed Fasciotomy

There were a total of 3 amputations (2 above-knee and 1 below-knee) in 163 extremity vascular injuries, an incidence of 1.8%. All had extensive popliteal vessel trauma. Of the 3, 2 had primary fasciotomy and 1 had delayed fasciotomy after failure of popliteal artery repair (Table 5).

Table Graphic Jump LocationTable 5. Characteristics of Patients With Amputations

Eleven patients had evidence of neurologic injury. Six of them had a delayed fasciotomy (Table 6). It was difficult to establish whether the neuropathy was the result of the original trauma or a consequence of the delay in fasciotomy.

Table Graphic Jump LocationTable 6. Characteristics of Patients With Nerve Damage

Compartment syndrome, as defined by Matsen et al,10 is the development of increased pressure in a limited space compromising the circulation and causing ischemia of muscles and nerves in that space. Unless treated, this increased compartment pressure will ultimately result in loss of neural and muscle function and lead to permanent deformity of the extremity as was described by von Volkmann.14 Although compartment syndrome may be caused within an intact compartment by hemorrhage (fracture, arterial injury) or muscle cell swelling (crush injury), it is most commonly a result of ischemia-reperfusion injury.1,6,15 Clinical examples of this phenomenon include traumatic arterial lesions, the use of pneumatic antishock garments for the lower extremities,16 and prolonged periods of compression of the upper extremities in drug addicts.17 The major relevance of compartment syndrome is that there are no classic clinical findings that enable a successful prediction of the need for treatment.6,15 In view of the irreversible neurologic and muscular sequelae of a missed compartment syndrome, there has been a trend for a liberal use of fasciotomy ("prophylactic fasciotomy") to decompress the extremity compartments in peripheral vascular injuries.18 Traditional teaching recommends fasciotomy be based on the patient's clinical status (ischemia time, shock), operative findings (combined arterial and venous injuries), and techniques of repair (eg, ligation of major venous outflow).6,1925 Tradition has also supported fasciotomy as a "no risk/high gain" procedure.

Fasciotomy is not, however, without complications. Infection, prolonged hospital stay and the need, in some patients, for reoperation for closure can be troublesome.7 Iatrogenic nerve injury is a rare complication. Furthermore, the concept that fasciotomy is without functional impairment of the limb during the long-term has recently been questioned. In a recent report, Bermudez and associates26 followed up 17 patients with fasciotomy for a period of 6 months to 20 years. The extremities were studied with air plethysmography, comparing the contralateral limb as a control. The limbs with fasciotomy showed a significant reduction in ejection fraction and residual volume as a measure of calf muscle pump function, even though none showed evidence of venous obstruction or venous reflux. These findings were similar in all limbs with fasciotomy, regardless of the primary etiology (vascular repair or soft tissue injury). These authors concluded that fasciotomy independently contributed to long-term calf muscle pump function and chronic venous insufficiency.

These new findings suggest that fasciotomy may cause a functional abnormality and is perhaps best reserved for strict indications. In fact, several recent series suggested a decreasing role of fasciotomy after arterial, combined, or venous injury. In a retrospective review of 233 patients with 321 femoral vascular injuries and fasciotomy in 60 patients, Cargile and colleagues20 reported that fasciotomies were performed in 39%, 13%, and 3% of combined arterial and venous, isolated arterial, and isolated venous injuries, respectively. Field and coworkers,7 in a retrospective review designed to identify patients who will benefit from prophylactic fasciotomy, did not find that the presence of combined injuries influenced the need for fasciotomy. In a review of 141 combined vascular injuries, of which 83% had venous ligation, Timberlake and colleagues27 found no permanent sequelae of venous ligation. Transient extremity edema developed in 32% of patients, regardless of whether the vein was ligated or repaired. A similar experience was reported by Yelon and Scalea.28 Our experience supports these concepts. In our series, venous repair or ligation or combined vascular injuries did not influence the need for fasciotomy or the incidence of compartment syndrome, perhaps because of our use of venous stump pressures and compartmental pressure monitoring.

