Forearm Fasciotomy

Forearm Fasciotomy & Arterial Exploration are necessary in case of acute compartment syndrome of the forearm.

Compartment syndrome is a condition in which increased tissue pressure within a limited space compromises the circulation and function of the contents of that space.

See Also: Forearm Muscles Anatomy & Function

Forearm Fasciotomy Procedure

• The Forearm Fasciotomy procedure involves performing a volar fasciotomy by following a curved incision technique similar to McConnell’s method for exposing the median and ulnar nerve neurovascular bundles. The approach, described by Henry, begins with an anterior curvilinear incision located on the inner side of the biceps tendon. The incision should cross the elbow flexion crease at an angle. To allow for carpal tunnel release, extend the incision downwards into the palm, but avoid crossing the wrist flexion crease perpendicularly.
• Start by dividing the lacertus fibrosu​s proximally and removing any hematoma present. In cases where a brachial artery injury is suspected, expose the artery and assess the blood flow. If the flow is inadequate, remove the adventitia to expose any underlying clot, spasm, or intimal tear. Resection of the adventitia and subsequent artery anastomosis or grafting may be necessary.
• Next, release the superficial volar compartment by using open scissors to free the fascia covering the muscles in the compartment. Locate the flexor carpi ulnaris and retract it, along with the underlying ulnar neurovascular bundle, medially. Also, retract the flexor digitorum superficialis and median nerve laterally to expose the flexor digitorum profundus in its deep compartment. Check the tightness of the overlying fascia or epimysium of the flexor digitorum profundus and make a longitudinal incision if necessary.
• If the muscle appears gray or dusky, the prognosis for recovery may be poor. Nevertheless, the muscle should still be allowed to perfuse as it might still be viable. Continue the dissection distally by incising the transverse carpal ligament along the ulnar border of the palmaris longus tendon and median nerve.
• In cases of median nerve palsy or paresthesias, thoroughly inspect the entire injury zone to ensure that the median nerve is not severed, contused, or trapped between the ulnar and humeral head of the pronator teres. If such entrapment is detected, perform a partial pronator tenotomy. For patients with a supracondylar fracture, reduce and stabilize the fracture using Kirschner wires, and control any bleeding.
• At this stage of forearm fasciotomy, avoid closing the skin. Plan for secondary closure at a later time. If the median nerve is exposed within the distal forearm, loosely suture the distal radial-based forearm flap over the nerve. Clinically evaluate the dorsal compartments or repeat pressure measurements. In most cases, the volar fasciotomy alone is sufficient to decompress the dorsal musculature. However, if involvement of the dorsal compartments is still suspected, release them as well.
• To complete the forearm fasciotomy, make an incision distal to the lateral epicondyle, between the extensor digitorum communis and extensor carpi radialis brevis. The incision should extend approximately 10 cm distally. Carefully undermine the subcutaneous tissue and release the fascia covering the mobile wad of Henry and the extensor retinaculum.
• Finally, apply a sterile moist dressing and a long-arm splint, ensuring that the elbow is not left flexed beyond 90 degrees.

Aftercare

• After the Forearm Fasciotomy Procedure is done, the arm is elevated for 24 to 48 hours after surgery. 
• If closure is not possible within 5 days, a split-thickness skin graft should be applied. 
• Alternatively, closure of fasciotomy wounds can be accomplished gradually with progressive tension using vessel loops. 
• The vessel loops are tightened progressively postoperatively during dressing changes. 
• Wound closure by this method usually can be accomplished in 2 weeks. 
• A vacuum-assisted wound closure system may be used to assist in wound management. 
• The splint is worn until sutures are removed or as determined by fracture care.

References & More

1. Campbel’s Operative Orthopaedics 12th edition Book.
2. Chandraprakasam T, Kumar RA. Acute compartment syndrome of forearm and hand. Indian J Plast Surg. 2011 May;44(2):212-8. doi: 10.4103/0970-0358.85342. PMID: 22022031; PMCID: PMC3193633. Pubmed
3. Jimenez A, Marappa-Ganeshan R. Forearm Compartment Syndrome. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556130/