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JC Clasper1, D Standley2, S Heppell3, S Jeffrey4, PJ Parker5 77
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Defence Professor Trauma & Orthopaedics, Academic Department of Military Surgery and Trauma, Royal Centre for Defence 80
12 Medicine, Birmingham; 2 Consultant Orthopaedic Surgeon, Royal Devon and Exeter NHS Foundation Trust; 3 Consultant 81
13 Plastic and Reconstructive Surgeon, Portsmouth Hospitals NHS Trust; 4 Consultant Plastic and Reconstructive Surgeon, 82
14 University Hospital Birmingham NHS Foundation Trust; 5 Senior Lecturer, Academic Department of Military Surgery and 83
15 Trauma, Royal Centre for Defence Medicine, Birmingham 84
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21 Introduction diagnosis has been made in hospital, fasciotomy must take place 90
22 immediately. Any delay in treatment is associated with an adverse 91
23 A limb acute compartment syndrome (ACS) occurs when an outcome and an increase in complications such as amputation and 92
24 increase in the pressure in a closed fascial compartment results in even death [2]. 93
25 microvascular compromise resulting in muscle ischaemia. As the In the military environment there is little place for pressure 94
26 duration and magnitude of the pressure increase, myoneural monitoring even in an unconscious patient due to prolonged 95
27 function is impaired and necrosis of the soft tissue eventually evacuation, and the potential difficulties with regular observation 96
28 develops [1]. This can lead to significant morbidity, amputation and treatment during evacuation. A twelve hour CCAST 97
29 and even death [2]. Treatment of suspected ACS is by urgent evacuation at high altitude in darkness, where resuscitation and 98
30 decompression of the compartment. transfusion are often ongoing after IED injury, is no place for a 99
31 As in previous conflicts, the majority of casualties from Iraq and latent compartment syndrome : Put simply, a fasciotomy should be 100
32 Afghanistan have sustained limb injuries [3,4]. ACS clearly occurs carried out if there is any clinical suspicion of, or significant 101
33 in severely injured limbs following injury, but due to different potential for, compartment syndrome [5]. 102
34 methodology used in published work, it is difficult to determine 103
35 the exact incidence of ACS in civilian populations. It is generally General Principles 104
36 accepted to be approximately 1-5% following leg injuries, and less 105
37 than 1% within the upper limb [2]. This compares to a recent Fasciotomy can be associated with a high rate of complications [5] 106
38 military publication when 16% of casualties evacuated out of Iraq which in many cases is due to poor technique rather than 107
39 and Afghanistan had undergone a fasciotomy [5]. underlying injury. Regrettably most of the following consensus 108
40 Due to this relatively low incidence in civilian populations, it is statements and guidelines below have had to be re-learnt in recent 109
41 infrequently seen during civilian surgical training, with a mean of conflicts. They represent what we believe to be current best 110
42 only 3 fasciotomies, seen across 6 years of training in Trauma and practice. 111
43 Orthopaedic Surgery [6]. This article offers trainees and 112
44 consultants within the deployed surgical team guidelines on 1. Following diagnosis, fasciotomy should be carried out as 113
45 performing fasciotomies for the treatment or prevention of ACS. soon as practical due to the increase in complications with delay 114
46 ACS can occur in any in any muscle compartment, but is [2]. 115
47 commonest in the leg followed by the forearm [2,5]. The cardinal 116
48 symptom of a compartment syndrome is excessive pain. The 2. All compartments should be decompressed. In the lower leg 117
49 compartment is tense, and any further pressure worsens the pain, failure to decompress the deep posterior compartment is relatively 118
50 as does passive stretching of the muscles within the compartment common: Missed compartment syndrome is associated with a very 119
51 such as extending the toes or fingers. Absence of distal pulses (and high complication rate [5]. 120
52 sensation) is a very late sign, and only occurs after arterial 121
53 occlusion. 3. Full length incisions must be performed. A common error is 122
54 The diagnosis is clinical, although pressure monitoring can be that the incision is too short; usually the decompression appears 123
55 used if the condition is anticipated or suspected and accurate adequate but post-operative muscle swelling leads to ACS 124
56 clinical examination is not possible, such as with a head injured recurrence due to the tourniquet effect of tight skin and fascia at 125
57 patient, or an anaesthetic limb [7]. As pressure monitoring has not the extremes of the incision (Figure 1). 126
58 been shown to be more accurate than clinical monitoring [8], it is 127
59 not indicated in a conscious patient if regular assessment is 128
60 possible. Clinical suspicion remains the key. 129
61 Regular re-assessment is required as there may be a delay in 130
62 presentation, with a recent paper reporting a mean delay between 131
63 injury and fasciotomy of 22 hours even in monitored patients [9]. 132
64 Even though the development of ACS may be delayed, once the 133
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66 Corresponding Author: Lt Col J Clasper, Professor of Trauma 135
67 and Orthopaedics, Academic Department of Military Surgery 136
and Trauma, Royal College of Defence Medicine, Birmingham Figure 1 An inadequate lower limb fasciotomy. These short incisions
68 have not allowed full compartment decompression 137
69 Email: Prof.TandO@rcdm.bhm.ac.uk 138
The author has requested enhancement of the downloaded file. All in-text references underlined in blue are linked to publications on ResearchGate.