Compartment Syndromes and Fasciotomies of the Extremities 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction: 
All surgeons caring for patients with trauma 
to the extremities, or practicing vascular surgery 
must be able to recognize and surgically treat 
compartment syndromes. This entity results from a 
variety of causes. The final outcome is increased 
compartment pressure that exceeds the arterial 
inflow, with resultant ischemia and necrosis. Failure 
to identify and treat compartment syndromes in a 
timely fashion leads to preventable morbidity and 
mortality, and is a common source of litigation. The 
diagnosis of compartment syndrome is largely 
clinical, but measurement of compartment pressures 
may be useful in patients with equivocal findings or 
altered level of consciousness. The below- knee 
lower extremity is most commonly affected, 
followed much less frequently, by the forearm, thigh, 
buttock, foot and hand  
 
Pathophysiology/Epidemiology: 
Compartment syndrome has been found 
wherever a compartment is present: hand, forearm, 
upper arm, abdomen, buttock and the entire lower 
extremity. The pathophysiology of compartment 
syndrome is relatively straightforward. Groups of 
muscles and their associated nerves and vessels are 
surrounded by thick fascial layers that define the 
various compartments of the extremities. These 
compartments are of relatively fixed volume, as the 
fascial layers are unable to expand. Compartment 
syndrome occurs either when compartment size is 
restricted or compartment volume is increased. This 
can occur because of fractures, vascular injuries, 
electrical burns, blast injuries, crush injuries, too 
tight casts of splints, or tissue trauma after fracture 
reduction. 
As the pressure within the compartment 
(from blood, fluid, or external pressure) increases, 
the 
tissue 
perfusion 
decreases 
and 
cellular 
metabolism is impaired, leading to cellular death. If 
this pressure is not relieved in a timely fashion, 
irreversible damage will occur. The usually quoted 
time is 4 to 6 hours, but it may be as little as an hour 
for a patient in shock. Polytrauma patients with 
hypotension can sustain irreversible injury at lower 
compartment pressures than normotensive patients, 
and a very high index of suspicion should be 
maintained in this group. 
The leg (calf) is the area that is most 
commonly affected, accounting for 68% in a large 
civilian series (Branco), followed by the forearm 
(14%), and the thigh (9%). In a review of 294 
combat-injured 
soldiers 
undergoing 
494 
fasciotomies, Ritenour et al reported the calf as the 
most common site (51%) followed by the forearm 
(22%), thigh (8%), upper arm (7%), hand (6%), and 
the foot (5%).  
Certain injury patterns have been associated 
with higher likelihood of needing fasciotomy. 
Branco et al found that incidence of fasciotomy 
varied widely by mechanism of injury (0.9 % after 
motor vehicle collision to 8.6% after a gunshot 
wound). Additionally, the need for fasciotomy was 
related to the type of injury, ranging from 2.2% for 
patients with closed fractures to 41.8% in patients 
with combined venous and arterial injuries. The 
study by Branco identified ten risk factors associated 
with the need for fasciotomy after extremity trauma: 
young males, with penetrating or multi-system 
trauma, requiring blood transfusion, with open 
fractures, elbow or knee dislocations, or vascular 
injury (arterial, venous, or combined) are at the 
highest risk of requiring a fasciotomy after extremity 
trauma. 
 