The experience at our center with the intraoperative estimation of venous stump pressures has been very helpful in the stable patient with complex venous injuries that cannot be repaired by simple techniques. Venous ligation is an option in these patients, provided it will not lead to venous hypertension from the lack of adequate collateral venous drainage due to extensive soft tissue destruction, multiple injuries of the venous system, or other factors. Under such circumstances, we have used the distal (caudal) venous stump pressure as a guide for the need for repair. The measurement of venous stump pressure is simple and consists of placing an intravenous infusion catheter in the caudal end of the injured vein either via the injured segment or via a branch distal to injury. Venous pressure is measured by an attached water manometer. Patients with documented venous hypertension (pressures >40-45 cm of saline) may benefit from venous reconstruction with or without fasciotomy. The venous pressures should fall substantially after reconstruction and fasciotomy.12,13

In our review, the single most important factor influencing the incidence of fasciotomy and/or compartment syndrome was the location of the injury. The incidence was 57% for isolated popliteal arterial injuries and 62% for combined popliteal injuries. In their review of 85 popliteal vascular injuries, Jaggers and colleagues29 performed fasciotomies for 24 of 56 patients with popliteal artery injuries, an incidence similar to ours. In a recent review of 81 popliteal artery injuries (39 arterial and 42 combined), Fainzilber and associates30 performed primary fasciotomy on 53% of their patients. Of the 35 patients who did not have a primary fasciotomy, 6 required an amputation. From these data, they concluded that a fasciotomy at the time of operation was associated with a reduced amputation rate and recommended its routine use at the time of vascular repair. The increased use of fasciotomy in popliteal injury may in part be due to the often prolonged repair time and warm ischemia. In this retrospective review, there were 2 amputations for extensive popliteal vascular injury despite primary fasciotomy, and one amputation after a delayed fasciotomy and failure of the vascular repair. Our overall amputation rate for popliteal injuries was 9%, an incidence similar to recent reports.2931

The incidence of neurologic damage after vascular injury to the extremity, whether due to a delayed fasciotomy or from the initial wounding agent, is often difficult to estimate.15 It is, however, noteworthy that in the present series 4 of the 9 patients who had neurologic deficit in the extremity also had failure of the vascular repair and delayed fasciotomy. Another patient with femoral venous ligation had a fracture of the femur and extensive soft tissue injury and subsequently developed neuropathy from a compartment syndrome. Prophylactic fasciotomy could be considered under such circumstances, but it cannot replace careful assessment of the clinical situation, intraoperative judgment, and monitoring of the vascular status of the limb, as well as early diagnosis of impending compartment syndrome by clinical and compartmental pressure evaluation.

Compartment fasciotomy remains a valuable adjunct to the treatment of vascular injuries to the extremities. However, current data suggest that the presence of a combined vascular injury does not by itself necessitate routine fasciotomy, regardless of venous repair or ligation, especially in injuries proximal to the knee. The procedure may be used selectively based on objective criteria and not as a routine addition.

Corresponding author: Rao R. Ivatury, MD, Department of Surgery, Medical College of Virginia, Richmond, VA 23298.

