Eur J Plast Surg (2016) 39:99106

DOI 10.1007/s00238-015-1156-4

ORIGINAL PAPER

A comparison of fasciotomy wound closure methods following

extremity compartment syndrome at a regional trauma centre
Gareth Price 1 & Nicholas Hodgins 1 & Brendan Fogarty 1

Received: 4 August 2015 / Accepted: 21 September 2015 / Published online: 19 October 2015
# Springer-Verlag Berlin Heidelberg 2015

Abstract
Background Extremity fasciotomy wound closure following
acute compartment syndrome is often prohibited by residual
swelling, producing wounds that significantly contribute to
patient morbidity. The aim of this study was to assess patient
and fasciotomy wound outcomes associated with dynamic
closure (DYN), delayed primary closure (DPS) and split skin
grafting (SSG) techniques.
Methods A retrospective review of all trauma-related compartment syndrome patients managed between January 2000
and March 2010 was conducted, and a comprehensive patient
and wound outcomes analysis was performed.
Results DYN was employed in 109 wounds, DPS in 66
wounds and SSG in 7 wounds. DPS wounds achieved closure
in a significantly shorter timescale than other methods (p=
<0.05). DYN and SSG group wound closure times were comparable; however, SSG techniques were employed later postfasciotomy. SSG patients had longer hospital stays (p=<0.05)
and the lowest wound complication rate (0 %). Wound complication rates were significantly higher in the DYN (55 %)
and DPS groups (15 %) (p=<0.05), and these wounds required a higher number of further surgical procedures. The
need for repeated wound debridements was higher in the
DYN group than any other (p=<0.05).
Conclusions DPS provided the fastest method of fasciotomy
wound closure and the shortest inpatient stay. DYN techniques were associated with higher wound complication rates

* Nicholas Hodgins
nickhodgins@googlemail.com
1

Northern Ireland Regional Burns Unit, Royal Victoria Hospital,

Grosvenor Road, Belfast, Northern Ireland BT12 6BA,
United Kingdom

and the need for further surgical procedures. SSG techniques

were associated with low complication rates and fewer surgical procedures and, if applied earlier, could result in shorter
inpatient stay.
Level of evidence IV, therapeutic study.
Keywords Wound closure . Fasciotomy . Compartment
syndrome

Introduction
Compartment syndrome can occur in any closed anatomical
space where interstitial pressure exceeds perfusion pressure. If
left untreated, the condition can result in compartmental tissue
necrosis, neurovascular compromise and irreversible functional impairment [1]. Although a potential sequelae of multiple aetiologies, the condition is most frequently associated
with trauma, particularly following long-bone fractures of the
extremities [2]. Compartment syndrome has an annual incidence of 3.1 per 100,000 and is frequently seen in young
patients who have strong fascia filled with well-developed
muscle [3, 4].
Treatment of compartment syndrome primarily involves
emergency fasciotomy which creates large wounds extending
along one or both sides of the limb to permit compartmental
decompression through the fascia and skin. Early fasciotomy
wound closure is often precluded by significant soft tissue
oedema associated with compartment syndrome. Fasciotomy
can therefore produce wounds that can significantly contribute
to patient morbidity and result in prolonged hospitalisation
[5].
Split skin grafting of fasciotomy wounds can provide early
wound coverage provided graft take is achieved [6]. However,
it produces a donor site that can be painful and result in further

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scarring. Skin grafts can also leave a wide, hairless, depressed

scar over the fasciotomy site that can limit effective muscular
function within the compartment [7]. Many studies have focused on delayed and dynamic wound closure techniques and
devices to achieve early fasciotomy wound closure [816].
Dynamic wound closure involves applying gradual and progressive external forces to the wound margins until direct
approximation and delayed primary closure is achieved.
Such techniques avoid creating donor sites but often require
prolonged periods of application before wound approximation
can be achieved.
The majority of current published literature investigating
fasciotomy wound closure focuses on outcomes of one particular method or technique. Relatively few studies compare outcomes from differing methods of wound closure. This study
was therefore designed to investigate the optimal method of
fasciotomy wound closure in patients treated for traumarelated compartment syndrome. Its principal aim was to compare outcomes of fasciotomy wounds subject to split skin
grafting, dynamic and delayed primary closure techniques
employed at the regional trauma centre for Northern Ireland.

