Eur J Vasc Endovasc Surg 13, 48-53 (1997)
Compartment Syndrome and Fasciotomy in Vascular Surgery.
A Review of 57 Cases
S. L. Jensen and J. Sandermann*
Department of Vascular Surgery, Aalborg Hospital, Denmark
Objective: To investigate the occurrence of compartment syndrome and the results of fasciotomy in vascular surgical
Design: Retrospective study of case records from 1980-1994.
Materials: Fifty-seven limbs in 53 patients had fasciotomies following surgical revascularisation. Fifty~three (93%) limbs
were acutely ischaemic, while four (7%) had undergone elective vascular surgery. Forty-four (77%) limbs had signs of
compartment syndrome, while 13 (23%) fasciotomies were prophylactic.
Methods: The fasciotomies were done as subcutaneous procedures (n = 40), as double-incision fasciotomies (n = 11), or
by an unknown method (n = 6). The skin incisions were closed primarily in 26 (46%) cases, delayed primarily in 11 (19%)
cases, and by skin grafting in eight cases (14%).
Results: Five (13%) subcutaneous fasciotomies required revision. Surgical debridement was required in four (7%) limbs.
At discharge, 36 (68%) patients had kept their limbs, 11 (21%) patients were amputated, and six (11%) had died. No
complications relating to the fasciotomies were observed.
Conclusions: Compartment syndrome is usually related to acute ischaemia and rarely following elective vascular surgery.
Subcutaneous fasciotomy does not always ensure sufficient decompression of all four lower leg compartments.
Complications related to fasciotomy are rare.
Key Words: Compartment syndrome; Fascia surgery; Ischaemia surgery; Postoperative complications; Reperfusion injury;
Compartment syndrome is a condition in which high
pressure within a closed fascial space reduces capil-
lary blood perfusion below a level necessary for tissue
viability. 1 In relation to vascular surgery the condition
is known as a post-ischaemic compartment syndrome,
in which tissue swelling following reperfusion of
ischaemic extremities leads to compartmental hyper-
tension. ~'2 This swelling is a consequence of a biphasic
ischaemia-reperfusion injury, in which tissue damage
initiated in the ischaemic phase is continued by the
reintroduction of oxygenated blood. 3"4 The ischaemia-
reperfusion injury appears to be mediated by the
interaction of oxygen derived free radicals, endothelial
factors and neutrophils. 5 Oxygen derived free radicals
can peroxidate the lipid component of cell mem-
branes, leading to enhanced capillary permeability. 3
Unless rapidly decompressed, compartment syn-
*Please address all correspondence to: Jes Sandermann, Vascular
Surgical Unit, Department of Surgery, Viborg Hospital, DK-8800
drome will eventually result in irreversible neu-
romuscular damage. 1 Fasciotomy has been recom-
mended as an adjunct in the treatment of ischaemic
limbs, 1'2'6 but uncertainties still remain. The clinical
diagnosis of compartmental hypertension is difficult,
and no absolute objective criteria for performing
fasciotomy exist, z'7 Complications, in particular infec-
tion, may be related to the procedure, which has lead
to debate of its appropriateness in ischaemic extre-
mities. 8-1° Several procedures for lower extremity
fasciotomy have been described, L6'7Al-~3 but there is
no agreement on which method is preferable.
This study was conducted to investigate the occur-
rence of compartment syndrome and the results of
fasciotomy in relation to vascular surgery.
Materials and Methods
The case records of all patients undergoing fasciotomy
at the Department of Vascular Surgery in Aalborg
from 1 January 1980 to 31 December 1994 were
1078-5884/97/010048 + 06 $12.00/0 © 1997 W. B. Saunders Company Ltd.
Compartment Syndrome and Fasciotomy 49
reviewed. Fifty-three patients with a median age of 65
years (range 11-96) and a male/female ratio of 2:1
underwent fasciotomy. As four patients underwent
bilateral fasciotomy, a total of 57 limbs were treated.
Fifty-six were lower leg procedures and one was a
forearm fasciotomy. Sixteen patients (30%) had under-
gone vascular surgery on a previous occasion.
Fifty-three (93%) limbs were acutely ischaemic and
revascularisation was carried out after an average
ischaemic period of 26 h (range 3 h - 6 days) from
onset of symptoms to operation. The remaining four
limbs (7%) underwent reconstructive vascular surgery
because of severe chronic ischaemia with either rest
pain (n = 1) or gangrene (n = 3). The causes of
ischaemia and the subsequent revascularisation proce-
dures are listed in Table 1. In Table 2, the frequency of
fasciotomy in the various ischaemic conditions has
Fasciotomy was either done because one or more
accepted clinical signs of compartment syndrome had
developed (n = 44) 1'7'13 or as a prophylactic procedure
(n = 13). The signs of compartmental hypertension
were not usually recorded as related to specific
compartments, but in six cases the anterior and lateral
compartments of the lower leg were mentioned as the
only ones having signs of compartment syndrome.
