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Upper Extremity Fasciotomies

April 12, 2022 - read ≈ 8 min



Tiffany Bellomo, MD.

Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA


Tommy Alan Brown, II, MD

Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA


I. Introduction

Compartment syndrome occurs when pressures within fascial compartments exceed perfusion pressures, causing injury to the muscle, blood vessels, and nerves within the compartment. Although this condition most commonly occurs in the lower extremities, it can also occur in the upper extremities associated with ischemia, burn injuries, crush injuries, and bone fractures. If there is any concern that compartment syndrome is present or the patient could quickly develop undiagnosed compartment syndrome after prolonged ischemic time or electrical injuries, a fasciotomy should be performed. In this section, we focus specifically on upper extremity compartment syndrome, how to perform fasciotomies, and post-operative care.

To fully understand compartment syndrome and how to perform fasciotomies, it is important to know the anatomic compartments of the arm.

There is one compartment of the shoulder:

  • Muscles: deltoid
  • Nerves: musculocutaneous, median, ulnar
  • Artery: axillary
  • Vein: axillary

There are two compartments of the upper arm:

  • Anterior 
    • Muscles: biceps brachii, brachialis, coracobrachialis
    • Nerves: musculocutaneous, median, ulnar
    • Artery: brachial artery
    • Vein: basilic vein, brachial veins
  • Posterior
    • Muscles: triceps brachii lateral head, triceps brachii long head, triceps brachii medial head  
    • Nerve: radial nerve

There are four compartments of the forearm:1

  • Volar superficial
    • Muscles: pronator teres, flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, palmaris longus
    • Nerve: median, ulnar
    • Artery: ulnar
  • Volar deep
    • Muscles: flexor digitorum superficialis, pronator quadratus, flexor digitorum profundus, flexor pollicis longus
    • Nerve: anterior interosseous
    • Artery: anterior interosseous
  • Dorsal
    • Muscles: extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, extensor indicis
    • Nerve: posterior interosseous
    • Artery: posterior interosseous
  • Lateral (aka “mobile wad”)
    • Muscle: brachioradialis, extensor carpi radialis longus and brevis
    • Nerve: superficial radial
    • Artery: radial

There are 10 compartments of the hand:

  • 4 dorsal interossei
    • Muscles: extensor carpi radialis longus, extensor carpi radialis brevis, extensor pollicis longus, extensor indicis, extensor digitorum communis, extensor digiti minimi
    • Nerves: median, ulnar, and radial
    • Arteries: superficial palmar arch
    • Veins: cephalic and basilic
  • 3 volar interossi
    • Muscles: volar muscles
    • Nerves: median, ulnar, and radial
    • Arteries: deep palmar arch
  • Hypothenar
    • Muscles: extensor carpi ulnaris
    • Nerve: ulnar
    • Artery: ulnar
  • Thenar
    • Muscles: abductor pollicis longus, extensor pollicis brevis
    • Nerve: radial
    • Artery: radial
  • Adductor pollicis
    • Muscle: adductor pollicis
    • Nerve: branch of ulnar nerve
    • Arteries: deep palmar arch

There are several structures in the carpal tunnel that may need to be release:

  • Tendons: flexor digitorum profundus, flexor digitorum superficialis, flexor pollicis longus
  • Nerve: median

One of the most notable risk factors for compartment syndrome is acute extremity ischemia, especially lasting longer than 6 hours.2 Some mechanisms of injury are also more associated with the development of compartment syndrome: burn injuries and crush injuries.3 Long bone fractures are also commonly associated with compartment syndrome, where supracondylar humerus fractures or radial fractures predispose patients to volar compartment fractures.4

II. Indications/Contraindications

There are no true contraindications to a fasciotomy and the diagnosis of compartment syndrome is an indication to perform a fasciotomy. The diagnosis is based on symptoms of pain on passive stretch of the fingers or muscles, tense firm compartments on palpation, and compartment specific neurovascular findings. Neurovascular symptoms related to acute limb ischemia are best summarized as the 6 Ps (paralysis, pain, pallor, paresthesia, poikilothermia, and pulselessness)

Pressure monitors can be used to measure compartment pressures. It is agreed upon that a compartment pressure greater than 30 mmHg warrants a fasciotomy.5 Devices used to measure the pressures are handheld manometers, i.e. Stryker device, simple needle manometer systems, or wick slit catheter techniques.