Material and methods

We conducted a 10-year retrospective review of all patients
who underwent an extremity fasciotomy procedure for
trauma-related compartment syndrome at the Royal Victoria
Hospital between January 2000 and March 2010. Patients
were identified from the Fractures Outcome Research
Database (FORD) by running the search term Bfasciotomy^
(OPCS code T55.5) to identify all patients who underwent a
fasciotomy procedure for trauma-related compartment syndrome in the timescale specified. Patient case notes were requested for all patients identified by the search. Patient cases
for which notes were unavailable following two consecutive
requests were excluded.
Figure 1 provides a summary flow chart of our patient
selection and exclusion criteria. Available patient case
notes identified by our search were scrutinised to ensure
accuracy of the coded diagnosis and that adequate clinical information was available to permit analysis of patient and wound outcomes. Two cases were excluded as
they were given an inaccurate diagnostic code and six
cases were excluded due to inadequate clinical information in the notes. Six patient cases that had clinical record of compartment loss or amputation secondary to
their compartment syndrome were also excluded from
wound outcome analysis as their fasciotomy wounds no
longer required treatment. These six cases were still included in analysis of our patient sample demographic, as
they still required a fasciotomy procedure as an emergency intervention.

Eur J Plast Surg (2016) 39:99106

Figure 2 represents the proforma utilised to collect all relevant data from the patient case notes to facilitate analysis of
patient and wound outcomes. Table 1 presents a summary of
definitions, terms and criteria used in our proforma. Data was
collected on patient demographics, co-morbidities, mechanism of injury/indication for fasciotomy, anatomical site affected, dates of injury, admission, discharge and length of
hospital stay. Operation notes were reviewed to collect data
on fasciotomy procedures, fasciotomy wound treatments and
any associated complications. All fasciotomy wounds were
analysed individually as a single patient may have had multiple fasciotomy wounds that may have been subject to differing
treatment methods. As this was a retrospective study, patients
included in the wound outcomes analysis had already been
pre-selected to a fasciotomy wound closure group. The authors of this study were therefore not involved in selecting
patients into fasciotomy wound closure groups.
Completed proforma data was input into a spreadsheet
using Microsoft Excel 2008 for Mac Version 12.2.0. This
was analysed with PASW Statistics Version 18.0.3 for
Macintosh (SPSS Inc. 19892010). Due to wide variation in
the size of fasciotomy wound treatment groups, assumptions
of normality could not be satisfied. Therefore, wound outcomes for each of the treatment groups were compared using
non-parametric statistical methods. Continuous data was
analysed using the Kruskal-Wallis test and categorical wound
outcomes were analysed using Pearsons chi-squared test to
assess for statistical significance (p=<0.05).

Results
One hundred and thirty-nine patients were identified by initial
searching of the FORD database. One hundred patients were
suitable for demographic analysis, and 94 patients with 182
fasciotomy wounds were suitable for wound-based analysis.
The mean patient age was 30.9 years old (range 1379).
Eighty-six patients were male and 14 were female. Fifty-two
percent of patients in our sample had no pre-existing co-morbidities. Forty, six and two percent had a clinical history of
one, two and three co-morbidities respectively. The most prevalent co-morbidity identified was active smoking, identified in
32 % of patients. Fourteen percent of patients were noted to be
malnourished as defined by Table 1. In seven cases, alcohol
was involved in the trauma mechanism or as a chronic comorbid condition. There were no diabetics in the patient sample. One patient was on oral steroid medication.
Table 2 presents the injury mechanisms identified in our
patient sample. Road traffic accidents (RTAs) were the most
frequent mechanism of injury that resulted in compartment
syndrome in 24 % of patient cases. The decision to perform
fasciotomy was based upon raised intracompartmental pressures in the presence of suspicious clinical symptoms and

Eur J Plast Surg (2016) 39:99106

Fig. 1 Flow diagram of patient
selection and inclusion/exclusion
criteria

101

Coding search of FORD database

using OPCS code T55.5 Fasciotomy
of inpatients at our institution
between Jan 2000 and Mar 2010
(Search Result n=139)
Are the c linical patient notes
available from medical records?

