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Leg Compartment Release - Two Incision Approach

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

3

Patient positioning

  • patient supine

Technique

D

Superificial Anterolateral Incision

1

Mark the incision halfway between the fibula and the crest of the tibia

  • make the incision directly over the anterolateral intermuscular septum
  • extend the incision 15 to 20 cm distally

2

Identify the superficial peroneal nerve

  • the nerve is 10 to 12 cm proximal to the tip of the lateral malleolus
E

Anterior Compartment Release through Anterolateral Incision

1

Incise the anterior fascia

  • localize the intermuscular septum at the proximal end of the wound
  • make a short transverse incision anterior to the intermuscular septum
  • the transverse incision should be long enough to fit the tip of curved mayo scissors for the fasciotomy

2

Perform the fasciotomy

  • run the scissors cephalad and caudally

3

Assess the musculature of the anterior compartment

  • evaluate the color, consistency, contractility and capillary refill
F

Lateral Compartment Release through Anterolateral Incision

1

Incise the lateral fascia

  • localize the intermuscular septum at the proximal end of the wound
  • make a short transverse incision posterior to the intermuscular septum
  • the incision should be long enough to fit the tip of curved mayo scissors for the fasciotomy

2

Perform the fasciotomy

  • run the scissors cephalad and caudally

3

Assess the musculature of the lateral compartment

  • evaluate the color, consistency, contractility and capillary refill
G

Superficial and Deep Compartment Release

1

Mark the incision 2 cm medial to the posterior border of the tibia

  • make an anteriormedial incision 2 cm medial to the posterior medial border of the tibia
  • make incision 15-20 cm distally
  • retract the saphenous vein and nerve anteriorly
  • perform fasciotomy
  • incise the fascia directly under the incision for a short distance
  • place the tip of the curved mayo scissors into the incision
  • direct the mayo scissors cephalad and caudally
  • this decompresses the superficial posterior compartment

2

Assess the musculature of the superficial posterior compartment

3

Release the deep posterior compartment

  • release the fascia distally and run mayo scissors proximally through and under the soleus bridge
  • release the the soleus attachment to the tibia more than half way
  • release the fascia over the posterior tibia muscle

4

Assess the musculature of the deep compartment

H

Superficial Compartment Release through the Anteromedial Incision

1

perform fasciotomy

2

incise the fascia directly under the incision for a short distance

  • place the tip of the curved mayo scissors into the incision
  • direct the mayo scissors cephalad and caudally
  • this decompresses the superficial posterior compartment

3

Assess the musculature of the superficial compartment

I

Deep Compartment Release through Anteromedial Incision

1

Release the deep posterior compartment

  • release the fascia distally and run mayo scissors proximally
  • continue release through and under the soleus bridge
  • release the the soleus attachment to the tibia more than half way

2

Assess the musculature of the deep compartment

J

Wound Closure

1

Place negative pressure dressings

2

Place in splint with the ankle in neutral

  • this prevents equinus contracture

3

Return to OR in 48-96 hours for additional wound debridement

4

Return to OR in 5-7 days for primary wound closure

Patient Care

K

Preoperative H & P

1

Perform focused orthopedic exam

  • assess lower extremity compartments
  • document distal neurovascular status

2

Order basic imaging studies

  • need biplanar radiographs of entire tibia/fibula, knee, and ankle

3

Perform operative consent

  • describe complications of surgery including
  • scarring
  • injury to the superficial peroneal nerve
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

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam

  • assess lower extremity compartments
  • document distal neurovascular status
  • check for associated orthopedic injuries

2

Interpret basic imaging studies

  • biplanar radiographs of the leg

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

  • timing of long bone fixation
  • 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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