A Technique of Fasciotomy Wound Closure
Department of Orthopaedic Surgery,
Cork University Hospital
Open fasciotomy via full length skin incisions is mandatory in acute compartment syndrome to prevent permanent injury to the soft tissues. There is no skin loss at the time of the fasciotomy but difficulty in closure of the wound is common due to retraction of the skin edges away from the open wound. The common practice of covering the wound with a split-skin graft leaves a unsatisfactory appearance and often requires prolonged inpatient care.
We describe a technique that we recently developed for gradual closure of fasciotomy wounds which minimises the requirement for skin grafting.
The patient is returned to the operating theatre at least 48 hours after performing the fasciotomy. The wound is debrided and irrigated. The tip of a latex rubber catheter (10 French) is fixed to the skin at one end of the fasciotomy incision using skin staples. The catheter is then held about 5cm beyond the point of fixation and stretched until the rubber just blanches. The stretched catheter is then progressively fixed with staples to alternate skin edges of the fasciotomy at intervals of 2cm. The staples are placed so that the catheter can slide beneath each staple. The catheter is then anchored to the skin at the other end of the wound. The wound is usually not closed by this process but the skin edges are placed under a sustained approximating force by the stretched elastic catheter (Fig. 1). Great care is taken to avoid placing the wound edges under excessive tension by stretching the catheter beyond its elastic limit. The patient is returned to the operating theatre 7-10 days later and at this stage formal closure using 3/0 nylon interrupted sutures is usually possible (Fig. 2).
Techniques of gradual closure of fasciotomy wounds which rely on the elastic properties of skin and which reduce the need for skin grafting have been previously described but these usually involve repeated tightening of fixation devices. Almekinders (1991) described the placing of staples along the skin edges at the time of fasciotomy and passing interrupted large nylon suture through the staples like shoe eyelet’s. Postoperatively, these suture were tightened daily and delayed primary closure was possible after 5 to 10 days using simple sutures or steri-strips.
A similar technique of gradual closure of fasciotomy wounds using interrupted rubber vessel loops has also been described (Cohn et al, 1986; Harris, 1993). This technique involves running a silastic vessel loop through the skin staples placed at the skin edges along the initial fasciotomy incision. Daily tightening of the vessel loop permits gradual approximation of the skin edges
Recent techniques for closure of fasciotomy wounds which utilise the viscoelastic properties of the surrounding skin have emphasised the importance of excessive tension being applied at the points of fixation at the wound edges. The commercially available SureClosure device (Life Medical Sciences Inc, USA) (Narayanan et al, 1996) uses multiple intradermal needles. Callanan (1997) passed K wires subdermally along both sides of the fasciotomy before passing elastic bands to share the tension along the wound edges equally. We emphasise that the method we describe seeks not to close the wound but rather to apply constant low tension which prevents wound edge retraction. We propose that opposition of the wound edges occurs due to resolution of the oedematous process after compartment syndrome and subsequent reduction in the limb volume. Towards this effect, we suggest elevation of the limb and leaving a period of at least one week between application of the catheter to formal closure the method is important. To date, we have achieved full secondary wound closure with a cosmetically result on fasciotomy wounds in five legs and one forearm to date using this technique.
The technique we describe successfully opposes the edges of fasciotomy wounds without the need for periodic tightening of sutures and uses materials required are cheap, readily available and easy to use.
Almekinders LC. Gradual closure of fasciotomy wounds. Orthopaedic Rev 1991; 20:82.
Callanan I, Macey A. Closure of Fasciotomy Wounds: A technical modification. Journal of Hand Surgery (British and European Volume) 1997; 2: 264-265.
Cohn BT, Shall J, Berkowitz M. Forearm fasciotomy for acute compartment syndrome. A new technique for delayed primary closure. Orthopaedic. 1986; 10: 1234.
Harris I. Gradual closure of fasciotomy wounds using a vessel loop shoelace. Injury 1993; 24(8): 565-6
Narayanan K, Latenser BA, Jones LM, Stofman G. Simultaneous primary closure of four fasciotomy wounds in a single setting using the SureClosure device. Injury, 1996 Jul; 27(6): 449-51