Postoperative care of the forearm includes a bulky dressing and splinting. The dressing is changed in 3 to 4 days in the operating room. Split-thickness skin grafts are almost always required, but skin grafting and closure are postponed until all necrotic tissue has been debrided, edema has resolved sufficiently, and wounds are appropriate for skin grafting. Active and active-assisted range-of-motion exercises for the hand are started immediately after surgery. The bulky dressing is usually removed at 3 weeks, and volar splints are then used until full motion is restored.
Compartment syndromes of the forearm associated with fracture of the distal humerus, radius, or ulna are usually treated with open reduction and internal fixation. Treatment of an associated arterial injury must be individualized.
Decompression of the hand may be required after crushing injuries. Diagnosis is made on the increased pressure in the interosseous compartments. There are 10 compartments of the hand. Incisions are made on the radial side of the thumb metacarpal, dorsally over the index and ring metacarpals, and one over the ulnar aspect of the little finger to release the thenar muscles, four dorsal interossei, three volar interossei, hypothenar muscles, and adductor pollicis muscle. Decompression of the arm and shoulder uses longitudinal incisions over the involved muscles. With involvement of the deltoid muscle, where fascia and epimysium form one layer, multiple incisions in the fascia are necessary.
INCISIONS FOR LEG
Current treatment of compartment syndromes of the leg is decompression that avoids fibulectomy while providing adequate decompression to the four compartments of the lower leg (anterior, lateral, superficial posterior, and deep posterior). This can be accomplished through either a single-incision or two-incision technique. The single-incision technique is technically more challenging but provides the benefit of only having one skin incision requiring definitive closure/coverage.
The single-incision, or perifibular, approach is described through a single linear lateral incision just posterior to the fibula from the fibular head to the tip of the lateral malleolus. This exposure requires proximal identification and protection of the common peroneal nerve. The fasciotomy is made between the soleus and flexor hallucis longus distally and carried proximally to the soleus origin, allowing access to both posterior compartments. The anterior and lateral compartments are accessed by carefully retracting the anterior border of the incision (with care taken to avoid the superficial peroneal nerve), allowing the fasciotomies in the lateral and anterior compartments to be made.
When the two-incision technique is used, the two skin incisions can be shorter (approximately one-third the length of the leg) if intraoperative pressure monitoring is performed. Decompression of the anterior and lateral compartments is performed through an incision placed halfway between the shaft of the fibula and the tibial crest. The incision is made approximately over the intermuscular septum dividing the anterior and lateral compartments, allowing easy access to both. When a slightly shorter incision is used, it is extremely important to undermine the skin incisions proximally and distally to allow wide exposure of the fascia. A transverse incision is made just through the fascia to identify the anterior intermuscular septum that separates the anterior and lateral compartments. This is important because the superficial peroneal nerve that lies in the lateral compartment next to the septum must be located. Fasciotomy of the lateral compartment is made in line with the shaft of the fibula posterior to the anterior intermuscular septum.
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