Pallister Ian, Morris Rhys M, Lloyd Tom, Marsden Nicholas J, Wright Thomas, Gilbert Michael, Phillips Jonathan
Department of Trauma & Orthopaedics, Morriston Hospital, College of Medicine, Swansea SA6 6NL, United Kingdom.
Department of Trauma, Morriston Hospital, College of Medicine, Swansea SA6 6NL, United Kingdom.
Injury. 2016 Apr;47(4):962-8. doi: 10.1016/j.injury.2016.02.007. Epub 2016 Feb 21.
Incorrectly placed fasciotomy incisions can lead to catastrophic complications in compartment syndrome. Two distinctly different techniques are widely practiced to decompress the anterior and peroneal compartments. In one technique the anterior compartment is decompressed directly, and then the peroneal via the inter-muscular septum, avoiding the peroneal perforators. The second technique relies on surface anatomy landmarks to place the skin incision immediately over the inter-muscular septum, and then the respective fascial envelopes are incised separately. A study in healthy active volunteers was conducted to explore the feasibility of a new technique for the placing the incision very accurately over the inter-muscular septum and so avoiding perforator vessels. Hypothesis The inter-muscular septum can be reliably identified using hand-held ultrasound, and confirmed with MRI.
Fourteen healthy active volunteers underwent hand-held ultrasound to identify the antero-lateral inter-muscular septum in the left lower limb, which was then marked using cod liver oil capsules. The positions of the anterior, septal and peroneal perforators were then identified using hand-held Doppler, and marked in the same way. MRI was then used to measure the relationship between the surface land marks, the septum (compared to its US position), and the relationship of the perforators themselves.
Hand held ultrasound was successful in identifying the position of the inter-muscular septum in healthy volunteers, as confirmed on MRI scanning. The position and number of peroneal and anterior perforators proved very variable. Direct decompression of the anterior compartment would result in the loss of all anterior perforators in all subjects. Decompression with the skin incision over the inter-muscular septum would not jeopardise any peroneal muscular perforators.
This new technique enables decompression both the anterior and peroneal compartments through an accurately placed incision, sparing the greatest number of perforators. Two brief case histories in which the technique was used are presented.
筋膜切开术切口位置不当可导致骨筋膜室综合征出现灾难性并发症。目前广泛应用两种截然不同的技术来对前侧和腓骨骨筋膜室进行减压。一种技术是直接对前侧骨筋膜室进行减压，然后通过肌间隔对腓骨骨筋膜室减压，避开腓骨穿支。第二种技术依靠体表解剖标志将皮肤切口直接置于肌间隔上方，然后分别切开各自的筋膜包膜。开展了一项针对健康活跃志愿者的研究，以探索一种新技术的可行性，该技术可将切口非常精确地置于肌间隔上方，从而避开穿支血管。假设：使用手持超声能够可靠地识别肌间隔，并通过磁共振成像（MRI）加以确认。
14名健康活跃志愿者接受手持超声检查，以识别左下肢的前外侧肌间隔，然后用鱼肝油胶囊进行标记。接着使用手持多普勒超声确定前侧、肌间隔和腓骨穿支的位置，并以同样方式进行标记。随后使用MRI测量体表标志、肌间隔（与超声检查确定的位置相比）以及穿支血管本身之间的关系。
手持超声成功识别了健康志愿者肌间隔的位置，MRI扫描证实了这一点。腓骨和前侧穿支的位置和数量差异很大。对所有受试者直接减压前侧骨筋膜室会导致所有前侧穿支丧失。在肌间隔上方做皮肤切口进行减压不会危及任何腓骨肌穿支。
这项新技术能够通过精确放置的切口对前侧和腓骨骨筋膜室进行减压，最大限度地保留穿支血管。本文介绍了使用该技术的两个简要病例。