Exclusion Criteria / Excluded Cases (n=45)

Case note availability
-31 patient case notes were unavailable after 2 consecutive requests

YES (n=108)
Coded diagnosis mismatch
Does the coded diagnosis from the
original search match the clinical
diagnosis from the med ical notes?
YES (n=106)

-2 patient cases did not have a fasciotomy for compartment syndrome

Clinical information availability
-6 patient cases had inadequate clinical information available in the notes
Precluding factors from wound outcome analysis

Is adequate clinical information

available from the notes to permit
patient + wound outcome analysis?

-6 patient cases exhibited compartment loss and/or amputation secondary

to their compartment syn drome

YES (n=100)
Patients for demographic analysis
n=100

Are there any factors that preclude

these patients from wound outcome
analysis?

NO (n=94)
Patients for wound based analysis
n=94 (182 wounds)

signs in over half the patients in our sample (56 %).

Measurements of compartment pressure >30 or <30 mmHg
below diastolic blood pressure using a portable
intracompartmental pressure monitor were taken as diagnostic
threshold values. Less than one third of patients were diagnosed and underwent fasciotomy on the basis of clinical suspicion alone (30 %).
The timing of fasciotomy with respect to associated extremity fracture fixation surgery was variable. Fifty-five percent of extremity compartment syndromes were identified prior to definitive fracture fixation. In 22 % of cases,
fasciotomies were performed as a prophylactic measure in
the intraoperative setting where findings in theatre indicated
an impending compartment syndrome. Twenty-three percent
of fasciotomies were performed after definitive fracture fixation. The mean time to fasciotomy following initial traumatic
injury was 1.47 days.
One hundred and eighty-two fasciotomies were performed
in 94 patients suitable for wound-based analysis. Table 3 presents the anatomical distribution of these wounds. The majority of fasciotomy wounds involved the lower extremity

(88 %). The mean inpatient stay for all trauma patients requiring fasciotomy was 18.55 days (range 386 days). Analysis of
treatment intentions for 182 fasciotomy wounds revealed
three main methods of fasciotomy wound closure: dynamic
wound closure (DYN), delayed primary suturing (DPS) and
split thickness skin grafting (SSG).
The DYN group contained 60 % of fasciotomy wounds
analysed (n=109). These wounds were subject to dynamic
closure techniques as presented in Table 1. The majority of
these closure methods were instigated at the time of
fasciotomy and therefore the median time to employ this technique was 0 days. The median inpatient hospital stay in this
group was 13 days with a median time to final wound closure
of 6 days.
The DPS group contained 36 % of fasciotomy wounds
analysed (n=66). The median time at which delayed primary
suturing occurred was 3 days post-fasciotomy. The median
inpatient stay in this group was 11 days with a median time
to final wound closure of 3 days. Two patients in this group
had wound closure times of greater than 150 days. Closure
was delayed in one case due to chronic wound infection and in

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Eur J Plast Surg (2016) 39:99106

Fig. 2 Data collection proforma

another due to a prolonged trial of conservative wound management with dressings.

The SSG group contained 4 % of fasciotomy wounds
analysed (n=7). Split skin grafting occurred at a median time
of 7 days post-fasciotomy. The median inpatient stay in this
group was 19 days. As there were no graft failures, the time at
which split skin grafting was performed was taken as the time
of achieving definitive soft tissue cover. The median time to
final wound closure post-fasciotomy in this group was 7 days.
Table 4 presents a comparison of wound outcomes for each
of the primary treatment method groups. Inpatient stay was
comparable between the DYN and SSG groups. Patients in the
DPS group spent on average 34 days less in hospital. The
difference in inpatient stay between the treatment groups was

statistically significant (p=<0.05, Kruskal-Wallis). Inpatient

stay was longest in skin-grafted wounds. However, these were
applied significantly later than the other methods of wound
closure (p = <0.05, Kruskal-Wallis). The median time to
wound closure for the DYN group was 6 days compared with
3 days in the DPS group whereas soft tissue cover was provided immediately in the SSG group as no further surgical
intervention or complications occurred. Time differences from
fasciotomy to wound closure were statistically significant between the groups (p=<0.05, Kruskal-Wallis).
The overall fasciotomy wound complication rate was 38 %.
Sixty wounds within the DYN group (55 %) and ten wounds
within the DPS group (15 %) encountered complications as
presented in Table 1. There were no complications identified