Perry  MO Compartment syndromes and reperfusion injury. Surg Clin North Am. 1988;68853- 864
Du Plessis  HJCMarais  TJVan Wuk  Fak  et al.  Compartment syndrome and fasciotomy. S Afr J Surg. 1983;21193- 206
Ernst  CB Fasciotomy: in perspective. J Vasc Surg. 1989;9829- 830
Link to Article
Sheridan  GWMatsen  FA Fasciotomy in the treatment of acute compartment syndrome. J Bone Joint Surg Am. 1976;8112- 115
Vitale  GCRichardson  DJGeorge  SM  et al.  Fasciotomy for severe, blunt and penetrating trauma of the extremity. Surg Gynecol Obstet. 1988;166397- 401
Martin  RRMattox  KLBurch  JM  et al.  Advances in treatment of vascular injuries from blunt and penetrating limb trauma. World J Surg. 1992;16930- 937
Link to Article
Field  CKSenkowsky  JHollier  LH  et al.  Fasciotomy in vascular trauma: is it too much, too often? Am Surg. 1994;60409- 411
Khalil  IMLivingston  DH Management of lower limb vascular injuries. Clin Plast Surg. 1986;13711- 722
Matsen  FAKurgmire  RB Compartment syndromes. Surg Gynecol Obstet. 1978;147943- 949
Matsen  FAWinwuist  RAKurgmire  RB Diagnosis and management of compartmental syndromes. J Bone Joint Surg Am. 1980;62286- 291
Rollins  DLBernard  VMTowne  JB Fasciotomy: an appraisal of controversial issues. Arch Surg. 1981;1161474- 1481
Link to Article
Sharma  PVIvatury  RRSimon  RJVinzons  AT Central and regional hemodynamics determine optimal management of major venous injuries. J Vasc Surg. 1992;16887- 894
Link to Article
Sharma  PVIvatury  RRIvatury  RRedCayten  CGed Extremities: veins. The Textbook of Penetrating Trauma Baltimore, Md Williams & Wilkins1996;
von Volkmann  R Verletzungenund Krannkheiten der Bewegungsorgane. Handbuch der Allgemeinen und Speziellen Chirugie Erlangen, Germany F Enke1872;234
Feliciano  DVCruse  PASpjut-Patrinely  V  et al.  Fasciotomy after trauma to the extremities. Am J Surg. 1988;156533- 536
Link to Article
Christensen  KS Pneumatic antishock garments (PASG): do they precipitate lower-extremity compartment syndromes? J Trauma. 1986;261102- 1105
Link to Article
Geary  N Late surgical decompression for compartment syndrome of the forearm. J Bone Joint Surg Br. 1984;66745- 748
Austin  OMBRedmond  HPBurke  PE  et al.  Vascular trauma: a review. J Am Coll Surg. 1995;18191- 108
Agarwal  NShah  PMClauss  RH  et al.  Experience with 115 civilian venous injuries. J Trauma. 1982;22827- 832
Link to Article
Cargile  JSHurt  JLPurdue  GF Acute trauma of the femoral artery vein. J Trauma. 1992;32364- 371
Link to Article
Menzoian  JODoyle  JECantelmo  NL  et al.  A comprehensive approach to extremity vascular trauma. Arch Surg. 1985;120801- 805
Link to Article
Borman  KRJones  GHSnyder  WH A decade of lower-extremity venous trauma: pattern and outcome. Am J Surg. 1987;154608- 612
Link to Article
Pasch  ARBishara  RASchular  JJ  et al.  Results of venous reconstruction after civilian vascular trauma. Arch Surg. 1986;121607- 611
Link to Article
Hobson  RWHoward  EWWright  CB Hemodynamics of canine femoral venous ligation: significance in combined arterial and venous injuries. Surgery. 1973;74824- 829
Mullins  RJLucas  CELedgerwood  AM The natural history of following venous ligation for civilian venous injuries. J Trauma. 1980;20737- 743
Link to Article
Bermudez  KKnudson  MMorabito  DKessel  O Fasciotomy, chronic venous insufficiency and the calf muscle pump. J Trauma. 1997;42162
Timberlake  GAO'Connell  RCKerstein  MD Venous injury: to repair or ligate, the dilemma. J Vasc Surg. 1986;4553- 558
Link to Article
Yelon  JAScalea  TM Venous injuries of the lower extremities and pelvis: repair vs ligation. J Trauma. 1992;33532- 538
Link to Article
Jaggers  RCFeliciano  DVMattox  KL  et al.  Injury to popliteal vessels. Arch Surg. 1982;117657- 661
Link to Article
Fainzilber  GRoy-Shapira  AWall  MJ  et al.  Predictors of amputation for popliteal artery injuries. Am J Surg. 1995;170568- 571
Link to Article
Folsian  TCTurkleson  MLCornelly  TL  et al.  Injury to the popliteal artery. Am J Surg. 1982;143225- 228
Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Mechanism and Nature of Injury and Associated Fractures
Table Graphic Jump LocationTable 2. Site, Nature, and Treatment of Vascular Injury
Table Graphic Jump LocationTable 3. Venous Repair in Combined Injuries*
Table Graphic Jump LocationTable 4. Characteristics of Patients Who Had Delayed Fasciotomy
Table Graphic Jump LocationTable 5. Characteristics of Patients With Amputations
Table Graphic Jump LocationTable 6. Characteristics of Patients With Nerve Damage