Diagnosis: 
The diagnosis of compartment syndrome is a 
clinical diagnosis. The classically described five 
“Ps” – pain, pallor, paresthesia, paralysis, and 
pulselessness – are pathognomonic of compartment 
syndrome. However, these are usually late signs. 
Extensive and irreversible injuries may have taken 
place by the time they are manifested. The most 
important symptom of compartment syndrome is 
pain greater than expected due to the injury alone. 
Remember that the loss of pulse is a late finding, and 
the presence of pulses does not rule-out compartment 
syndrome! The presence of open wounds does not 
exclude compartment syndrome. In fact, the worst 
open fractures are actually more likely to have 
compartment syndrome.  
Compartment Syndromes and Fasciotomies of the Extremities 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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In 
actual 
practice, 
tissue 
pressure 
(compartment pressure) measurements have a 
limited role in making the diagnosis. However, in 
polytrauma patients with associated head injury, 
drug and alcohol intoxication, intubation, spinal 
injuries, use of paralyzing drugs, extremes of age, 
unconsciousness, 
or 
low 
diastolic 
pressures, 
measuring compartment pressures may be of use in 
determining the need for fasciotomy. The pressure 
threshold for making the diagnosis of compartment 
syndrome is controversial, though most prevalent in 
the literature is 30 mm Hg . Many surgeons use the 
“Delta-P” system. The compartment pressure is 
subtracted from the patient’s diastolic blood pressure 
to obtain the Delta-P. Muscle is at risk when the 
compartment pressure is within 10-30 mmHg of the 
diastolic pressure.  If the Delta-P is less than 30, the 
surgeon should be concerned that a compartment 
syndrome may be present.  Other factors to consider 
when considering fasciotomy are length of time of 
transport to definitive care and ability to do serial 
examination.  
Compartment 
syndrome 
is, 
first 
and 
foremost, a clinical diagnosis. A patient manifesting 
signs and symptoms of compartment syndrome 
should be operated on expeditiously. In patients with 
polytrauma, compartment syndrome should be a 
diagnosis of exclusion and one should have a low 
threshold for performing fasciotomy- especially in 
patients with vascular trauma. The safest approach is 
to err on the side of early and aggressive intervention. 
In other words, if you are thinking about doing a 
fasciotomy, it should be done. 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. 
 
Treatment of Compartment Syndrome: 
The definitive treatment of compartment 
syndrome is early and aggressive fasciotomy. In 
patients with vascular injury who require fasciotomy 
in conjunction with a vascular repair, it makes great 
sense to perform the fasciotomy before doing the 
repair. The rationale for this is that the ischemic 
compartment is likely to already be tight and thus 
will create inflow resistance to your vascular repair, 
making it susceptible to early thrombosis.  
The remainder of this chapter will detail the 
relevant anatomy, landmarks, step by step surgical 
techniques, and pitfalls associated with fasciotomy 
of the extremities most commonly affected by 
compartment syndrome. 
 
Lower Leg Fasciotomy: 
The lower leg (calf) is the most common site 
for compartment syndrome requiring fasciotomy. 
The leg has four major tissue compartments bounded 
by investing muscle fascia: 
 
Cross-sectional anatomy of the mid-portion of the left lower 
leg, depicting the four compartments that must be released 
when performing a lower leg fasciotomy. 
 
It is important to understand the anatomical 
arrangement of these compartments as well as some 
key structures within each compartment in order to 
perform a proper four-compartment fasciotomy. It is 
not necessary to remember the names of all the 
muscles in each compartment, but it is useful to 
remember the following:  
● The anterior compartment contains the anterior 
tibial artery and vein and the common peroneal 
nerve (recently renamed the common fibular 
nerve);  
● The lateral compartment contains the superficial 
peroneal nerve (recently renamed the superior 
fibular nerve), which must not be injured;  
● The superficial posterior compartment contains 
the soleus and gastrocnemius muscles;  
● the deep posterior compartment contains the 
posterior tibial and peroneal vessels and the tibial 
nerve. 
Compartment Syndromes and Fasciotomies of the Extremities 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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When dealing with a traumatically injured 
extremity, there is absolutely no role for getting 
fancy. The use of a single incision for four-
compartment fasciotomy of the lower extremity is 
mentioned only to condemn it. Attempts to make 
cosmetic incisions should also be condemned and the 
mantra should be “bigger is better.” Compartment 
syndrome of the lower extremity dictates two 
incision 
four-compartment 
fasciotomy 
with 
generous skin incisions. 
There are several key features that will enable 
a 
successful 
two 
incision 
four-compartment 
fasciotomy. One of the key steps is proper placement 
of the incisions. As extremities needing fasciotomy 
are often grossly swollen or deformed, marking the 
key landmarks will aid in placement of the incisions.  
It is useful to mark the patella and the tibial 
tuberosity as well as the tibial spine which serves as 
a reliable midpoint between the incisions. The lateral 
malleolus and fibular head are the landmarks used to 
identify the course of the fibula on the lateral portion 
of the leg. The lateral incision is marked just anterior 
(~1 fingerbreadth) to the line of the fibula, or “A 
FINGER IN FRONT OF THE FIBULA.” It is 
important to stay anterior to the fibula as this 
minimizes the chance of damaging the superficial 
peroneal (superior fibular) nerve and helps to 
correctly identify the intermuscular septum between 
the anterior and lateral compartments.  
 