Eur J Plast Surg (2016) 39:99106

Table 1 Definitions of terms and
criteria used in data proforma

103

Primary closure method (comparison groups)

Delayed primary closure (DPS)

Closure by direct wound edge approximation

Dynamic closure (DYN)

Using sutures/sloops or devices requiring

progressive tightening to achieve closure

Primary split skin grafting (SSG)

Other methods (other)
Mechanism of injury

Skin grafting as primary closure method

Any other method other than above
(e.g. negative-wound pressure therapy)
e.g. crush, fall, road traffic collision

Injury sustained
Surgical site

Any associated injury

Fasciotomy site e.g. arm, leg, forearm, thigh

Day intervention applied

Number of days post-fasciotomy

Co-morbidities

Any co-morbidity which could have affected

wound healing including age, smoking,
diabetes, cardiovascular disease (CVD),
peripheral vascular disease (PVD), steroid use,
malnutrition defined by the requirement for
dietician input and subsequent intervention.
The time at which soft tissue cover was achieved

Timing to healing/closure
Length of hospital stay
Wound infection

The number of days from admission to discharge

This was divided into clinical evidence of wound
infection e.g. documented clinical cellulitis in
the medical notes, a positive wound microbiology
swab result for which antibiotics were initiated
or prolonged courses of antibiotics for the
fasciotomy wound (> 5 days).
Any complication associated with the wound e.g.
infection, dehiscence or graft loss.
Any further procedure required in theatre solely
for the treatment of the wound.

Wound complications
Further procedure required

in the SSG group. Fasciotomy wounds in the DYN and DPS

groups had significantly higher levels of wound complications
then those in the SSG group (p=<0.05, Pearson chi-squared).
Table 5 presents the frequency of wound complications observed by treatment group. The number of fasciotomy wounds
requiring further debridement was significantly higher in the
DYN group than the other two treatment groups (p=<0.05,
Pearson chi-squared). There was no statistically significant
Table 2 Mechanisms of injury identified resulting in compartment
syndrome
Mechanism of injury

Number of compartment
syndrome patient cases

RTA (patient within vehicle)

RTA (patient pedestrian)
Assault
Sports-related injury
Fall from own height
Fall from greater than own height
Crush injury
Other

24
14
6
14
10
12
17
3

difference between treatment groups for any other wound

complication observed.
None of the wounds treated by SSG required a further
surgical procedure or a change to an alternative method of
wound closure. Fifty-five wounds in the DYN group (51 %)
and seven wounds in the DPS group (11 %) required a further
surgical procedure to achieve wound closure. Table 6 summarises the further procedures required by treatment group. The
number of wounds requiring further surgical procedures in
DYN and DPS groups were significantly higher than in the
SSG group (p=<0.05, Pearson chi-squared). Wound complication rates were compared with patient co-morbidities identified. A higher proportion of patients with malnutrition (n=
17) were noted to have wound complications than those without this co-morbidity (n=13).

Discussion
There are currently few studies in the literature that have performed a comparative analysis of treatment modalities for
fasciotomy wound closure following compartment syndrome.
Medina et al. found that patients with fasciotomy wounds who

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Table 3

Eur J Plast Surg (2016) 39:99106

Anatomical distribution of fasciotomy wounds

Fasciotomy site

Number of fasciotomy
wounds

Arm

Forearm

20

Hand
Thigh

2
7

Leg

131

Foot

22

underwent dynamic wound closure achieved earlier closure

than those who had split skin grafting [17]. However, this
finding was not statistically significant and was based on a
retrospective review of 14 patients. Johnson et al. found that
fasciotomy wounds closed by delayed primary closure had a
significantly higher complication rate than those reconstructed
by skin grafting in a series of 68 patients [18].
Rogers et al. found that patients who had delayed primary
closure of fasciotomy wounds had more operative procedures
but a significantly shorter hospital stay and improved scar
appearance when compared with skin-grafted wounds [7]. A
randomised study by Kakagia et al. found wound closure
times were significantly longer in wounds treated by
negative-pressure wound therapy (NPWT) when compared
against wounds treated by dynamic closure methods. In addition, 20 % of wounds treated by NPWT eventually required
skin grafting to achieve definitive closure [5].
These studies focused on one or two wound outcome variables or the effects of closure method on hospital inpatient
Table 4
groups

