After the four-compartment fasciotomy, intraoperative monitoring of compartmental pressure should be performed to document the decompression. Very little muscle should be debrided at the time of initial decompression, because it is difficult to determine an infarcted muscle from an ischemic but recoverable muscle.

Postoperative care of the leg wounds is similar to that of the forearm wounds, but in compartment syndrome without associated fractures, closure in a week is often possible without skin grafting. Necrotic muscle is debrided once or twice a week until a satisfactory granulation bed is present. Skin grafting or closure before this may lead to infection and the need for subsequent amputation. To prevent the insidious development of contractures, the ankle is splinted posteriorly in neutral position.

Compartment syndrome associated with fractures of the tibia should be treated with internal fixation, using either intramedullary rods or plates, but open fractures may require external fixation. A major disadvantage of the external fixation device is that mobilization of skin for delayed primary closure is not feasible and thus skin grafting is nearly always required.

Prophylactic decompression of the leg should be performed after tibial osteotomy or use of the tibia as the donor site of a bone graft. During debridement of an open fracture of the tibia, compartments accessible through the exposed wound should also be opened if the anatomy is not distorted by the fracture and the location of the superficial nerves is apparent. Arterial injury, thrombosis, and arterial bypass surgery also predispose to compartment syndromes. If the period of ischemia lasts longer than 6 hours, prophylactic decompression of the four compartments should be considered.

INCISIONS FOR THIGH, BUTTOCK, AND FOOT

Compartment syndrome of the thigh and gluteus muscles is not common but may progress to a crush syndrome because of the large bulk of muscle involved. Longitudinal incisions are made over the thigh to decompress the adductor, quadriceps, or hamstring muscles. Measurement of pressure is helpful in the diagnosis of compartment syndromes in these areas because sensory deficits are rare. Gluteus compartment syndromes, most often due to limb compression after drug overdose, involve three separate compartments: the gluteus maximus, gluteus medius/gluteus minimus, and tensor fasciae latae muscles. The choice of approaches may vary based on surgeon familiarity, but one should be chosen that will allow adequate access to all three compartments. The fascia superficial to the gluteus maximus muscle is relatively thin and blends with the epimysium, which sends septa into the muscle, forming multiple subdivisions. For adequate decompression, multiple incisions in this fascia-epimysium are required.

In the foot, the interosseous compartments are released via longitudinal incisions over the dorsum (medial to the second metatarsal and lateral to the fourth metatarsal), and the medial plantar structures are released using a separate medial incision or dissecting medially through the more medial dorsal incision. Again, measurement of intracompartmental pressure is helpful to ascertain the need for decompression.