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I'm trying to give some perspective of compartment syndrome for a doctor dealing with significant injuries of a ballistic or crush nature. And so I want to set the scene and I've lifted some of this from the literature and most of these phrases aren't my own. Uh I can't take credit, but I think this is really important and this is how I see compartment syndrome and fasciotomy is do no more harm to the alive patient. What do I mean by that? You want to be able to not cause somebody that's already physiologically embarrassed, already shocked, already got a lot to deal with. You don't want to cause someone more harm. How can you cause them harm? Either by not performing an intervention such as a fasciotomy or forming an intervention such as a fasciotomy badly. So I think this is a principle I have the main principal is first do no more harm to the alive patient because you've got enough work to do already. And essentially anybody dealing with these injuries. It's a constellation of injuries and care. These injuries seldom come in isolations. A mangled limb is seldom attached to a perfectly otherwise unharmed patient. And it's keeping that perspective, which I think is really important. And anybody that's done significant trauma or done any military work knows that most of the work in the first couple of weeks can be described like this. We need to stop bleeding, castroville hemorrhage and we need to revascularize limbs that have not got vascular supply. We need to prevent that horrible triads contributed to by hypothermia. We need to control contamination to prevent further harm. And this is what I'm thinking about, particularly when we go on to talk about foot, fasciotomy is perhaps we don't want to give the bacteria anymore ingress to a body that's already troubled. And the reason I've put an asterix against the prevent further disability is because this is where the compartment syndrome and the fasciotomy question really lies. So I want to put the perspective of the limb intervention for compartment syndrome and fasciotomy amongst the badly injured patient, there's a lot of work to do and we need to see where it fits. So fasciotomy and compartment syndrome sit with preventing further disability. It can cross over into mortality, of course, but that's where it sits. So it's all part of a bigger injury pattern. And I often find with these big cases that sometimes it's just too busy, there's too many compartments, there's too many parts of the body that are injured. And often if you just break it down to these principles, it's easier to work out what you're doing. So compartment syndrome just keep us on the same page. You know, we know there's many definitions but it is essentially an elevation of the interstitial pressure in a closed. Now, for most ballistic and crush injuries, it may not be closed, osteo fascial compartment, the results in micro vascular compromise. Now, whichever way you like to define it, that is essentially what compartment syndrome is and it's soft tissue swelling secondary to trauma and it's a mismatch of the arterial inflow and the ability of the end microvascular bed to function because blood might be coming in. But if it isn't being distributed properly and it can't get out, you're going to have compartment syndrome. Injuries from conflict are susceptible to compartment syndrome. And the reasons are multifactorial ballistic injured limbs are more likely to get compartment syndrome, the non ballistically injured limbs in the generality. So if you have someone obviously that's got ballistic injury, push injury, you should be thinking obviously about compartment syndrome when you think about compartment syndrome and fasciotomy and whether to do it in this patient group. Much of the literature that we talk about in the civilian world, much of the work that's been done is about diagnostics and it's about pressure thresholds and it's about sticking a needle with a monitor into somebody that's very diagnostic for the severely injured patient, the mangled limb, the threatened limb, the blown up body. I put it to you and I think the best way to look at it is it's not so much about diagnostics. It's more about prophylaxis and the balance between diagnosis and prophylaxis in the military or conflict injured is probably closer than it is in civilian patient's in civilian patient's. We sometimes think a bit more about diagnosing either that be the clinical or pressure. But in the military or the conflict injured compartment syndrome management is much more anticipatory, much more prophylactic and less diagnostic. So I'm not going to talk about pressure monitoring. I'm not going to talk about the in's and outs of that because it's a different type of patient group really. So that's because the luxury of the controlled environment is the ward in a stable country is just not there in the conflict management patient. You can't do serial examinations by the same person and the cosy ward, it just doesn't work like that. And the prophylaxis outweighs the reaction essentially. So getting on and doing something is more more what we're talking about than trying to diagnose and or prevaricate. That's the type of patient group that we're talking about. We're not talking about how to diagnose and whether we should