The medial incision is made one thumb-
breadth below the palpable medial edge of the tibia, 
or A THUMB BELOW THE TIBIA. The extent of 
the skin incision should be to a point approximately 
three fingerbreadths below the tibial tuberosity and 
above the malleolus on either side. It is very 
important to mark the incisions on both sides prior to 
opening them, as the landmarks of the swollen 
extremity will become rapidly distorted once the 
incisions are made. 
Placement of the lateral incision, as shown on the right leg: the 
fibular head and lateral malleolus are used as reference points 
to mark the edge of the fibula. The lateral incision (dotted line) 
is marked one finger-breadth in front of this (“A FINGER IN 
FRONT OF THE FIBULA”). 
Compartment Syndromes and Fasciotomies of the Extremities 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Placement of the medial incision, shown on the Right leg: a 
dotted line is marked one thumb breadth below the palpable 
medial edge of the tibia (solid line). A THUMB BEHIND THE 
TIBIA. 
 
The Lateral Incision of the Lower Leg: 
The lateral incision is made ONE FINGER 
IN FRONT OF THE FIBULA and should in 
general extend from three fingerbreadths below the 
head of the fibula down to three fingerbreadths above 
the lateral malleolus. The exact length of the skin 
incision will depend on the clinical setting. Care 
must be taken to make sure that it is long enough so 
that the skin does not serve as a constricting band. 
The skin and subcutaneous tissue are incised to 
expose the fascia encasing the lateral and anterior 
compartments. Care should be taken to avoid the 
lesser saphenous vein and peroneal (fibular) nerve 
when making these skin incisions. 
Once the skin flap is raised, the intermuscular 
septum is identified. This is the structure that divides 
the anterior and lateral compartments. In the swollen 
or injured extremity, it may be difficult to find the 
intermuscular septum. In this setting the septum can 
be identified by following the perforating vessels 
down to it, as seen below: 
 
 
The lateral incision on a right lower extremity demonstrates the 
intermuscular septum (dotted line), which separates the 
anterior and lateral compartments of the lower leg. Note one of 
the perforating vessels (arrow) which enters and helps to 
identify the septum. 
 
Classically the fascia of the lateral lower leg 
is opened using an “H”-shaped incision. The cross 
piece of the “H” is made using a scalpel which will 
expose both compartments and the septum.  The legs 
of the “H” are made with curved scissors at least one 
cm away from the septum using just the tips which 
are turned away from the septum to avoid injury to 
the peroneal (fibular) nerves. The superficial 
peroneal (superior fibular) nerve originates around 
the head of the fibula and descends to the foot within 
the lateral compartment becoming superficial two 
thirds to three fourths of the way down the leg and 
Compartment Syndromes and Fasciotomies of the Extremities 
Mark W. Bowyer 
 
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then crossing over to the anterior compartment. Care 
must be taken to avoid injury to this nerve as the 
fascial incisions approach the ankle.  The fascia 
should be opened by pushing the partially opened 
scissor tips in both directions on either side of, and at 
least one cm away from, the septum, opening the 
fascia from the head of the fibula down to the lateral 
malleolus. 
Inspection 
of 
the 
septum 
and 
identification of the common peroneal (fibular) 
nerve and/or the anterior tibial vessels confirms entry 
into the anterior compartment. The skin incision 
should be closely inspected and extended as needed 
to ensure that the ends do not serve as a point of 
constriction. 
 
