Management of Fasciotomy Wounds
Acute compartment syndrome occurs when the tissue pressure within a closed muscle compartment exceeds the perfusion pressure and results in muscle and nerve ischemia. It typically occurs subsequent to a traumatic event, most commonly a fracture.
The cycle of events leading to acute compartment syndrome begins when the tissue pressure exceeds the venous pressure and impairs blood outflow. Lack of oxygenated blood and accumulation of waste products result in pain and decreased peripheral sensation secondary to nerve irritation.
Late manifestations of compartment syndrome include the absence of a distal pulse, hypoesthesia, and extremity paresis, because the cycle of elevating tissue pressure eventually compromises arterial blood flow. If left untreated or if inadequately treated, the muscles and nerve within the compartment undergo ischemic necrosis, and a limb contracture, called a Volkmann contracture, results. Severe cases may lead to renal failure and death.
Rorabeck concluded ‘almost complete recovery of limb function if fasciotomy was performed within six hours‘ . When fasciotomy was performed within twelve hours normal limb function was regained in only 68% of patients; after twelve hours only 8% regained normal function.
Fasciotomy after 8 hours in cases of ACS is controversial. The myoneural damage is irreversible at this stage and the increased risks may outweigh any potential benefit.
“Avoid performing fasciotomy beyond 24hrs of compartment syndrome complications and risk greater than benefit“
“Once compartment syndrome is diagnosed avoid elevating limbs it further reduces the arterial pressure compromising perfusion proceed with fasciotomy“
Management of Fasciotomy Wounds
First step of management of fasciotomy wound is getting it right and proper release of all compartments.
The next step is physiological stabilization of patient
Ischemia that lasts 4 hours leads to significant myoglobinuria, which reaches a maximum about 3 hours after the circulation is restored but persists for as long as 12 hours. In the face of rhabdomyolysis, IV fluid administration and, potentially, bicarbonate may be used to keep urine output at 1-2 mL/kg/hr.
The combination of hypovolemia, acidemia, and myoglobinemia may cause acute renal failure. Alkalization of the urine and diuresis appear to be renal-protective, presumably because hemoglobin and myoglobin are more soluble in an alkaline solution. Patients who survive almost always recover renal function, even those patients who require prolonged hemodialysis. Current recommendations are as follows:
Correct hypovolemia with crystalloid solution
Infuse 500 mL/hr of crystalloid solution and 22.4 mEq bicarbonate (12 L/day, forcing diuresis of approximately 8 L/day)
If diuresis is less than 300 mL/hr, administer mannitol dose of 1 g/kg
If blood pH is greater than 7.45, administer 250 mg acetazolamide
Monitor vital signs and urine pH level and volume hourly
Assess osmolarity and electrolytes and arterial blood gas every 6 hours
Management of Wound
Management of fasciotomy wounds remains controversial. Most advocate leaving the wounds open with delayed primary closure or skin grafting within 7-10 days when the compartment syndrome has completely resolved. A second look and debridement is usually necessary at 48-72 hours
Fasciotomies are not benign procedures and there are multiple associated complications
Altered sensation within the margins of the wound (77%)
Dry, scaly skin (40%)
Discolored wounds (30%)
Swollen limbs (25%)
Tethered scars (26%)
Recurrent ulceration (13%)
Muscle herniation (13%)
Pain related to the wound (10%)
Tethered tendons (7%)
Chronic venous insufficiency due to impaired calf muscle pumps
Furthermore, fasciotomy wounds are ofen aesthetcally unappealing and this can be debilitatng for the patents. In a study of 60 patents following fasciotomy wound closure, 23% were upset by the appearance of the wound and did not expose it, 28% changed hobbies and 12% changed occupaton.
The Single most Important step in management of wound ELEVATE LIMB
Split-thickness skin grafting
Split-thickness skin grafting is the most common procedure to close fasciotomy wounds . It uses a skin graft from a
donor site to reduce the apposition required for skin closure. As a result, this technique is often tension free. However, this technique requires another operative procedure, results in another wound, complicates wound care, extends hospital stay by roughly 3-5 days, and requires immobilizaton of the wound. There is also chance that the graft may fail. The final result is a thin, aesthetically unappealing scar without sensation.
Negative pressure wound Therapy
VAC uses negative pressure to exploit the elastic properties of the skin. This causes stretching of the skin, reduces edema, promotes blood flow, lowers bacterial counts and increases the tissue granulation rate to ultimately create a wound that is more conducive to closure. However, this technique requires dressing changes roughly every 3 days and is very expensive to use. Furthermore, VAC itself may fail to provide adequate skin edge approximation for final closure and as a result, another closing technique would be required.
Closure of fasciotomy wounds by dermatotraction
Dermal apposition takes advantage of the elastic properties of the skin. Essentially, a constant load is placed on the
wound margin resulting in a gradual increase in skin length and reduction in force required to maintain that length. With cycles of re-loading the wound margin, primary closure is possible. In the literature, there is a plethora of techniques and variations that take advantage of dermal apposition, including the vessel loop shoelace, sub-cutcular suture, Ty-Raps, Sure-Closure, Dynamic Wound Closure, STAR and Silver Bullet Wound Closure Device (SBWCD).
These dynamic closure devises offer benefit of delayed primary closure of wound with minimal scarring. Only disadvantage is the cost involved and daily tightening of apparatus to bring edges together.
A product worth mention is TopClosure which works on stress relaxation method where primary closure of large wound under tension can be undertaken easily.
Methods for Resource constrained areas
A method Developed by Pasha et al is very helpful in situations where these commercially available gadgets cannot be affordable. A new modified Device from Ilizarov set was used. Locally made K-wires were passed subcutaneously / subdermally along the long axis of fasciotomy wound. These were bent at 15 – 20 degree to clear skin then fixed to threaded rods with cannulated bolts. A vacuum suction vacuum pack was applied as needed on individual basis. The rods were compressed till patient get tightening effect on skin on first post operative day. K-wires were gradually compressed at rate of 1 – 2 millimeter twice a day thereafter. Once the fasciotomy defect was approximated, delayed primary closure done.
Shoe Lace technique
The vessel loops are placed intraoperatively during the compartment release and are attached to the wound margins using standard skin staples. The loops are tightened progressively postoperatively during routine dressing changes, resulting in closure of the wound within 2 weeks.
If Vessel loops are not available pediatric nasogastric tubes or urinary tubes may be used.
Key to management of compartment syndrome is Early fasciotomy, strict Limb ELEVATION after fasciotomy and early placement of Dermotaxis/ Dermatotraction devices for primary closure of wounds.