or not. And it's anticipation. It's understanding that crush injuries, significant ballistic trauma have such a high likelihood compartment syndrome that we should be anticipating that the patient is going to have a problem. And often there are so many distracting injuries, there are obtunded patient's that the diagnosis clinically is difficult. And like I say, think less of pressures and think more about the wider physiology. Someone is incredibly shocked that pressure differential may not work, you may not be having a BP to work against. So I hope you're seeing that this whole concept of pressure measurement is not for this type of patient group. This is more about just getting on and doing it and thinking about it, anticipating it. Why? Because we've got crush injury, we know that crush injury can cause us to have a compartment syndrome. And if you have a ballistic injury and you happen to be in a building and you might get shot and you might get burnt, you might have that as the whole patient presentation and that's the difference. Too much compartment syndrome management in civilian patient's because that multiple insult of the burn, the shooting crushing just isn't seen in most civilian environments. So what I'm saying is you have many reasons to have compartment syndrome and they're very much additive. So, crush injury, reperfusion of either a crush injury or in the scheme at lim into compartmentalize bleeding, massive bleeding, particularly in the thigh and then there's rhabdomyolysis depending on the timing. So there's lots of reasons why. And therefore, I prefer to think more about prophylaxis than actually diagnosis. So this is a really important concept and everyone's got a view on this. And I just think I like to keep it really, really straightforward. Now, this isn't the textbook answer. This isn't a medical, legal type environment, but this is just sensible advice. So if you're going to do a fasciotomy, one of the questions always is, am I doing it too early? Uh risking doing it for a reason? I don't need to do one. What if I do it too late? Am I going to intervene and cause a problem? So it's, this isn't, as I say, this is just the way that I like to think about it that would help people in the generality. The first thing to remember is that timelines are not always as advertised when you're having people moving around I/O of conditions of threat, I/O of areas where there is ballistic activity, sometimes you may be told that it's X hours old and often it isn't. So you can't always fix that. That's the first thing to remember. Whilst the timeline doesn't have advertised always is in what I mean by that is, it's not always what you think it might be. The compartment, however, does have defined timelines. So the compartment will have trouble over certain timelines. So the clock is ticking from the moment of injury. So what is that clock? So if you're anticipating a limb that's being re perfused or has significant catastrophic injury to the soft tissue envelope and the underlying bone up to eight hours fasciotomy should be performed. In my opinion that keeps it very easy. So 8 24 hours, because there are so many different physiological variables and you may not have the full picture. You can do it up to 24 hours. We'd obviously prefer to do it earlier. But the way that I see it is that after 24 hours, the risk benefit is lesser. So trying to keep that patient alive and trying to keep that patient from further harm as the clock goes on, that's how I do that. Now, that is open for debate. But I think that that's a ballpark which one can work from relatively safely. So when does treatment become threat, that's how I look at it. So now this is the other thing, right? So what about the foot? So we all look at the lower leg and everyone's got pretty unified feelings. I'd imagine. I would like to think about how well to manage the fasciotomy in the lower leg where to place your incisions that's well advertised by certainly by the B O A and B operas. And I think that's probably, um that's probably well looked after. Now. What about the foot? And it's a cause of debate. So I, I remind you of this. So what you need to do is save the patient's life and not do any harm or not, do more harm. So we need to stop bleeding, revascularized. We need to prevent hypothermia. We need to control contamination, not give the body any more chances of assault by microbiology and we need to prevent further disability. That's what we're trying to do. So when you come to the foot, for me, in the multiple e injured patient, the foot becomes less important compared to the other parts of this and doing a fasciotomy around the foot if it's not done well, can cause considerable harm. So the there are lots of people who advise that you should always do foot fasciotomy is, there are lots of people who say they don't believe in foot fasciotomy, knees. I just simply put it in perspective of what I'm trying to do to save the patient's life and prevent further harm because the foot fasciotomy is not a benign element. So I would far rather personally have a foot with one compartment, perhaps that became ischemic, but have a limb otherwise. And a patient that's well perfused and is alive. Now that's, that's open for debate, but I'm not a big fan of the foot fasciotomy. It can be done and some people do do it, but I put it in perspective of everything else. That's the way that I look at it. If you want to do it. There's very easy textbook way of doing it. There is much debate as to how efficiently you can control access to all of these compartments and whether it makes a difference. So for me, I just step back to those principles of what I'm trying to achieve. And I would rather an intact patient that's alive without another assault to their body. So, one of the things I looked at to help you and to give some of this some perspective and some really interesting stuff that isn't just theory and my thoughts. Um so there's work being done on complications and this is really, really nice because this is just about compartment syndrome, fasciotomy, right? So this is the whole military trauma population. These are people that have been operated on in theater conflict, Afghanistan and Iraq coming back through land still in Germany. And work has been done on looking at compartment syndrome, looking at fasciotomy is and trying to identify key areas that made a difference or where things went wrong. And I think this is really, really important. I'd like to share with you. So most of the fasciotomy is that were revised were to the lower leg or I think that's because there were more injuries to the lower leg. So fascial incisions were extended in 63% of patient's skin incisions were extended in 14%. So what that means is people are making adequate holes in the skin, they're not making adequate holes in the Fashir underneath. And that's really important. So the one of the biggest cause of problems was if you see in the in the majority of patient's that the fascia wasn't incised. So big, generous incisions in the skin, big, generous incisions in the fashion. So the learning points from this is that people aren't making big enough fashion decisions. So that's one thing we can take away. And then the other second thing particularly thinking about the lower leg of the the bulk of unopened compartments. These are compartments have had a fasciotomy. There's been a skin incision in, placed over a compartment, but the compartment was not opened was not fasciotomy sized. The vast majority were in the anterior compartment. And that's because of where people place in swollen legs, people tend to go more lateral than an trilateral. It's just because of the way a swollen leg works. So again, if we're ever in a leg and we're thinking goodness me, these compartments are all over the place. I don't know quite where I am. I go after the intervening fascia with a little h and I really work, I search for that and it normally is more anterior. It's never normally posterior on the lateral incision. So if we're thinking that if we're going to go wrong, it's most likely anterior. We should be thinking about placing our incision a bit more anterior. It doesn't have to be crazy, just more anterior and we need to go after the anterior compartment. That's really, really important. I think this piece of work is really valuable because this is in that population. This isn't over all. This isn't pressure monitoring in football players that have broken the tibia. This is unique to this population. So the learning point is fascial incisions, not long enough, anterior compartment not opened. So if we can do that better, we will make a difference. So the conclusion was fasciotomy revision was associated with a four fold increase in mortality. That's probably because they weren't done properly in people that were badly injured. So there is a point here that although compartment syndrome is a very basic of orthopedics, talk to our most junior of doctors, there is impact in the conflict wounded. So that's why it's so important. That's why I've really taken time to go into this paper. The most common revision procedures were extension of fascial incisions and opening new compartments. The most commonly unopen compartment was the anterior compartment. The lower leg patient's who were underwent delayed fasciotomies clearly are going to have more end organ threat. So I think that we've covered the background. I think I've identified that this patient population are different. And so the literature needs to be thought about differently. For me, pressure monitoring in the majority of these patient's is not my main focus. The balance of prophylaxis versus diagnosis is much more on prophylaxis. It's on anticipation and Axion versus serial examination and wondering particularly about if these patient's are being evacuated. We want to do these things and if you keep this as your primary principals, you can't really go wrong. So I'm Colonel Alan Kay, I'm still serving in the British military. I do have to give this disclosure. These are my own reflections and shouldn't be construed as official UK defense medical Services policy. Now, with the forearm in the hand, this is much more tolerant of swelling compared to the lower lake that the fascial envelope is softer. The actual fascia is thinner. If you feel there is a need to release the compartment in the forearm as a minimum, you should always release the superficial and the deep flexor compartments. And the guide separating those two is the median nerve. When it comes to the dorsal forearm, I have very, very rarely ever had to release the extensor aspect of