 
The fascia of the right lateral lower leg (foot is to the right of 
the photo) is opened in a classic “H”-shaped fashion for the 
length of the compartments with scissors turned away from the 
septum to avoid damage to underlying structures. 
 
 
 
 
The superficial peroneal (superior fibular) nerve (arrows) runs 
in the lateral compartment from the knee and crosses over the 
septum (star) into the anterior compartment 2/3 to 3/4 of the 
way down the leg towards the ankle. This must be carefully 
avoided by keeping the scissor tips pointed away from the 
septum and looking for the nerve as the fasciotomy is extended 
to the lateral malleolus. The left lateral lower leg (foot to the 
left) is seen on the top and the right lateral lower leg (foot to 
the right) is seen on the bottom. 
 
Pitfalls of the Lower Leg Lateral Incision: 
 
The anterior compartment is the most 
commonly missed compartment when performing a 
fasciotomy of the lower extremity. The most 
common reason the anterior compartment is missed 
is due to the incision being made too far posteriorly, 
either over or behind the fibula. If the incision is 
made too far posteriorly, the intermuscular septum 
between the lateral and superficial posterior 
compartments is mistaken for the septum between 
the anterior and lateral compartments and the 
anterior compartment is not opened, as shown below: 
Compartment Syndromes and Fasciotomies of the Extremities 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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As seen here on the lateral Left leg, there is an intermuscular 
septum (Red arrow) between the lateral and superficial 
posterior (post) compartments which can be mistaken for the 
septum between the anterior and lateral compartments (Blue 
arrow) if the incision is made too far posteriorly. 
 
     
 
 
     
 
As seen here on the left leg, if the lateral incision is made too 
far posteriorly the intermuscular septum (Red arrow) between 
the lateral (L) and superficial posterior (SP) compartments can 
be mistaken for the septum between the anterior (A) and lateral 
(L) compartments. In this situation, the anterior compartment 
would not be decompressed. The proper incision, shown by the 
Blue arrow, is made when the incision is made “ONE FINGER 
IN FRONT OF THE FIBULA” 
The 
medial 
incision 
is 
made 
one 
fingerbreadth below the palpable medial edge of the 
tibia (ONE THUMB BEHIND THE TIBIA). 
When making this incision, it is important to identify 
and preserve the greater saphenous vein, and ligate 
any perforators to it. After making an incision 
through the skin and subcutaneous tissues, the fascia 
overlying the superficial posterior compartment is 
exposed. This compartment   contains the soleus and 
gastrocnemius muscle. Opening this fascia, from the 
tibial tuberosity to the medial malleolus, effectively 
decompresses the superficial posterior compartment. 
 
 
The medial incision as seen on the right lower leg, ankle is to 
the left in this picture. The incision is placed such that the 
saphenous vein can be identified and preserved. Here, the 
superficial posterior compartment is opened first. The fascia 
(star) is opened to expose the soleus and gastrocnemius muscles 
in the superficial posterior compartment below the edge of the 
tibia (arrows.) 
Compartment Syndromes and Fasciotomies of the Extremities 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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The key to entering the deep posterior 
compartment is the soleus muscle. The soleus muscle 
attaches to the medial edge of the tibia. Dissecting 
these fibers (referred to by some as the soleus bridge) 
completely free from and exposing the underside of 
the tibia ensures entry into the deep posterior 
compartment. Identification of the posterior tibial 
neurovascular bundle confirms that the compartment 
has been entered. The muscle in each compartment 
should be assessed for viability. Viable muscle is 
pink, contracts when stimulated with diathermy, and 
bleeds when cut. Dead muscle should be debrided 
back to healthy viable tissue. The skin incision is left 
open and either covered with gauze or a vacuum-
assisted wound closure device. Vacuum wound 
closure after fasciotomy has been shown in recent 
studies to speed up and improve the chances of 
definitive closure of these wounds. 
 
 
On the right medial lower leg the soleus muscle (stars) is 
dissected off of the inferior border of the tibia (arrow) allowing 
entry into the deep posterior compartment. Seeing the 
neurovascular bundle (Red circle) confirms entry into the deep 
posterior compartment.  
 
 
 
 
 
Identification of the posterior tibial neurovascular structures 
(arrows) confirms entry into the deep posterior compartment 
after taking the soleus muscle down from the tibia. Top: the 
medial left leg, ankle is to the right of the photo. Bottom: the 
medial right leg, ankle is to the left of the photo.  
 
Pitfalls of the Medial Incision: 
 
The deep posterior compartment is the 
second most commonly missed compartment when 
performing a fasciotomy of the lower extremity. The 
most 
common 
reason 
the 
deep 
posterior 
compartment is missed is due a dissection plane 
made between the gastrocnemius and soleus muscles 
Compartment Syndromes and Fasciotomies of the Extremities 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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and believing that opening the fascia over the soleus 
muscle equates to having opened the deep posterior 
compartment. 
           
 
           
 
As seen here in the medial left leg, if the dissection plane is 
made between the soleus (S) and gastrocnemius (G) muscles, 
the deep posterior (DP) compartment is unopened. The soleus 
fibers must be detached from the underside of the tibia (star) to 
separate the superficial posterior (SP) from the deep posterior 
compartment such that it can be opened.  
 
 
In the injured extremity, a prominent 
plantaris tendon (also known as the “intern’s nerve”) 
may 
be 
mistaken 
for 
the 
posterior 
tibial 
neurovascular bundle leading one to erroneously 
believe that the posterior compartment has been 
entered and decompressed.  
 
In this photo of the medial right leg, the ankle is to the left of 
the photo. The plantaris tendon (arrow) is found in the plane 
between the soleus and gastrocnemius muscles and may be 
mistaken for the posterior tibial neurovascular bundle. Note 
that the soleus muscle has not yet been detached from the tibia 
(as shown in the photos above), therefore the deep posterior 
compartment has not yet been decompressed.  
 
 
Inadequate length of either the fascial or skin 
incision can result in failure to reduce compartment 
pressures to acceptable levels. 
 
Inadvertent injury to the saphenous vein can 
cause significant bleeding. The saphenous system 
should be always preserved if possible, but 
especially in the case of vascular trauma. Note that 
entry into the deep posterior compartment, as 
described here, allows access to the neurovascular 
bundle of the lower leg. This is the preferred 
exposure for repair of the popliteal and tibial vessels 
in 
trauma 
situations. 
In 
this 
case, 
fascial 
decompression is part of the operation, which is 
appropriate. This approach is discussed elsewhere in 
this Manual.  
 
Compartment Syndrome of the Thigh: 
Compartment syndrome is uncommon in the 
thigh because of the large volume that the thigh 
requires to cause an increase in interstitial pressure. 
In addition, the compartments of the thigh blend 
anatomically with the hip allowing for extravasation 
of blood or fluid outside the compartment. Major risk 
factors for thigh compartment syndrome include: 
severe femoral fractures, vascular injury, severe 
blunt trauma/crush or blast injury to the thigh, 
Compartment Syndromes and Fasciotomies of the Extremities 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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iliofemoral deep vein thrombosis, and external 
compression of the thigh. The thigh contains three 
compartments: anterior, posterior and medial. The 
anterior (not the medial) compartment contains the 
femoral artery and vein and is the most likely to 
develop compartment syndrome.  
 
This cross-section of the mid right thigh shows the three 
compartments of the thigh: anterior (Purple), medial (Orange), 
and posterior (Green). Note that the femoral artery and vein 
(arrow) are found in the anterior compartment. 
 
 
 
If compartment syndrome of the thigh exists, 
a lateral incision is made first as this enables 
decompression of both the anterior and posterior 
compartments. Often, the lateral incision is all that is 
needed, though on occasion with a severely swollen 
extremity a medial incision will be needed as well. 
The lateral incision of the thigh extends from the 
intertrochanteric line to the lateral epicondyle of the 
femur to expose the iliotibial band or fascia lata 
which is opened the length of the incision. The vastus 
lateralis muscle is reflected superiorly and medially 
to expose the lateral intermuscular septum (between 
the anterior and posterior compartments) which is 
incised the length of the incision. Commonly after 
the anterior and posterior compartments are 
decompressed 
the 
pressure 
in 
the 
medial 
compartment is measured and if elevated, this 
compartment is also decompressed through a medial 
incision. 
 
The two incisions required to decompress the compartments 
of the thigh are depicted with the anterior (Purple) and 
posterior (Green) compartments opened via the lateral 
incision and if indicated the medial (Orange) compartment 
opened through the medial incision. 
 
 
If needed, the medial compartment can be 
opened through a medial incision placed along the 
course of the saphenous vein. This is followed by 
rotation of the sartorius muscle, and incision of the 
medial intermuscular septum between the medial 
and anterior compartments. 
 
Compartment Syndrome of the Forearm and 
Hand: 
Compartment syndromes of the hand and 
forearm are much less common than in the lower 
extremity, but it is vital that they are recognized and 
treated when they occur. Compartment syndrome of 
the upper arm is very unusual, but may follow 
supracondylar fracture of the humerus. Compartment 
syndrome of the forearm may be associated with 
fractures, crush or blast injury, burns or vascular 
injury. Compartment syndrome of the hand can 
occur from trauma but is more commonly associated 
with infiltration of intravenous fluids. As there are no 
sensory nerves in the hand compartments, physical 
findings do not include sensory abnormalities, and 
the pressure threshold for release is much less than in 
the legs (15–20 mmHg). 
The forearm is classically described as 
having three compartments:  Volar (Anterior); 
Mobile Wad (Brachioradialis / Radial head area); 
and Dorsal (Posterior). Some anatomy texts and 
practitioners subdivide the volar into superficial and 
deep 
compartments. 
The 
literature 
contains 
Compartment Syndromes and Fasciotomies of the Extremities 
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descriptions of multiple volar incisions. The most 
commonly used and described volar fasciotomy 
incision of the forearm is a curvilinear incision (to 
release the anterior and mobile wad compartments) 
which is extended to the hand to release the carpal 
tunnel. The incision crosses the antecubital fossa in a 
curvilinear fashion to the radial aspect of the upper 
forearm and then is carried toward the ulnar aspect 
down to the wrist and then across the wrist in a 
transverse fashion and onto the palm to release the 
carpal tunnel. This volar incision allows for 
decompression of the volar (anterior) and mobile 
wad compartments as well as the carpal tunnel. This 
incision is preferred because of potentially better 
cosmetic results, and maintenance of an adequate 
skin blood supply between it and the dorsal incision 
at the wrist.  
 
The volar incision as seen on the right arm enabling 
decompression of the anterior (volar) and mobile wad 
compartments. 
 
The dorsal (posterior) compartment of the 
forearm is released through a linear dorsal incision, 
with two additional incisions on the dorsum of the 
hand to release the hand. To ensure that the 
compartments of the forearm are completely 
decompressed it is important to do a complete 
epimysiotomy (opening the fascia overlying the 
muscle) of each of the muscles, exposing the muscle 
bellies in the entire length of the forearm. Each 
muscle has its own separate fascial compartment 
which must be decompressed separately; simply 
opening up the forearm is not sufficient treatment.  
 