References

Perry  MO Compartment syndromes and reperfusion injury. Surg Clin North Am. 1988;68853- 864
Du Plessis  HJCMarais  TJVan Wuk  Fak  et al.  Compartment syndrome and fasciotomy. S Afr J Surg. 1983;21193- 206
Ernst  CB Fasciotomy: in perspective. J Vasc Surg. 1989;9829- 830
Link to Article
Sheridan  GWMatsen  FA Fasciotomy in the treatment of acute compartment syndrome. J Bone Joint Surg Am. 1976;8112- 115
Vitale  GCRichardson  DJGeorge  SM  et al.  Fasciotomy for severe, blunt and penetrating trauma of the extremity. Surg Gynecol Obstet. 1988;166397- 401
Martin  RRMattox  KLBurch  JM  et al.  Advances in treatment of vascular injuries from blunt and penetrating limb trauma. World J Surg. 1992;16930- 937
Link to Article
Field  CKSenkowsky  JHollier  LH  et al.  Fasciotomy in vascular trauma: is it too much, too often? Am Surg. 1994;60409- 411
Khalil  IMLivingston  DH Management of lower limb vascular injuries. Clin Plast Surg. 1986;13711- 722
Matsen  FAKurgmire  RB Compartment syndromes. Surg Gynecol Obstet. 1978;147943- 949
Matsen  FAWinwuist  RAKurgmire  RB Diagnosis and management of compartmental syndromes. J Bone Joint Surg Am. 1980;62286- 291
Rollins  DLBernard  VMTowne  JB Fasciotomy: an appraisal of controversial issues. Arch Surg. 1981;1161474- 1481
Link to Article
Sharma  PVIvatury  RRSimon  RJVinzons  AT Central and regional hemodynamics determine optimal management of major venous injuries. J Vasc Surg. 1992;16887- 894
Link to Article
Sharma  PVIvatury  RRIvatury  RRedCayten  CGed Extremities: veins. The Textbook of Penetrating Trauma Baltimore, Md Williams & Wilkins1996;
von Volkmann  R Verletzungenund Krannkheiten der Bewegungsorgane. Handbuch der Allgemeinen und Speziellen Chirugie Erlangen, Germany F Enke1872;234
Feliciano  DVCruse  PASpjut-Patrinely  V  et al.  Fasciotomy after trauma to the extremities. Am J Surg. 1988;156533- 536
Link to Article
Christensen  KS Pneumatic antishock garments (PASG): do they precipitate lower-extremity compartment syndromes? J Trauma. 1986;261102- 1105
Link to Article
Geary  N Late surgical decompression for compartment syndrome of the forearm. J Bone Joint Surg Br. 1984;66745- 748
Austin  OMBRedmond  HPBurke  PE  et al.  Vascular trauma: a review. J Am Coll Surg. 1995;18191- 108
Agarwal  NShah  PMClauss  RH  et al.  Experience with 115 civilian venous injuries. J Trauma. 1982;22827- 832
Link to Article
Cargile  JSHurt  JLPurdue  GF Acute trauma of the femoral artery vein. J Trauma. 1992;32364- 371
Link to Article
Menzoian  JODoyle  JECantelmo  NL  et al.  A comprehensive approach to extremity vascular trauma. Arch Surg. 1985;120801- 805
Link to Article
Borman  KRJones  GHSnyder  WH A decade of lower-extremity venous trauma: pattern and outcome. Am J Surg. 1987;154608- 612
Link to Article
Pasch  ARBishara  RASchular  JJ  et al.  Results of venous reconstruction after civilian vascular trauma. Arch Surg. 1986;121607- 611
Link to Article
Hobson  RWHoward  EWWright  CB Hemodynamics of canine femoral venous ligation: significance in combined arterial and venous injuries. Surgery. 1973;74824- 829
Mullins  RJLucas  CELedgerwood  AM The natural history of following venous ligation for civilian venous injuries. J Trauma. 1980;20737- 743
Link to Article
Bermudez  KKnudson  MMorabito  DKessel  O Fasciotomy, chronic venous insufficiency and the calf muscle pump. J Trauma. 1997;42162
Timberlake  GAO'Connell  RCKerstein  MD Venous injury: to repair or ligate, the dilemma. J Vasc Surg. 1986;4553- 558
Link to Article
Yelon  JAScalea  TM Venous injuries of the lower extremities and pelvis: repair vs ligation. J Trauma. 1992;33532- 538
Link to Article
Jaggers  RCFeliciano  DVMattox  KL  et al.  Injury to popliteal vessels. Arch Surg. 1982;117657- 661
Link to Article
Fainzilber  GRoy-Shapira  AWall  MJ  et al.  Predictors of amputation for popliteal artery injuries. Am J Surg. 1995;170568- 571
Link to Article
Folsian  TCTurkleson  MLCornelly  TL  et al.  Injury to the popliteal artery. Am J Surg. 1982;143225- 228
Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 17

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles