![]() ![]() The soleus muscle attaches to the medial edge of the tibia, and dissecting these fibers completely free from and exposing the underside of the tibia ensures entry into the deep posterior compartment (Fig. The key to entering the deep posterior compartment is the soleus muscle. If you open this fascia from the tibial tuberosity to the medial malleolus, you will have effectively decompressed this compartment (Fig. In most individuals, the fascia that you will next encounter will be that which overlies the superficial posterior compartment which contains the soleus and gastrocnemius muscles. As you make this incision, it is important to both identify and preserve the greater saphenous vein, as well as ligate any perforators to it. 61.3 and 61.4) is made one fingerbreadth below the palpable medial edge of the tibia. The skin incision should be closely inspected and extended as needed to ensure that the ends do not serve as a point of constriction. Inspection of the septum and identification of the deep peroneal nerve and/or the anterior tibial vessels confirm entry into the anterior compartment. The fascia should be opened by pushing the partially opened scissor tips in both directions on either side of the septum opening the fascia from the head of the fibula down to the lateral malleolus. You will then construct the legs of the “H” with curved scissors using just the tips which are turned away from the septum to avoid injury to the peroneal nerve (Figs. To do this you will make the cross piece of the “H” using a scalpel which will expose both compartments and the septum. Classically the fascia of the lower leg is opened using an “H”-shaped incision. Often you can find the septum by following the perforating vessels down to it (Fig. In the swollen or injured extremity, you may have difficulty finding the intermuscular septum. This is the structure that divides the anterior and lateral compartments. Once the skin flap is raised, the intermuscular septum is identified. The extent of the skin incision should be to a point approximately three fingerbreadths below the tibial tuberosity and above the malleolus on either side. The medial incision is made one thumb breadth below the palpable medial edge of the tibia or a thumb below the tibia (Fig. It is important to stay anterior to the fibula as this minimizes the chance of damaging the superficial peroneal nerve. The lateral incision is usually made just anterior (~1 fingerbreadth) to the line of the fibula or a finger in front of the fibula. ![]() The tibial spine serves as a reliable midpoint between the incisions, and the lateral malleolus and fibular head are used to identify the course of the fibula on the lateral portion of the leg (Fig. As extremities needing fasciotomy are often grossly swollen or deformed, marking the key landmarks will aid in the placement of the incisions. One of the key steps is proper placement of the incisions. The most commonly missed compartments are the anterior and the deep posterior. There are several key features that will enable you to perform a successful two-incision four-compartment fasciotomy. ![]()
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