The dorsal incision as seen on the right arm with additional 
incisions on the hand enabling decompression of the dorsal 
compartment of the forearm and the intraosseous 
compartments of the hand.   
 
 
In most cases of suspected compartment 
syndrome of the forearm, the carpal tunnel should 
be opened completely at the wrist. This is 
accomplished by identifying the median nerve at 
the wrist crease and using scissors passed on 
either side of the transverse carpal ligament above 
the median nerve and divided.  The transverse 
carpal ligament is generally wider than one might 
expect (> 2 cm) and there is a haptic and audible 
“crunch” that accompanies its division. If one 
“cuts until the crunch is gone”, the carpal tunnel 
is fully opened. If compartment syndrome of the 
hand is suspected it is best to involve a hand 
specialist early, as often additional incisions will 
be required to decompress the thenar and 
hypothenar compartments. 
Compartment Syndromes and Fasciotomies of the Extremities 
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The median nerve (star) is identified at the wrist crease running 
under the palmaris longus (PL) tendon. Scissors are placed 
above and below the transverse carpal ligament (arrow) which 
is divided to completely open the carpal tunnel. 
 
Aftercare and Complications: 
If necrotic muscle is present, it should be 
debrided at the time of original fasciotomy. As 
described above, these procedures will create large 
wounds that must be covered. The open wounds 
should be covered with non-adherent dressing or 
moist gauze. Wound closure can be accomplished 
with the assistance of traction such as the “shoelace 
technique” or vacuum- assisted devices. The wounds 
should be re-evaluated 24–48 h after the initial 
fasciotomy with further debridement as indicated. 
After the acute process subsides, delayed primary 
closure or split-thickness skin grafting may be 
performed. Often, after swelling has gone down one 
of the two calf wounds can be closed primarily, 
leaving the other one open to be grafted. Until 
definitive wound closure, patients with open 
fasciotomy wounds are at risk for infection.  
 
A system for closing wounds slowly over time using nylon 
ratcheting ties. Other practitioners have simply looped the ties 
through punctures in the skin edges and tightened them serially. 
Source: Ahmad I et al, 
https://www.doi.org/10.36106/ijsr  
 
Incomplete or delayed fasciotomies can lead 
to permanent nerve damage, loss of limb, multi-
system organ failure, rhabdomyolysis and death. 
Early recognition and aggressive fasciotomy will 
help to minimize these adverse outcomes. 
 
Conclusions: 
Compartment syndrome must be suspected in 
all polytrauma patients with extremity injury. 
Patients in the intensive care unit are also at risk to 
develop compartment syndrome from a variety of 
non-traumatic conditions – principally: sepsis, 
massive resuscitation, and reperfusion. It is essential 
that all clinicians caring for these patients have an 
intimate 
knowledge 
of 
the 
pathophysiology, 
etiology, and evaluation of compartment syndrome. 
Additionally, all surgeons need to have a 
comprehensive knowledge of the relevant anatomy, 
and the techniques for performing a proper 
fasciotomy. A high index of suspicion must be 
maintained (especially in patients with altered levels 
of consciousness), and early and aggressive 
fasciotomy will minimize the morbidity and 
mortality associated with failure to adequately treat 
compartment syndromes.  
 
Compartment Syndromes and Fasciotomies of the Extremities 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Disclaimer: 
The opinions or assertions expressed herein are those 
of the authors and are not to be construed as official 
or reflecting the views of the Department of Defense, 
the Uniformed Services University of the Health 
Sciences, or any other agency of the U.S. 
Government. The authors have nothing to disclose. 
 
Acknowledgement: 
The authors are grateful to Ms. Elizabeth Weissbrod, 
MA, CMI for her expert illustrations contained in 
this manuscript. 
 
Mark W. Bowyer, MD, FACS, FRCS 
Uniformed Services University of the Health 
Sciences 
Maryland, USA 
 
December 2023 
 
