SLR - July 2012 - Serra Park
Reference: Ebraheim, N., Ebraheim, A., Abdelgawad A., Sreenvivasa R-A. (2012). Bedside fasciotomy under local anesthesia for acute compartment syndrome: a feasible and reliable procedure in selected cases. J. Orthopaed Traumatology.
Scientific Literature Review
Reviewed by: Serra Park, DPM
Residency Program: New York Hospital Queens
Podiatric Relevance:
Delaying treatment of acute compartment syndrome has been shown to have irreversible consequences. While emergent fasciotomy in the operating room setting under general /regional anesthesia is usually the standard, various reasons can cause delay in performing this surgery including medical comorbidities, polytrauma or recent oral intake. This article describes a number of cases of bedside fasciotomy under local anesthesia used as an alternative to OR fasciotomy in order to prevent further delay of treatment.
Methods:
The outcome of 34 patients who underwent bedside fasciotomy by a single trauma surgeon over a four-year period was reviewed. Diagnosis of compartment syndrome in these patients was determined clinically (tense swelling, pain out of proportion to injury, increased narcotic requirement, pain on passive stretching, paresthesia) along with compartment pressure measurements. All 34 of these patients were determined to have an anticipated delay time to surgery of more than six to eight hours.
The procedure included release of the involved compartments under conscious sedation and local anesthesia. Compartment syndrome of the foot was managed with two dorsal longitudinal incisions over the second and fourth metatatarsals to release all interosseous compartments. All wounds were left open initially with saline soaked wet to dry dressings at the site of the fasciotomy. Delayed primary closure, grafting and/or negative pressure wound therapy assisted closure were then used on a case by case basis to eventually close the wounds. Antibiotics were given to all patients prophylactically and for 24 hours postoperatively.
Results:
All 34 patients tolerated the procedure well and had immediate and significant improvement in pain following the bedside fasciotomy. Thirty-three patients regained their normal muscle strength; 32 patients regained normal range of motion in related joints. Overall, there were no cases of deep infection, osteomyelitis or amputation. There were three cases of superficial wound infection, one patient who developed foot drop and one patient who developed flexion contracture of the great toe.
Conclusions:
According to this study, bedside fasciotomy under local anesthesia is a safe choice of treatment for acute compartment syndrome when a patient is not able to undergo immediate surgery in the operating theater. All of the patients who received this procedure achieved healing without any cases of deep infection. It is important to note that this study was performed by a skilled and experienced surgeon who was able to perform these bedside fasciotomies quickly and safely. It is also important to keep in mind the fact that there are limitations to bedside fasciotomies in the setting of an acute traumatic compartment syndrome: concomitant fracture fixations or debridement of nonviable muscles cannot be simultaneously performed. Therefore, while fasciotomy in the OR is the standard of care for acute compartment syndrome, bedside fasciotomy is a feasible and safe choice in patients with either delayed presentation or when significant delay to OR treatment is anticipated.