Michael S. Bednar

1. Increased forearm compartment pressure, either:

a. Greater than 30 mm Hg or

b. Greater than 20 mm Hg below diastolic blood pressure

2. Limb ischemia for greater than 6 h

3. Following open reduction and internal fixation of radius and ulna fractures in severe crush injury

4. Electrocution injury

None

Document status of preoperative neurovascular examination.

1. The patient is positioned supine on the operating table. The arm is positioned on an arm board.

2. An upper arm tourniquet is applied with cast padding.

3. The procedure may be done with general or regional anesthesia (not a Bier block).

4. Routine small-joint orthopaedic surgical instruments are required.

1. Attempt to release the forearm compartments within 6 h from when increased compartment pressures begin.

2. The structures that need to be released are the lacertus fibrosis, the mobile wad (fascia of the brachio-radialis, extensor carpi radialis longus, and extensor carpi radialis brevis), the palmar fascia, and the transverse carpal ligament. Therefore the skin incision must extend from the elbow to mid palm.

3. The median nerve exits from the muscle of the flexor digitorum superficialis in the distal 6 to 8 cm of the forearm. The skin incision should be ulnar at this distal location to provide soft tissue coverage for the nerve.

4. The epimysium of the individual muscles should be released in addition to the forearm fascia.

1. Avoid leaving the median nerve exposed at the end of the procedure.

2. Avoid injury of the cutaneous nerves during the approach.

3. Avoid closing the skin. If possible, the skin should be left open or partially closed with rubber bands or vessel loops and staples.

1. The extremity should be elevated so that it is above the level of the heart.

2. Active and passive range of motion of the fingers is encouraged as soon as the patient is comfortable.

3. Plan to return the patient to the operating room 48 to 72 h after the initial operation for a “second look” procedure. Consider possible debridement and skin closure (delayed primary or split-thickness skin graft).