Besides local symptoms from the compartments, four
of these limbs were characterised by extensor muscle
paresis of the ankle joint and toes, and from hypoaes-
thesia of the wrist. The recorded clinical signs of
compartment syndrome are listed in Table 3. The
prophylactic fasciotomies were performed because of
soft tissue swelling noticed during operation, a long
ischaemic period, or blunt soft tissue injury. In one
case of unilateral compartment syndrome, both legs
were treated because the initial cause of ischaemia was
a centrally occluded aortobifemoral graft.
In 30 cases (53%) the fasciotomy was performed
immediately after the revascularisation procedure.
Thirteen of these were done prophylacticall3~ while 17
were done because signs of compartment syndrome
had developed before the operation. The remaining 27
limbs (47%) developed compartment syndrome after
revascularisation and fasciotomy was done with a
mean delay of 24 h (range 5-98).
Two methods for lower leg fasciotomy were used,
always with bilateral skin incisions intending to
decompress all compartments. In 11 cases, it was
carried out as double-incision fasciotomies through
20-30cm long skin incisions, 1"13 while subcutaneous
procedures with limited skin incisions were used in 39
cases. 6 In six cases, it was not possible to establish
from the case record whether subcutaneous or double-
incision fasciotomy had been used. The forearm
fasciotomy was done as a subcutaneous procedure
through dorsal and volar incisions. 6 During the fi~st 10
years of the period studied, all fasciotomies were
subcutaneous or unknown, while all the double-
incision fasciotomies were done during the last 5
The skin incisions were treated as shown in Table 4.
Delayed primary suture was undertaken at an average
of 7 days (range 4-12) and autologous split-thickness
skin grafting at an average of 13 days (range 5-20)
after fasciotomy. Three limbs were amputated and one
patient died in the early postoperative period, before
further treatment of the open fasciotomy incisions
could be carried out.
In five limbs which underwent fasciotomy by the
subcutaneous technique (13%), signs of compartment
syndrome continued in spite of fasciotomy. All were
reoperated with long skin incision. In three cases, the
deep posterior compartment needed further decom-
pression, while in two, lengthening the skin incisions
Table 1. Causes of ischaemia and subsequent revascularisation procedures in 57 limbs undergoing fasciotomy.
Ischaemia Cause of ischaemia No. (%) Revascularisation procedure
Graft thrombosis t
Ruptured abdominal aortic anurysm
Graft thrombectomy and supplementary surgery$
Arterial repair (n=2) or vein bypass (n=l)
Femoropopliteal bypass (n=2), aortobifemoral bypass (n=l),
*Eight patients had supplementary reconstructive surgery: aortobifemoral bypass (n=3), femorofemoral crossover bypass (n=l), or
femoropopliteal vein bypass (n=4).
tThe primary reconstruction was suprainguinal in nine cases, infrainguinal in five cases, and both supra- and infrainguinal in two cases.
SEither revision at the distal anastomosis (n=10) or further reconstructive surgery (n=6).
~Average intraoperative aortic occlusion time 185 min (range 145-240).
Eur J Vasc Endovasc Surg Vol 13, January 1997
50 S.L. Jensen and J. Sandermann
Table 2. Frequency of fasciotomy for various ischaemic conditions.
Ruptured abdominal aortic
Surgical debridement of necrotic muscle tissue was
required in four limbs (7%); one of these was later
amputated. During hospitalisation a total of 14 limbs
(25%) were amputated: one hip-disarticulation, five
femoral, seven crural, and one humeral amputation.
The average time from the revascularisation proce-
dure to amputation was 8 days (range 1-53). All
amputations were done because of ischaemia. Com-
paring the limbs undergoing debridement or amputa-
tion with the remainder, the average ischaemic peri-
ods were 38 and 21 h respectively. There was no
difference regarding the method of fasciotomy.
The patients were hospitalised for an average of 12
days (range 1-58). In many cases their limb function
had returned to the preadmission level (Table 5). The
neuromuscular sequelae were extensor paresis of the
ankle joint and/or hypoaesthesia of the wrist. One
patient had paresis of both the flexor and extensor
muscle groups of the lower leg. Six patients (11%) died
during hospitalisation: five within the first week and
one patient after 58 days. The causes of death were
Table 3. The recorded clinical signs in 44 extremities with
diagnosed compartment syndrome.
