Del IV milenio
Capítulo 21.- Egipto: el marco físico-temporal
Although there is an abundance of data regarding the acute management and in-hospital complications of fasciotomy, the topic of long-term sequelae after this procedure has been poorly studied. As is typical of a trauma population, patients undergoing fasciotomy are young, mobile, and healthy and many are lost to follow-up. Further complicating matters is the difficulty in determining which disabilities are the result of the fasciotomy and which are related to the injury that prompted the procedure. With these limitations in mind, several recent studies are worthy of discussion.
In 2000, Fitzgerald and colleagues196 published their experience with the care of 60 patients who had undergone 45 leg and 15 forearm fasciotomies. Most of these patients were male (90%), and the average patient age was 28 years. Associated extremity fractures were present in 81% of the patients, and coverage of the wound was accomplished with primary closure in 25 patients and skin grafting in the remaining 35 patients. On follow-up evaluation at an average of 59 months (range, 25-117 months), 54% of patients complained of chronic pain in the extremity, with 10% of patients localizing it to the fasciotomy site.
Almost all patients had some alteration in local sensation, and in 84% of the patients, this was limited to the fasciotomy site. This alteration in sensation was more common after skin grafting (100%) than after primary closure (40%). There were a variety of other complaints (Table 7). In addition, patients were often unhappy with the cosmesis of their wounds.
This led to a change in occupation in 12% and a change in hobbies in 28%. Finally, 23% reported that they always kept their wounds covered with clothing.196
TABLE 7. Long-term sequelae of fasciotomy
Chronic limb pain 54%
Limited to fasciotomy 10%
Altered sensation 95%
Limited to fasciotomy (primary closure) 100%
Limited to fasciotomy (skin graft) 40%
Dry skin 40%
Pruritus 20%
Discoloration of skin 30%
Edema 15%
Venous ulceration 13%
Contracture 26%
Muscle herniation 13%
Reprinted with permission from Fitzgerald et al.196
Another report of long-term morbidity described 18 patients who had follow-up at an average of 62 months after a fasciotomy in the thigh. All patients had some form of chronic pain or difficulty with ambulation.
Eight patients underwent strength and endurance testing in the quadriceps and hamstring muscle groups. Compared with the patients’ healthy extremities, quadriceps strength and endurance were decreased 52% and 23%, respectively. In addition, hamstring strength and endurance were reduced 64% and 19%, respectively.197This was more pronounced with a higher Injury Severity Score and if the patient had had myonecrosis, which, as mentioned previously, is an example of the difficulty in determining the contribution of the fasciotomy itself to a patient’s long-term disability.
Finally, a recent study documented a 2.4-year follow-up on 24 patients who underwent a fasciotomy in the leg after blunt trauma.198 All patients underwent delayed primary closure of the fasciotomy site during the initial hospital stay. Despite this fact, circumference of the injured leg was asymmetric with the patient’s healthy leg in 67% of patients. Approximately one half had an increase in circumference in their injured leg and one half had a decrease in circumference compared with the healthy leg. Moreover, more that one half of the patients had limitations in plantar flexion of the injured leg and nearly 70% had reduced dorsal extension of the ankle. Muscle strength for dorsal extension was reduced 27%, and strength of plantar flexion was reduced 23%. Finally, 15% of patients had chronic pain at rest and an additional 26% had pain with exertion. More than one half the patients reported a sensory deficit despite no patient requiring a skin graft.198 As with the prior study, this report makes little mention of the extent of the patients’ original injuries, so it is hard to ascertain the true effect of the fasciotomy itself on chronic symptoms.
Summary
Fasciotomy is a common and often limb-saving procedure that is performed as part of both elective and emergent operative procedures in the extremities. This review describes the history, defines the disease, and describes the options for diagnosing a compartment syndrome. The technical aspects of both decompressing affected compartments and covering the fasciotomy wound are described as well. Finally, the sparse data on long-term sequelae are reviewed.
With a working knowledge of the techniques of diagnosis and management in this article, limbs of many critically ill patients may be salvaged.
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