Compartment syndrome is a serious complication that might occur following fractures. Untreated, it would cause serious damage to the nervous and muscular structures of the involved compartment(s), which might lead to serious and permanent functional deficit of the involved limb. The treatment of choice is emergent fasciotomy of all the involved muscle compartments to lower the compartment pressure [
Between June 2006 and May 2010, 17 patients with fracture-related compartment syndrome were managed by fasciotomy in the Orthopaedic Casualty Unit of our university hospital (Table
Patients' data.
Patient number | Sex | Age (years) | Fracture | Delay before fasciotomy (hours) | Number of fasciotomy wounds | Method of final closure | Number of tightening sessions | Further debridement after shoelace | Duration till complete wound healing (weeks) | Initial method of fixation | Definitive method of fixation | Duration to fracture healing (weeks) | Additional procedures | Followup (months) |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | M | 19 | BB | 20 | 1 | 1ry | 3 | No | 3 | Ex Fix | IMN | 14 | 12 | |
2 | M | 21 | BB | 16 | 1 | 1ry | 3 | No | 3 | IMN | IMN | 16 | Dynamization | 18 |
3 | M | 27 | Fem | 31 | 1 | 2ry | 5 | 1 | 4 | IMN | IMN | 14 | Removal | 18 |
4 | F | 17 | BB | 19 | 1 | 1ry | 4 | No | 3 | Ex Fix | MIPO | 16 | 16 | |
5 | M | 17 | BB | 24 | 1 | 1ry | 4 | No | 3 | Ex Fix | IMN | 14 | Bone graft | 24 |
6 | M | 23 | BB | 22 | 2 | 1ry | 5 | No | 4 | Ex Fix | MIPO | 16 | 16 | |
7 | M | 30 | Fem | 30 | 1 | 2ry | 5 | 1 | 4 | IMN | IMN | 14 | Bone graft | 12 |
8 | M | 29 | BB | 12 | 2 | 1ry | 3 | No | 3 | Ex Fix | IMN | 16 | 18 | |
9 | M | 31 | BB | 14 | 1 | 1ry | 4 | No | 4 | Ex Fix | IMN | 14 | 20 | |
10 | M | 27 | BB | 12 | 2 | 1ry | 3 | No | 3 | Ex Fix | IMN | 12 | 12 | |
11 | F | 18 | BB | 15 | 2 | 1ry | 5 | No | 4 | Ex Fix | MIPO | 14 | Bone graft | 22 |
12 | M | 26 | Fem | 34 | 2 | 2ry | 7 | 2 | 6 | IMN | IMN | 22 | Removal | 24 |
13 | F | 35 | BB | 29 | 1 | 2ry | 5 | 1 | 5 | Ex Fix | IMN | 16 | 16 | |
14 | M | 21 | Fem | 21 | 1 | 1ry | 4 | No | 4 | IMN | MIPO | 16 | 18 | |
15 | M | 20 | BB | 33 | 2 | 2ry | 5 | 1 | 5 | IMN | IMN | 18 | Dynamization | 20 |
16 | F | 16 | BB | 15 | 1 | 1ry | 4 | No | 4 | Ex Fix | IMN | 16 | Bone graft | 12 |
17 | M | 19 | BB | 12 | 1 | 1ry | 3 | No | 3 | Ex Fix | IMN | 14 | 12 | |
| ||||||||||||||
Average | 23.3 | 21.1 | 4.2 | 3.8 | 15.4 | 17.1 |
F: female, M: male, Fem: femur, BB: both bones of the leg, 1ry: primary, 2ry: secondary, Ex Fix: external fixator, IMN: intramedullary nail, MIPO: minimally invasive plate osteosynthesis.
26-year-old male. Car accident. Fracture midshaft femur.
Preoperative X ray
Final follow up X ray
Immediately after fasciotomy
After application of shoelace apparatus
After 2 more tightening sessions
After Complete healing of skin
19-year-old male. Fracture tibia and fibula. After fasciotomy and fixation by external fixator.
Daily dressing was applied for the fasciotomy wound and the wound was reinspected after 48 hours. This delay was deemed necessary to identify any damage to the muscles and deep structures that might compromise the cleanliness of the wound and prevent its closure. In three cases, the fasciotomy wound had to be debrided in the operative theatre 2 to 3 times before it was judged clean enough to begin wound closure.