Comparison of outcomes for primary treatment method

No. of wounds
Inpatient stay (days)

Dynamic
wound
closure
(DYN)

Delayed
primary
closure
(DPS)

Split
thickness
skin grafting
(SSG)

n
Median
Max
Min

109
13
159
3
p=<0.05

66
11
59
4

7
19
25
15

Median
Max
Min

0
3
0
p=<0.05
6
74
0
p=<0.05

3
29
0

7
13
5

3
168
0

7
13
5

Difference (KW) test

Fasciotomy to primary
method (days)
Difference (KW) test
Fasciotomy to final
wound closure (days)
Difference (KW) test

Median
Max
Min

stay. Conclusions drawn were based on relatively low patient

numbers and none of the studies compared more than two
closure methods. Our study provides direct comparison of
three wound closure methods in a larger patient cohort with
a more detailed analysis of wound outcomes.
Demographic findings of this study are typical of an expected trauma study population. The majority of patients were
young with a strong preponderance to the male sex and few
associated co-morbidities. Smoking and alcohol intake were
prevalent in our sample but were not shown to have a negative
impact on fasciotomy wound outcomes. Malnutrition was the
only co-morbidity associated with increased wound complication rates. It has been shown to negatively impact wound
healing and increase wound infection rates [18, 19]. Our study
highlights malnutrition as a greater contributing factor to
wound complications than any other patient co-morbidity.
Our patient dataset partially predates the BOA/BAPRAS
lower limb trauma guidelines that suggest compartment pressure is most reliably measured by an intra-compartmental
pressure-monitoring device [20]. This may explain why device monitoring was only used to formulate diagnosis in 56 %
of patients. We recommend that all suspected compartment
syndrome patients undergo serial diagnostic intracompartmental pressure measurements, provided this does
not delay progression to surgery.
This study identified compartment syndrome occurring
most frequently in the lower extremity, a finding also seen in
other large UK series [4, 21]. Fasciotomy timing relative to
definitive fracture fixation was variable. Although our results
suggest that compartment syndrome most frequently develops
prior to fracture fixation, it is important to highlight that compartment syndrome monitoring should begin on patient admission, through the peri-operative period and well into the
postoperative stages of patient care.
In this study, dynamic closure technique was the most frequently employed method of fasciotomy wound closure
achieving a median wound closure time of 6 days. This is
faster in comparison to times already published in the literature for dynamic techniques (510 days, Berman et al. [9];
15 days, Galois et al. [22]) and commercial tension closure
devices (710 days, McKenney et al. [13]; 10 days, Medina
et al. [17]; 11.5 days, Taylor et al. [23]). The only report of
more rapid wound approximation (2.6 days, Singh et al.) occurred in lateral lower leg wounds only [14].
DYN group wounds had significantly higher levels of
requirement for further debridements and alternative secondary methods to achieve wound closure in comparison
with the DPS and SSG groups. Identifying use of a secondary method of wound closure as a complication may
have given a falsely elevated complication rate in the
DYN group if it was a planned procedure rather than a
true complication. However, distinguishing planned from
unplanned procedures in the documentation under review