Tense and swollen compartments
Tenderness at palpation/pain on passive stretch
Paresis of ankle joint or toes
Hypoaethesia of foot
acute renal failure (n -- 3), multisystem organ failure
(n = 1), acute myocardial infarctation (n = 1), and
stroke (n -- 1). Eight extremities had open wounds at
discharge; in five of these cases the patients were
discharged to further treatment at other hospitals,
while three were followed at our hospital with
uneventful wound healing within 6 months.
The potential for ischaemia-reperfusion injury and
post-ischaemic compartment syndrome is always pre-
sent when an acutely ischaemic limb is reperfused,
regardless of the cause for the ischaemia. 4 Thus
compartment syndrome has been reported following
various acute ischaemic conditions such as traumatic
amputation of extremities, vascular injuries, arterial
Although not as common, we found that fasciotomy
may also be needed following the successful repair of
ruptured abdominal aortic aneurysms. In these cases,
the aortic occlusion time probably contributed con-
siderably to the development of compartment syn-
drome. Ischaemia-reperfusion injury may occur after
only 1 h of total ischaemia. 4 In the only previous study
comparing the frequencies of fasciotomy in different
ischaemic conditions, Patman 6 found that 32% of
extremities with arterial injuries and only 2% with
embolic occlusions were fasciotomised. In studies of
thromboembolic occlusions alone, fasciotomy fre-
quencies as high as 16-22% have been reported. 15'16
An increase in intramuscular pressure has been
demonstrated following reconstructive vascular sur-
gery, but the pressure rarely reaches levels initiating a
compartment syndrome. -
need for fasciotomy following elective surgery at
0.15%, while in a previous study, the frequency was
0.45%. 6 The four patients in this series all had severe
chronic ischaemia with either rest pain or gangrene.
This could indicate that the increase in intracompart-
mental pressure may be correlated to the severity of
graft thrombosis. 6'1°'14'15
We have estimated the
Table 4. Treatment of skin incisions following 57 fasciotomies subdivided according to the method of fasciotomy.
Subcutaneous Double-incision Unknown
No. (%) No. (%) No. (%)
Delayed primary suture
Split-thickness skin grafting
Open at discharge
Open at amputation or death
Eur J Vasc Endovasc Surg Vol 13, January 1997
Compartment Syndrome and Fasciotomy 51
Table 5. Limb function at time of discharge of 53 patients
*Includes three patients who had undergone amputation.
preoperative chronic ischaemia. The postoperative
pressures in patients with claudication and patients
with rest pain have been compared, but the difference
was small and not significant. 17
In 17 acute ischaemic extremities, signs of compart-
ment syndrome had developed before surgical reper-
fusion. This phenomenon has been reported with
almost the same frequency in two other series. 15'16
Allenberg and Meybier ~5 have called this condition
primary compartment syndrome and suggested that it
may be caused by a spontaneous reperfusion, either
through lysis of the embolus/thrombus or through
opening of collaterals. In contrast, Mubarak and
Hargens ~ have proposed that the swellings are due to
an incomplete ischaemic condition in which ischaemic
injury and reperfusion injury are taking place simulta-
neously. Studies of cell damage following partial
ischaemia supports this theory. 2
The clinical signs and symptoms of compartment
syndrome are (1) pain, that can be out of proportion to
the clinical situation, (2) pain on passive stretch of the
muscles in the compartment, (3) paresis of the muscles
in the compartment, (4) hypoaesthesia in the distribu-
tion of the nerves running through the compartment,
and (5) tenseness and swelling of the fascial bounda-
ries of the compartment. 1"7'~3 Distal pulses may dis-
appear if the intracompartmental pressure is high
enough. ~ Frequently the signs of compartment syn-
drome can be difficult to distinguish from the signs
and symptoms of severe arterial insufficiency. 1'~°
However, when pain persists or develops after revas-
cularisation, an impending compartment syndrome
should always be suspected. In this series the most
commonly used objective indicator of compartmental
hypertension was compartment tenseness. Although
the symptom is crude and might be masked by a
simultaneous subcutaneous oedema, a swollen and
tense compartment is the earliest and sometimes the
only objective finding
Intracompartmental pressure measurement as an
adjunctive diagnostic technique in doubtful cases may
be useful, but there is no agreement on the pressure
level above which fasciotomy should be performed.