Prophylactic fasciotomies can benefit patients, especially in the case of ischemia that has been present for more than three hours. High-voltage electrical injury6 may also require prophylactic fasciotomies. First and foremost, these electrical injuries require formal resuscitation with lactated ringers to maintain a urine output of greater than 1mL/kg/hr to decrease the very substantial risk of acute renal failure. Electrical injuries leading to compartment syndrome can manifest remote from the visible external injuries. Soft tissue injury is typically the greatest surrounding the long bones located between the presumed entry and exit sites and often lead to significant myonecrosis. All patients suffering electrical injury should be monitored for 24 hours for dysrhythmia if resources allow.

III. Equipment

Instruments necessary for the operation are minimal: a scalpel is needed for the incision, electrocautery to be used for hemostasis, and scissors with a dull apex to avoid damage to surrounding structures while completing fasciotomies. A hand table or a table to extend the arm would be useful for adequate exposure.

IV. Preparation

Preparing the field in a sterile fashion is ideal, but not always possible. Antibiotic prophylaxis should be given to cover skin organisms, such as Ancef if available.

V. Steps

There are many ways to perform fasciotomies of the upper extremity. Outlined here are commonly used methods to release compartments.

Shoulder/Deltoid Fasciotomy (Figure 1)

  • Longitudial incision from the lateral most origin on the clavicle towards its insertion on the deltoid tuberosity of the humerus
  • Longitudinal incision from the anteriolateral most origin on the scapula towards its insertion on the deltoid tuberosity of the humerus
  • Carry incisions down to deltoid fascia and open

Brachial Fasciotomy (Figure 2)

  • Oblique incision from medial epicondyle towards axilla
  • Incise anterior compartment fascia over the biceps
  • Incise posterior compartment fascia over the triceps
  • Isolate and protect ulnar nerve

Triceps/Posterior Brachium Fasciotomy

  • Linear incision between the long and lateral heads of the triceps from the inferior edge of the deltoid to the approximately 2-3 fingerbreadths above the olecranon
  • Incise lateral compartment fascia over the triceps
  • Incise long compartment fascia over the triceps

Forearm Fasciotomy (Figure 2)

  • Volar Incision
    • Backwards S shaped skin incision over the center of the volar forearm
      • 1cm proximal and 2cm lateral to Medial epicondyle, extend oblique over AC fossa, arc around to the middle of the mid forearm, then extend longitudinally to the wrist as pictured below.
    • Incise the superficial volar compartment fascia with scissors 
    • Dissect over palmaris longus to expose volar compartment
    • Incise the deep volar compartment fascia over flexor digitorum superficialis with scissors
  • Dorsal Incision
    • Dorsal longitudinal incision 2cm distal to lateral epicondyle toward midline of wrist
    • Incise the dorsal compartment fascia with scissors
    • Dissect between extensor digitorum communis of the dorsal compartment and the extensor carpi radialis longus of the mobile wad
    • Incise the mobile wad compartment fascia with scissors

Figure 2. Brachial and Forearm Fasciotomies

Hand Fasciotomy

  • Dorsal Incisions
    • Dorsal longitudinal incision in line with the 2nd and 4th metacarpal
    • Incise all 4 dorsal compartment fascia, 3 volar compartment fascia, and adductor pollicis fascia with scissors
  • Lateral Incision
    • Lateral longitudinal incision on the radial aspect of the first metacarpal
    • Incise the thenar compartment fascia with scissors  
  • Medial Incision
    • Medial longitudinal incision on the ulnar aspect of the 5th metacarpal
    • Incise the hypothenar compartment with scissors