Eur J Plast Surg (2016) 39:99106

Table 5 Frequency of wound
complications by treatment
method groups

105

Wound complication

DYN group

DPS group

Positive wound swab

12

Wound associated cellulitis

11

Wound infection requiring antibiotics

11

Wound needing further debridement

Wound dehiscence

14
12

1
7

Failed wound healing

14

was not always obvious. Therefore, the complication rate

in this group should be interpreted with caution.
Few published studies comment on complication rates associated with dynamic closure as most are small case series or
case reports as outlined previously. Occurrence of successful
wound closure and the frequency of wound infections are
highlighted most frequently in these studies. Barnea et al.
found dynamic wound closures were associated with a 12 %
complication rate, which is lower than the 55 % rate observed
in the DYN group in this study [15].
DPS group wounds had the shortest overall time to closure
but were still associated with a 15 % complication rate, with
70 % of these requiring a further surgical procedure. Again,
differentiating planned from an unplanned secondary procedure was not always easily distinguishable from the patient
medical records allowing for this figure to be potentially
overestimated. There were also significantly fewer wounds
returned to theatre for further debridement in the DPS group
than in the DYN group.
Delayed primary suturing was the most frequent secondary method used to treat wounds undergoing a secondary procedure in theatre. This was expected as many
wounds treated in the DYN group may have required final
suturing to achieve closure. There are few previous studies in the literature that specifically focus on delayed primary closure of fasciotomy wounds from which to draw
comparisons. Bengezi et al. investigated the use of limb
elevation followed by delayed primary closure in 12 patients with fasciotomy wounds finding a median time to
wound closure of 3.4 days [24]. This is comparable with
Table 6 Number of fasciotomy
wounds requiring further surgical
procedure by treatment method
group

Number of fasciotomy wounds affected

the median time of 3 days in the DPS group identified by

this study.
Skin grafting accounted for only seven wounds and was
employed later than the DYN and DPS methods with a median time of application of 7 days post-fasciotomy. One may
expect a higher rate of infective complications due to the delay
in application of this method as wounds may have had time to
become colonised with bacteria. However, this finding was
not observed as no complications were noted in the SSG
group. This may be explained by the fact that the skin grafts
were applied without tension, using tissue from outside the
original zone of injury.
In comparison, DYN and DPS methods invariably apply
tension to the wound edges involved in the zone of injury,
often in association with an underlying fracture and soft tissue
injury, which may account for their higher wound complication rates. Johnson et al. found complication rates for skingrafted fasciotomy wounds to be significantly lower than DPS
wounds [25]. However, fasciotomy wounds in this series occurred in patients with vascular disease, and therefore, our
patient populations may not be directly comparable.
Patients in the SSG group had significantly longer inpatient
stay than those in the DYN and DPS groups. However, it was
noted that skin grafts were, on average, applied approximately
the same number of days later than the other methods. It could
therefore be deduced that earlier application of skin grafts,
with the benefits of lower complication and further procedure
rates, may permit a reduction in overall inpatient stay.
Findings of this study were derived from a retrospective
series from a single institution. Our series did not extend to

Further procedure required to establish wound closure

Suturing
Alternative DYN closure method
Application of SSG
Application of other closure method

Number of fasciotomy wounds requiring

further surgical procedure
DYN group

DPS group

40
7
4
4

5
1
1

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Eur J Plast Surg (2016) 39:99106

include patients who developed compartment syndrome via

non-traumatic mechanisms. Therefore, patient demographics
and wound outcome results may not be directly comparable
with patients developing compartment syndrome due to alternative aetiologies. In addition, patients were pre-selected to
fasciotomy wound closure groups by the clinician responsible
for the patients care at the time of admission. The decision to
employ what method would be used would have been influenced by multiple factors. This highlights a potential selection
bias that should be taken into account when interpreting the
results of this study.

4.
5.

6.

7.

8.
9.

Conclusions
10.

Our study findings have shown that delayed primary suturing

applied 3 days post-fasciotomy gave the shortest time to
wound closure and the shortest overall inpatient hospital stay
with a wound complication rate of 15 %. Dynamic closure
methods took slightly longer to achieve wound closure than
delayed primary closure methods (6 days) and had a much
higher re-operation and complication rate of 55 %. Skingrafted wounds had no complications but were applied significantly later than other methods following fasciotomy, and
therefore, patients had a significantly longer hospital stay.
Skin grafts applied earlier have the potential to improve management given their low complication rate. This could result in
reduced wound complications, number of surgical procedures
required and overall hospital stay.

11.

12.

13.
14.
15.

16.

17.
Compliance with ethical standards
Ethical standards For this type of retrospective study formal consent
from a local ethics committee is not required.

18.
19.

Conflict of interest Gareth Price, Nicholas Hodgins, Brendan Fogarty

declare that they have no conflict of interest.

20.

Patient consent Informed consent was obtained from all individual participants included in the study.
Funding This study received no funding.

21.
22.

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