the forearm. And if you do feel you have to, what you have to remember is each extensive muscle is in its own compartment. So you do have to release every single muscle separately. So here we're looking at a cross section of the probably junction between upper third, lower two thirds of the forearm and we've got the radius on this side and the ulnar over here, we'll just focus on the volar aspect and on the flex of compartment here. So we've got the deep long flexes here says FDP the deep long thumb, flexor F P L, they're superficial long flexes. This is F C U F C are prorated quadratus. This is the fascial lining and there is the median nerve. You can basically as I'll show you in a second, do your skin incision pretty much anywhere along here. So what I suggest you do is having released superficially if you go much more distantly down by the wrist, where all of this muscle is tendon. If you find the median nerve, then progress back approximately and then where it starts to become more muscly. If you stick with the median nerve, it will be in the fascia which separates the superficial part from the deep part. So the median nerve guides you to the difference between the two. Now here are lines of election for forearm fasciotomy. He's none of those are wrong. What I would say is use the wounds as a guide come down to one wound, go across to the other wound and then go down from there. This is a fairly devastating ballistic injury. The primary operating surgeon had extended the wound to release the back of the hand. They didn't think it needed a Volga fasciotomy because the compartment was already fully released, but they had done a carpal tunnel release. But if we look on the volar aspect, massive swelling, they're very, very tense. That was their carpal tunnel release and it doesn't show particularly well, but there was virtually no perfusion of these fingers. Now, this had come through another facility and this has been several hours since this was done and what I decided to do a full release on the volar aspect and because there was a potential for a few hours of vascular compromise I wanted to also release the dina and hype athena muscles and back of the hand. And this is what it looked like at the end of that. So I'd fully opened up the volar aspect. We had got down to the deep compartment and I had extended up here to make sure the hand was fully released. And then on the doors last, except I did a separate incision there to fully release all of the intro CEO. That's about as extreme as that you can get in terms of a forearm and hand release. It's rare to have to be that extreme. Well, hand fasciotomy needs to do of most important is to release the interosseous muscles in the hand itself and occasionally release hyposthenia and thena now the way to release the interest, see I is to go dorsally and you do two incisions, one over the second ray, one over the fourth ray, you just retract the tendons one way or the other, put your scissors down, so it hits the bone and then just slip off the bone slightly and make an incision in the fascia that's overline the muscle and then take the tendons the other way, hit bone, slip to the side and you release it on each side and then you do the same to get yourself to the 3rd and 4th spaces through that incision. There, here is another ballistic injury to a forearm and this is what I think represents what needs to be done and is more often done in terms of the extent, this is very swollen and tense and needs to be released. And as part of the deprive mint that, that is what was done. And here it is at the end. So a much more considered approach to it, there was no swelling in the hand itself. And once we've gone from predominantly muscle belly to predominantly tendon, I don't think you need to fully released down into the carpal tunnel. All the swelling is in the muscle up here. That's what needs to be released. So when it comes to forearm fasciotomy is this is the picture I'd like you to keep in your mind a full release of the muscle bulk which has included going into the deep compartment, which you find by tracing the median nerve from more distantly. If the hand is involved, particularly it's been crushed, then you can consider doing a couple tunnel release. But I don't think that needs to be done routinely as part of the forearm fasciotomy. Well, come on to the lower leg. Now, the lower lake has four compartments, all of which must be fully released even if they've been involved in the injury. And as well mentioned, it's been my anecdotal experience having to deal with the complications of poor fasciotomy knees, that it is the anterior compartment that is the one most frequently missed. And also if you do lose your anterior compartment, that is a very significant disability. You've essentially got a permanent foot drop. One of the indications for doing a lower leg fasciotomy is because there has been a more proximal vascular insult. But in the process of addressing that vascular insult, there is a risk that you will get subsequent swelling. So you need to prophylactically release the compartment. And this is even if there has been no injury itself to the lower leg. But then there's also the case where you are doing it because there has been an injury to the lower leg itself. So the tissue there because of the direct