A paediatric urinary catheter was anchored to the skin edge beginning from one corner of the wound using skin staples. Then the catheter was passed from one edge of the wound to the other in an alternating fashion, each time being fixed to the skin using skin staples applied perpendicular to the wound edge. In five rather large wounds, two catheters were used starting from the two corners of the wound to meet at the centre of the wound. After the catheter(s) had been passed allover the wound, tightening was performed beginning at the end of the wound and proceeding towards the other end. In case of the five wounds where two catheters were used, tightening began from both ends of the wound and proceeded centrally. Tightening was done by pulling on the catheter and passing the slack through the staples one at a time until the maximal approximation of the edges without undue skin tension was obtained. Then the catheter was knotted on itself in small wounds, or tied to the other catheter over the centre of the wound in large wounds. A wet dressing was applied and the wound was left for two days to allow the skin to accommodate the approximation that has been obtained. Retightening was done in the operative theatre with only a sedative every two to three days.
The patients were discharged from the hospital after wound closure was obtained. They came back for follow upat 1, 3, and 6 months postoperatively. Afterwards they came for clinical and radiological followup every 6 months. The average followup was 17.1 months (range 12 to 24).
All fasciotomy wounds healed eventually. Wound closure occurred from the corners inward. The skin closure was obtained at an overall average of 4.2 tightening sessions (range 3–7). In twelve cases, as the skin at the corners was approximated, it became possible to place sutures or staples across the wound thus allowing delayed primary closure after an average of 3.8 tightening sessions (3–5). While in 5 cases, the wounds were allowed to close by granulation tissue. All fractures initially fixed by intramedullary nail (IMN) were managed definitively by the same implant. As regards, the 11 fractures was treated initially by an external fixator, 7 fractures were eventually fixed by IMN, while 4 were fixed by minimally invasive plate osteosynthesis (MIPO).
Fracture healing occurred at an average of 15.4 weeks (range 12 to 22 weeks). In 8 cases, additional procedures were performed during the follow-up period, either to assist healing (2 dynamizations and 4 bone grafts) or to remove the implant after healing because of deep infection (2 cases).
No major complications (e.g., vascular compromise, amputations) were encountered in this series. In five cases, persistent wound discharge indicated the presence of previously undetected deep soft tissue necrosis. The patient was taken to the operating theater for removal of the shoelace apparatus and further debridement of necrotic tissue (once in 4 cases, and twice in 1 case). When the local wound conditions improved, the shoelace apparatus was reapplied in the OR under general anaesthesia, and tightening sessions were carried out again as explained before. These wounds were allowed to heal by secondary intention.
Dermatotraction utilizes the skin’s characteristics of stress relaxation (creep). The results of dermatotraction have been shown to be superior to split thickness skin graft as it has better cosmetic appearance, provides sensate skin, and avoids donor site morbidity.
In our series, all fasciotomy wounds closed at an overall average of 4.2 tightening sessions. The shoelace apparatus used for closure consisted of one or two paediatric urinary catheter, plus surgical skin staples, which in our setting cost US $ 10–12. The material is readily available in any standard operating theatre, making this procedure useful for countries with limited resources. This supports our hypothesis that closure of fasciotomy wounds by dermatotraction could be performed in a staged fashion, using inexpensive equipment readily available in any standard operating room, until skin was approximated enough to heal either through delayed primary closure or secondary healing.
Numerous devices have been utilized to obtain skin closure by dermatotraction (Table
Comparison between different wound closure devices.
Authors | Devices | Advantages | Disadvantages |
---|---|---|---|
Barnea et al. [ |
Wisebands device | (i) Tension feedback control mechanism to safeguard against excessive skin tensioning | (i) Not readily available |
(ii) Expensive | |||
Hirshowitz et al. [ |
Sure Closure device | (i) Can measure the tension across | (i) Not readily available |
the wound edges | (ii) Expensive | ||
Janzing and Broos [ |
Marburger skin approximation system | (i) Not readily available | |
(ii) Expensive | |||
Taylor et al. [ |
Skin anchors | (i) Anchors placed 1 cm away from the wound edge to prevent circulatory compromise at the skin edge | (i) Not readily available |
(ii) Evenly distributed force over the full length of the wound | (ii) Expensive | ||
Govaert and van Helden [ |
Ty-Raps | (i) Not readily available | |
This study | Paediatric urinary catheters + skin staples | (i) Readily available | (i) Point loading on the staples may lead to their failure |
(ii) Inexpensive | (ii) No safe mechanism against excess tension |
However, the use is limited by availability and expense. This is especially important in a developing country with limited resources of the healthcare system.
Marek et al. [
An important limitation of this technique is the absence of a built-in monitoring system or other safety mechanism to monitor compartment pressure or skin tension. This is left to rely totally on the surgeon’s experience and judgment. This is why the technique should be performed only under the close direct supervision of an experienced surgeon.
Closure of fasciotomy wounds by dermatotraction could be performed in a staged fashion, using inexpensive equipment readily available in any standard operating room, until skin was approximated enough to heal either through delayed primary closure or secondary healing.
The authors declare that there is no conflict of interests.