Fasciotomy for Compartment Syndrome
Acute compartment syndrome, [right / left] [leg / forearm / thigh]
Same
Four-compartment fasciotomy, [right / left] leg [or specify location]
[***, MD/DO]
[Resident/Fellow/PA name]
General / spinal
Patient presents with [trauma / reperfusion / cast-related / crush injury] resulting in acute compartment syndrome of the [right / left] [lower leg / forearm]. Clinical findings include [pain with passive stretch, tense compartments, paresthesias, diminished pulses]. Compartment pressures measured: [anterior X mmHg, lateral X mmHg, superficial posterior X mmHg, deep posterior X mmHg]. Delta pressure <30 mmHg in [compartment]. Emergent fasciotomy indicated. Risks including wound complication, infection, scarring, and need for skin grafting discussed.
[Tense / severely tense] compartments on palpation. Skin intact [or compromised]. [Distal pulses [present / diminished / absent].] Muscle [viable / dusky] at time of fasciotomy. [All four compartments released with visible muscle expansion.]
The patient was brought emergently to the operating room. The extremity was prepped and draped in sterile fashion. [No tourniquet used to allow assessment of tissue viability.]
LATERAL INCISION: A longitudinal incision was made approximately 2 cm anterior to the fibula, extending from just below the fibular head to above the lateral malleolus. The superficial peroneal nerve was identified along the anterior intermuscular septum and protected throughout. The anterior compartment fascia was incised longitudinally under direct vision with scissors, releasing the anterior compartment. The lateral compartment fascia was incised on the opposite side of the septum, releasing the lateral compartment.
MEDIAL INCISION: A second longitudinal incision was made 1-2 cm posterior to the posteromedial tibial border. The superficial posterior compartment fascia was incised. The soleus muscle bridge was divided to access and release the deep posterior compartment. Tibialis posterior and flexor digitorum were visualized.
All four compartments released. Muscle appeared [viable / dusky / necrotic at X location]. [Fasciotomy sites left open / partially closed with vessel loops.] [Any necrotic muscle debrided.] Wounds dressed with [Xeroform / VAC / moist gauze].
Patient tolerated the procedure well. Plan for repeat washout in [48-72 hours] and delayed primary closure or skin grafting.
None
[Muscle biopsy if viability uncertain / None]
Minimal to [X] mL
Wounds left open / VAC dressings applied
Patient taken to PACU in stable condition. Return to OR planned in [48] hours.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Acute compartment syndrome, [right / left] [leg / forearm / thigh]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Four-compartment fasciotomy, [right / left] leg
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General / spinal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX presenting emergently with acute compartment syndrome of the [right / left] [lower leg / forearm] following [trauma / reperfusion / crush injury]. Clinical findings: pain with passive stretch, tense compartments, paresthesias. Measured compartment pressures: anterior *** mmHg, lateral *** mmHg, superficial posterior *** mmHg, deep posterior *** mmHg. Delta pressure <30 mmHg. Emergent fasciotomy indicated. Risks including wound complication, infection, scarring, and need for skin grafting were discussed.
FINDINGS: Severely tense compartments on palpation. Skin intact. Distal pulses [present / diminished]. Muscle [viable / dusky] at fasciotomy. All four compartments released with visible muscle expansion.
DESCRIPTION OF PROCEDURE:
Patient taken emergently to OR. Extremity prepped in sterile fashion. No tourniquet. LATERAL INCISION: Longitudinal incision approximately 2 cm anterior to fibula, from below fibular head to above lateral malleolus. Superficial peroneal nerve identified along anterior intermuscular septum and protected. Anterior compartment fascia incised longitudinally under direct vision. Anterior compartment released. Lateral compartment fascia incised. Lateral compartment released. MEDIAL INCISION: Second longitudinal incision 1-2 cm posterior to posteromedial tibial border. Superficial posterior compartment fascia incised. Soleus bridge divided to access and release the deep posterior compartment. Tibialis posterior and flexor digitorum visualized. All four compartments confirmed released. Muscle [viable / dusky at ***; necrotic tissue debrided]. Fasciotomy wounds left open and dressed with [Xeroform / VAC / moist gauze]. Patient tolerated the procedure well. Plan for return to OR in 48-72 hours for washout and delayed closure or skin grafting.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: [Muscle biopsy if viability uncertain / None]
COMPLICATIONS: None
DRAINS: Wounds left open. VAC/moist gauze dressings applied.
DISPOSITION: Patient taken to PACU in stable condition. Return to OR planned in 48 hours.
Signed: .ME, .MYDEGREE
.TODAYVariants
Forearm fasciotomy
Incisions: volar Henry approach and dorsal midline. Releases volar superficial flexors, deep flexors, and mobile wad (brachioradialis, ECRL, ECRB).
Thigh fasciotomy
The thigh has three compartments: anterior (quadriceps), medial (adductors), and posterior (hamstrings). Standard approach: lateral incision releasing anterior and posterior compartments. If medial (adductor) compartment is involved, a separate medial incision is required.
Delayed primary closure
Document use of vessel loops (shoelace technique) for gradual wound closure at return visit, or skin graft if unable to close primarily. Bill with staged-or-related-procedure reporting (planned staged procedure) when return was anticipated at the time of initial fasciotomy.
Charting Tips
- Document all measured compartment pressures and delta pressure calculation (diastolic BP minus compartment pressure; surgical threshold <30 mmHg per McQueen and Court-Brown)
- State all four compartments decompressed individually
- Lateral incision: document identification and protection of the superficial peroneal nerve
- Describe muscle viability in each compartment, as this determines need for debridement
- Wounds must be left open; document this explicitly
- Plan for return to OR at 48-72 hours must be stated
- Any muscle debridement performed should be documented by compartment
- ICD-10: use T79.A- for traumatic compartment syndrome (T79.A21 right leg, T79.A22 left leg, T79.A11 right forearm, T79.A12 left forearm)
Documentation & Reimbursement Considerations
- Report Fasciotomy for Compartment Syndrome as the primary service when it is the definitive operation performed.
- Bill based on compartments released, not incision count.
- Global period is 90 days (major). Staged closure and secondary procedures within the global period (delayed primary closure, skin grafting) require staged-or-related-procedure reporting (planned staged procedure) to be separately billable. Staged-or-related-procedure reporting applies when the return was planned at the time of the initial procedure; use related unplanned return-to-the-operating-room reporting for unplanned returns due to complications.
- Document graft area in sq cm.
- If bilateral extremities are released, bill each side separately with right- or left-side reporting modifiers. Bilateral rate is 150% of the single-side unilateral fee schedule amount.
- ICD-10 coding: traumatic compartment syndrome (crush, reperfusion, cast, fracture) = T79.A- (e.g., T79.A21 for right lower extremity, T79.A22 left lower extremity). Nontraumatic compartment syndrome (exertional, postoperative without injury) = M79.A-. Most fasciotomies in this template involve traumatic etiology — use T79.A-, not M79.A-. This distinction affects DRG grouping and payer authorization.