Fasciotomy & Escharotomy

its about Introduction, indications and techniques of Fasciotomy & Escharotomy.

1. Fasciotomy & Escharotomy Introduction, Indication & Techniques

2. Dr. M . Zaid ur Rehman House Officer Allied Burn & Reconstructive Surgery Centre, Faisalabad

3. Compartment Syndrome It develops when the pressure within an osteofascial compartment of muscle causes ischemia and subsequent necrosis. Common areas for compartment syndrome include Lower leg, Forearm, foot, hand, gluteal region & thigh. The end results of unchecked compartment syndrome are catastrophic. They include neurologic deficit, muscle necrosis, ischemia contracture, infection, possible amputation.

4. Causes Bone fracture Crush injuries Burns Overly tight bandaging Vigorous exercise

5. Signs & Symptoms Increasing pain greater than expected and out of proportion to the stimulus. Palpable tenderness of the compartment Pain on passive stretch of the affected muscle Altered sensation Don’t look for absent distal pulses (Late finding)

6. Diagnosis Clinical diagnosis is based on the history of injury & physical signs. Intra-compartmental pressure measurements may be helpful in diagnosing this. Tissue pressures that are greater than 30-45 mmHg suggest decreased capillary blood flow. “ Delta-P ” method is used to calculate the tissue pressure. If Delta-P value is 30 mmHg or less, it indicates the patient may have a compartment syndrome .

7. Fasciotomy It is a surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle . Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome.

8. Principles Release all fascial compartments Preserve neurovascular structures Debride necrotic tissues

9. Indications Following are the indications for Fasciotomy : 1) Crush injuries 2) Athletes who have sustained one or more serious impact injuries 3) People with severe burns 4) Persons who are severely overweight

10. Commonly done Fasciotomies are : Leg Forearm Hand Thigh Foot Arm

11. Leg Fasciotomy

12. (Single Anterolateral Incision)

13. (Posteromedial Incision)

14. Forearm Fasciotomy A) Dorsal Incision B) S-Type Incision including Carpal Tunnel release

15. Thigh Fasciotomy

16. Hand Fasciotomy Two longitudinal incisions over 2nd and 4th metacarpals - Palmar /dorsal interossei Longitudinal incision radial side of 1st metacarpal - thenar compartment Longitudinal incision over ulnar side of 5th metacarpal - hypothenar compartment Carpal tunnel release

17. Foot Fasciotomy Medial Incision Dorsal Incisions

18. Escharotomy

19. Eschar : A thick, coagulated crust, slough which develops following a burn injury or chemical or physical cauterization of skin. In full thickness circumferential burns, coagulated collagen acts as a tourniquet in leading to vascular compromise of the affected body parts. Escharotomy : incision of eschar for decompressing the constrictive effects caused by deep circumferential burns.

20. Role of escharotomy in deep circumferential burns is crucial for relief of peripheral ischaemia or respiratory embarrassment. • Indications should be based on both careful clinical assessment and appropriate tissue pressure monitoring.

21. Indications Indications for emergency escharotomy are the presence of a circumferential eschar with one of the following : impending or established vascular compromise of the extremities or digits. impending or established respiratory compromise due to circumferential torso burns.

22. Contraindication Established irreversible gangrene of the extremity or digit.

23. Technique Clean the proposed surgical site with pyodine & drape with sterile drapes. Use electrocautery to create incisions in eschar upto the level of subcutaneous fat. Severely burned limbs may require performance of fasciotomy concomitantly with the escharotomy . After giving incision, an immediate release in tissue pressure is experienced as discernible popping sensation. Carry the incisions approx. 1 cm proximal and distal to the extent of the burn. Areas overlying joints have densely adherent skin and the incisions should extend across joints to allow for more decompression of neurovascular structures. Take care to avoid damage to the neurovascular bundles that run superficially and near joints.

24. Bleeding from incisions should be controlled by use of electrocautery The resulting wounds are potential source of infection and should be treated with the application of topical antimicrobial and dressing Adequacy of the escharotomy can be tested after completion by checking capillary filling pressures, using a handheld Doppler and by checking compartment pressures.

25. Complications Excessive blood loss Incision / injury to underlying healthy tissue Injury to neurovascular structures Infection Septic shock

26. Any questions?