Pressure values exceeding 30 mm Hg, 2°'21 exceeding
45 mm Hg, 7 and within 10-30 mm Hg of the diastolic
blood pressure 2a have all been proposed as relative
indications for fasciotomy. In addition, individuals
vary in their tolerance for increased tissue pressure. 7
Measurements of nerve conduction 7 are probably of
limited value in extremities that have also been
subjected to ischaemia due to arterial insufficiency.
It has been shown that muscle injury is significantly
reduced following prophylactic fasciotomy and reper-
fusion compared to reperfusion with fasciotomy done
after 2 h. 23 Criteria for prophylactic fasciotomy have
been evolved in relation to arterial injuries. These
include several hours of ischaemia, a period of
prolonged hypotension or shock, combined arterial
and venous injury, massive soft tissue injury, soft
tissue swelling developing before or at revascutarisa-
tion, and obvious failure of the arterial repair. 6'13 In
acute thromboembolic occlusions, Papalambros et aI. 16
have proposed that fasciotomy should be considered
when the ischaemic time exceeds 6 h, in young
patients, in cases of a very acute onset, when patients
are hypotensive, and when the back-flow is inade-
quate despite the passage of the embolectomy catheter
down to the foot.
Two methods of lower leg fasciotomy were used in
this series: the technique of limited skin incisions
(subcutaneous fasciotomy) 6 and double-incision fas-
ciotomy with bilateral long skin incisions. 1'13 Other
methods are parafibular decompression 7'12 and fibu-
lectomy-fasciotomy, 11 which both only require a single
lateral incision. This leaves the long saphenous vein
unexposed, which can be advantageous if later recon-
structive vascular surgery is required. Compared to
the double-incision technique, some have found the
parafibular technique to be less traumatising and to
give better cosmetic results. 14 The fibulectomy-fascio-
tomy is generally not advocated, because proper
decompression of all four compartments can be
achieved using methods without resecting the fib-
ula. 7'13"24 Whatever method is used, most authors
recommend that all four lower leg compartments
should be opened. 7'11'21'24 Concern about the subcuta-
neous method has been raised because complete
decompression requires full skin incisions. 7"25 Many
surgeons, including those at our department, have
abandoned the technique during the last few years,
and our results show that a subcutaneous fasciotomy
is not always sufficient. Because of the small skin
incisions, the skin can form the limiting boundary and
the deep posterior compartment is not always ade-
quately decompressed. This compartment becomes
superficial only on the distal aspect of the leg and
Eur J Vasc Endovasc Surg Vol 13, January 1997
52 S.L. Jensen and J. Sandermann
frequently requires detaching the soleus muscle at its
insertion on the tibial border to be properly
Limb swelling following revascularisation of acute
ischaemic extremities can reach a maximum as late as
1 week after the operation. 26 Therefore, primary skin
closure is not always appropriate. Several authors
recommend that the skin incisions should always be
left open for later closure. 1'2'7'1z This makes the
wounds accessible to later inspection and surgical
debridement as needed in 7% of the present series.
Delayed primary closure should be attempted, but
often autologous split thickness skin grafting is
required. To make delayed primary closure easier or to
reduce the skin defects to cover by grafting, the
wound edges can be approximated by daily applica-
tion of sterile paper tapes. 6'7
The results of the present series are comparable to
those previously reported in studies of vascular
surgical patients undergoing
Many patients were disabled by neuromuscular
sequelae, most often related to the anterior and lateral
compartments. Although fasciotomy was done as
soon as possible after the symptoms of compartment
syndrome were observed, compartmental hyperten-
sion could have contributed to this neuromuscular
damage. Neuromuscular sequelae are well known
after compartment syndrome and are inversely related
to the promptness with which decompression is
done. 21 The revascularisation of acute ischaemic limbs
can lead to severe systemic complications as toxic
metabolites are returned to the circulation. Four
deaths in this study could be attributed to such
complications, which include acute renal failure,
pulmonary oedema and muttisystem organ failure. 4"5
Systemic heparinisation and early amputation in
advanced ischaemic cases have been advocated to
reduce mortality, 29 but also collecting the returning
venous blood and controlling the initial reperfusate
have been proposed. 3° Forced diuresis and correction
of acidosis and electrolytic imbalance are important in
the prevention of systemic complications. 28 The
osmotic diuretic mannitol also acts as a free radical
scavenger and may reduce the local tissue injury. 5'31
Fasciotomy incisions constitute a potential route of
infection. Fear of such complications has lead to
reservations about the use of fasciotomy in ischaemic
extremities. 8 In a series of open fasciotomies, Rush et
alJ ° found that the only complications relating to
fasciotomy were easily treated superficial wound
infections. In the present study, no clinical detectable
infection or other complications were observed.