injury rather than secondary vascular injury is going to swell. If there has been an injury itself to the lower leg, there is a potential need for a complex reconstruction. Please use the release recommended by the reconstructive surgeons. Here is just an example where you might not think there is a potential need. This was a ballistic injury. It had been debrided. We can see part of the previous surgery, the wounded healed up nicely but did have a scab on it when the scab was picked off, a bit of clear fluid came out from it. Now, when this was explored, this was found to be a bit of dead bone which had been left in there at the original debridement were now left with a hole here. The tissue is quite injury rated around. There is no chance at all of getting a direct closure bone underneath is exposed. So this is potentially a really difficult problem. Some of the nice little flaps we can do because of this scar here, really rather difficult. One of the options would be a lateral fatty oh cutaneous flat. But if we look laterally, that's, that's a very rough plan of where you might make a fashion detainees flap on the lateral side. But they're fascial release because it's been done quite laterally has gone right through the middle of where you'd want that flat to be. So that reconstructive option has been removed and this is going to highlight switch compartments. A missed. This is a closed sporting injury that has had an intimate gallery nail put in. They did fasciotomy because they were concerned. But it's used that lateral approach, basically a line from the head of the fibula down to the lateral malleolus that goes right through the middle of where we would like to do our fascist anus flat. When we explored it a bit further, the anterior compartment had not been opened through that incision going, you see there, the anterior compartment was completely dead. So please don't do this. This is a lateral approach from head, a fibula down to lateral malleolus and to get that view to make sure you are opening the anterior compartment, you basically have to dig love the skin from the midpoint here all the way around too there. So that is now degloved tissue. If the reason you're doing your fasciotomy is because you have revascularized the leg more proximately and there is no injury at all below the knee, then maybe you could get away with this. But if there has been any injury itself to the lower leg, then I would advocate that this approach is not taken. This is on the medial side. Now that is the long saphenous vein. The long saphenous pain comes from more dorsally on the foot. Some point up here, it crosses the line of election, always divide the long saphenous vein because if you don't, you risk this happening and that did cause necrosis of underlying muscle. This is the key illustration that you need to keep in your minds. Let's start on the medial aspect. Here is subcutaneous border of the tibia and then coming more on this side can be more medially and then on the more anterolateral side. So this is towards the fibula and here's more on the medial side at a certain distance. We need to make our incision through the skin and fascia. Now I use two centimeters well, effectively two fingerbreadths. The exact distance doesn't matter but is not right around here laterally. And on the media aspect, go through skin and fascia and do not separate the skin and fat off the fascia, raise it as a single unit because that is a robust fashion, cutaneous flat thing. And all the dissection is done in the subfascial plane more distantly, there isn't the connection of the soleus muscle to the tibia more proximately it is and that has to be released but simply releasing the soleus off the back of the tibia doesn't necessarily open the deep compartment. So conscious effort has to be made to release the deep compartment. The key to that is the posterior tibial neurovascular bundle because that is inside the investing fascia of the deep compartment. So if you open and explore for the posterior tibial neurovascular bundle, you will be in the deep compartment and that is most easily done more distantly. Ok. Below, below where soleus is normally. So you make your decision there and you come in here, you release off there. You find the fascia which is over the top of the neurovascular bundle, make an incision in it and then explore it on the antral lateral side where we advocate this again is two fingerbreadths, an incision through skin and fascia okay without undermining at all, you are. Then in the anterior compartment, there is never a doubt about that. If all you've done is two fingerbreadths across there. You are in the anterior compartment to then avoid having to dissect all the way down here and degloved that skin, you do a subfascial dissection. And if you keep following, you follow the cursor there, the way it's going down, you keep separating muscle fiber from fascia, keep on going, keep on going. You keep on going down here and you follow it, you end up with the fibula and once you've reached the fibula, you just back off slightly and you make an incision through there. I tend to do mine closest to the fibula. Other people do it more closely up here. It doesn't really matter. But by having in size through there, you have then opened the lateral compartment and that is it done?