Carpal Tunnel Release

  • Proximal traverse incision at the wrist to the thenar crease
  • Identify the transverse carpal ligament
  • Identify the hypothenar V intersection
  • Incise the distal transverse carpal ligament with scissors
  • Identify and preserve the median nerve
  • Divide the proximal transverse carpal ligament with scissors

Post-operatively, it is recommended patients remain non-weight bearing for all fasciotomies. Specifically for upper extremities, it is also recommended the arm remains in the intrinsic plus position to prevent an extension contracture, which means 70-to-90-degree flexion position of the metacarpophalangeal joints. In terms of closure, it is recommended that the fasciotomy wounds be left open for 24 to 48 hours with potential return to the OR for a second look. In the interim, the wound can either be packed wet to dry or negative pressure wound therapy can be applied. On second look in the operating room, dead tissue can be debrided and potential for closure can be assessed. If the muscles are too edematous, surgeons often elect to perform delayed primary closure after 7 to 10 days or proceed with skin grafting7.

VI. Complications

The most common complication after an upper extremity fasciotomy is contracture due to positioning, including volkmann’s ischemic contracture. This can be prevented by keeping the arm mobile and flexed when appropriate. Other common complications include neurogenic deficits, especially from iatrogenic injury to the medial antebrachial nerve in the proximal forearm or palmar branch of the median nerve in the distal forearm. Another type of neurologic deficit is Sudeck’s Algodystrophy, which is a type of complex regional pain syndrome that cannot necessarily be prevented. Infections like gangrene can also occur secondary to segmental resection of the brachial artery.

VII. Summary

  • Compartment syndrome is a clinical diagnosis, but in obtunded patients compartment pressures over 30mmHg or a high suspicion are adequate for diagnosis.
  • Treat promptly with fasciotomies before irreversible damage occurs, especially in the upper extremities.
  • Release of all fascial compartments is required, including the:
    • Single compartment of the shoulder
    • Two compartments of the upper arm
    • Four compartments of the forearm
    • 10 compartments of the hand
    • Occasionally, the carpal tunnel when clinically indicated
  • Wounds are left open, packed wet to dry, or with negative pressure wound device
  • Perform second look after 24 hours to debride any necrotic tissue and determine closure plan.
    • Primary closure at that time
    • Delayed primary closure after 7 to 10 days
    • Skin grafting
  • Complications include contractures, nerve damage, and infection.

VIII. References:

  1. Ronel DN, Mtui E, Nolan WB. Forearm compartment syndrome: Anatomical analysis of surgical approaches to the Deep Space. Plastic and Reconstructive Surgery. 2004;114(3):697–705. 
  2. Ipaktchi K, Wingfield J, Colakoglu S. Fasciotomy: Upper extremity. Compartment Syndrome. 2019;:59–66. 
  3. Demetriades D. Upper Extremity fasciotomies. Atlas of Surgical Techniques in Trauma. 2019;:354–63. 
  4. Morin RJ, Swan KG, Tan V. Acute forearm compartment syndrome secondary to local arterial injury after penetrating trauma. Journal of Trauma: Injury, Infection & Critical Care. 2009;66(4):989–93. 
  5. Ardolino A, Zeineh N, O’Connor D. Experimental study of forearm compartmental pressures. The Journal of Hand Surgery. 2010;35(10):1620–5. 
  6. Ronel DN, Mtui E, Nolan WB. Forearm compartment syndrome: Anatomical analysis of surgical approaches to the Deep Space. Plastic and Reconstructive Surgery. 2004;114(3):697–705. 
  7. Kalyani BS, Fisher BE, Roberts CS, Giannoudis PV. Compartment syndrome of the forearm: A systematic review. The Journal of Hand Surgery. 2011;36(3):535–43. 
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