Severe complications following fasciotomy in vascular
surgical patients appear to be rare and fear of
additional morbidity should not influence the decision
to perform a fasciotomy.
1. MUBARAK SJ, HARGENS AR. Acute compartment syndromes. Surg
Clin North Am 1983; 63: 539-565.
2. PERRY MO. Compartment syndromes and reperfusion injury.
Surg Clin North Am 1988; 68: 853~864.
3. McCoRD JM. Oxygen-derived free radicals in postischemic
tissue injury. N Eng f Med 1985; 3: 159-163.
4. BEYERSDORF F. Protection of the ischemic skeletal muscle. Thorac
Cardiovasc Surg 1991; 39: 19-28.
5. GRACE PA. Ischaemia-reperfusion injury. Br J Surg 1994; 81:
6. PATMAN RD. Compartmental syndromes in peripheral vascular
surgery. Clin Orthop 1975; 103-110.
7. MATSEN FA, WINQUIST RA, KRUGMIRE RBJ. Diagnosis and
management of compartmental syndromes. J Bone Joint Surg Am
1980; 62: 286-291.
8. BLAISDELL FW. Is there a reason for controversy regarding
fasciotomy? J Vasc Surg 1989; 9: 828.
9. ERNST CB. Fasciotomy -- in perspective. J Vasc Surg 1989; 9:
10. RUSH DS, FRAME SB, BELL RM, BERG EE, KERSTEIN MID, HAYNES
JL. Does open fasciotomy contribute to morbidity and mortality
after acute lower extremity ischemia and revascularization?. J
Vasc Surg 1989; 10: 343-350.
11. ERNST CB, KaUFER H. Fibulectomy-fasciotomy. An important
adjunct in the management of lower extremity arterial trauma. J
Trauma 1971; 11: 365-38O.
12. COOPER GG. A method of single-incision, four compartment
fasciotomy of the leg. Eur J Vasc Surg 1992; 6: 659-661.
13. HYDE GL, PECK D, POWELL DC. Compartment syndromes. Early
diagnosis and a bedside operation. Am Surg 1983; 49: 563-568.
14. GAWENDA M, PROKOP A, WALTER M, ERASMI H. The compartment
syndrome with special reference to vascular surgery aspects. A
patient sample of the Cologne University Clinic 1981 to 1991.
Zentralbl Chir 1992; 117: 432-438.
15. ALLENBERG JR, MEYBIER H. The compartment syndrome from the
vascular surgery viewpoint. Chirurg 1988; 59: 722-727.
16. PAPALAMBROS EL, PANAYIOTOPOULOS YP, BASTOUNIS E, ZAVOS G,
BALAS P. Prophylactic fasciotomy of the legs followed acute
arterial occlusion procedures. Int Angiol 1989; 8: 120-124.
17. MELBERG PE, STYF l, BIBER B, HASSELGREN PO, KORNER L, SEEMAN
T. Muscular compartment pressure following reconstructive
arterial surgery to the lower limbs. Acta Chir Scand 1984; 150:
18. CHRISTENSON JT, QVARFORDT P. Intramuscular pressure changes
during and after revascularization of the femoral arteries in
humans. World J Surg 1983; 7: 646-652.
19. QVARFORDT P, CHRISTENSON JT, EKLOF B, OHLIN P. Intramuscular
pressure after revascularization of the popliteal artery in severe
ischaemia. Br J Surg 1983; 70: 539-541.
20. MUBARAK SJ, OWEN CA, HARGENS AR, GARETTO BS, AKESON xcVH.
Acute compartment syndromes: Diagnosis and treatment with
the aid of the Wick catheter. J Bone Joint Surg Am 1978; 60:
21. RORABECK CH. The treatment of compartment syndromes of the
leg. ] Bone Joint Surg Br 1984; 66: 93-97.
22. WHrrEsrDES TE, HANEY TC, MORIMOTO K, HARADA H. Tissue
pressure measurements as a determinant for the need of
fasciotomy. Clin Orthop 1975; 113: 43-51.
23. Ricci MA, CORBISIERO RM, MOHAMED F, GRAHAM AM, SYMES JF.
Replication of the compartment syndrome in a canine model:
experimental evaluation of treatment. J Invest Surg 1990; 3:
Eur J Vasc Endovasc Surg Vol 13, January 1997