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Forearm Compartment Release - Fasciotomy

Planning

B

Preoperative Plan

1

Execute surgical walkthrough

  • describe key steps of the procedure to the attending verbally prior to the start of the case
  • describe potential complications and the steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • curved mayo scissors

2

Room setup and equipment

  • standard OR table
  • hand table

3

Patient positioning

  • patient supine

Technique

D

Ulnar Volar Incision

1

Mark and make the incision

  • make a straight line incision over the first third of the ulnar aspect of the volar forearm
  • start the incision just proximal to the wrist crease and extend the incision to just distal to the ulnar aspect of the elbow flexion crease

2

Identify the volar compartment

  • carry the incision down through the fascia into the volar compartment
E

Deep Dissection

1

Open the fascia

  • open the fascia along the length of the compartment

2

Examine the soft tissues

  • examine the deep and the superficial muscles
F

Radial Incision

1

Mark and make the second volar incision

  • make a second incision starting with a middorsal straight line incision that begins 3 to 4 cm proximal to the wrist crease

2

Extend the incision

  • extend the incision down to the radial aspect of the flexion crease
G

Fascial Release

1

Release the compartments

  • release the mobile wad and dorsal compartment

2

Incise the fascia

  • incise the fascia for both compartments over the entire length of the incision
  • examine the muscles in both compartments
  • after release of the fascia, the muscles should bulge out of the incision
  • do not debride any muscle during this procedure
  • some muscles with questionable viability may recover after the fascial release
H

Wound Management

1

Pack the wounds

  • pack the wounds with moist dressing until the second look procedure
I

2nd Look Procedure

1

Debride necrotic tissue

  • aggressively debride any necrotic tissue with a no. 10 blade in a tangential manner until bleeding tissue is seen

2

Cover the wounds

  • place moist dressings over large wounds with exposed deep structures of neurovascular structures until coverage can be performed
  • if coverage is not needed, perform moist dressing changes for the next 7 to 14 days once the edema subsides, perform primary closure or skin grafting as needed

Patient Care

K

Preoperative H & P

1

Perform focused orthopedic exam

  • assess the forearm compartments
  • document distal neurovascular status

2

Order basic imaging studies

  • need biplanar radiographs of entire upper extremity

3

Perform operative consent

  • describe complications of surgery including
  • scarring
  • neurovascular injury
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • serial compartment checks x 24 hours
  • advance diet as tolerated
  • pain control
  • wound management
  • return to the OR in 48-96 hours for repeat compartment check and wound debridement
  • foley out when ambulating
  • check appropriate labs
  • antibiotics
  • prescribe DVT prophyhlaxis

2

Physical therapy

  • nonweightbearing

3

Appropriate medical management and medical consultation

4

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up in 2 weeks
  • wound care
M

Intermediate Evaluation and Management

1

Obtains focused history and performs focused exam

  • document distal neurovascular status
  • check for associated orthopedic injuries

2

Interpret basic imaging studies

  • biplanar radiographs of the forearm

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

4

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • staples/sutures removed
  • start range of motion exercises
  • diagnose and management of early complications
  • postop: ~ 3 month postoperative visit
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Prioritizes the needs of the polytrauma patient

  • works with consulting

2

Complex wound management and debridement

  • understanding need for consultation for flap coverage

3

Capable of treating complications both intraoperatively and post-operatively

  • manages post operative infection
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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