Delayed primary intention on postop day 5 is the preferred method for fasciotomy wound closure. Wounds should remain open to allow limb swelling to subside. In severe cases, when delayed primary intention cannot be performed in the window of time described, split-thickness skin grafts can be used. Postoperative wounds should be packed open with bulky dressings and changed daily. Negative-pressure wound dressings can be used for improved and accelerated wound closure.29
In the setting of ACS or limb ischemia, it is important to consider the possibility that tissue destruction will lead to significant myoglobinuria and potentially rhabdomyolysis.8 In patients presenting with crush injuries, or trauma patients who experience a significant rise in creatine kinase, the kidneys should be protected via extracellular resuscitation with isotonic fluids. The goal of resuscitation is to maintain urinary output of at least 200 mL/h to prevent renal failure.29
PATIENT EDUCATION
Patients who undergo fasciotomy within 12 hours of onset of signs and symptoms of ACS retain normal limb function in 68% of cases. However, this outcome falls to 8% if fasciotomy is delayed longer than 12 hours.30 Patients should understand that return to normal function usually takes two to three months and requires active participation by the patient. Furthermore, 20% of patients have some motor and sensory deficits at one year postfasciotomy.17
FOLLOW-UP
After fasciotomy, patients will require adequate pain control and an extensive rehabilitation program. Early physical therapy should progress slowly, with focus on range-of-motion and stretching exercises. Once patients have regained the ability to ambulate, resistance exercises and moderate exercise activities should be implemented to return them to their regular activities.31
CONCLUSION
ACS figures significantly in the long-term morbidity and mortality associated with trauma. Clinical research and laboratory science have indicated that ACS must be treated within six hours to prevent life-long deformity and disability. New diagnostic and therapeutic approaches must be investigated to improve outcomes. The most widely accepted surgical approach is the double-incision radical dissection of all fascia within the affected limb.
Appropriate management must include protection of the patient’s kidneys, given the risk for rhabdomyolysis, as well as extensive postoperative physical therapy. Given the invasive treatment required for ACS, progression toward full recovery is a long and difficult process. However, with prompt recognition and early intervention, full return to normal function is possible, with little to no deformity or dysfunction.
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