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
- Document whether the compartment syndrome is traumatic or nontraumatic and the affected limb and side, because they determine the diagnosis code.
Documentation & Reimbursement Considerations
- Primary service: Report Fasciotomy for Compartment Syndrome as the primary service when it is the definitive operation performed.
- Lower leg fasciotomy is reported by compartments released: anterior and/or lateral only (5.88 wRVU), posterior only (5.90 wRVU), or anterior and/or lateral plus posterior, which covers the standard four-compartment release (7.62 wRVU). Report by compartments released, not incision count. A separate leg decompression code with debridement (7.74 wRVU) applies when nonviable muscle is also debrided.
- Forearm fasciotomy is reported by extent: volar and dorsal release for the standard two-space release (10.52 wRVU without debridement, 17.49 wRVU with), or a single flexor or extensor compartment (5.91 wRVU without, 13.48 wRVU with). The forearm fasciotomy code that includes brachial artery exploration is only for cases with brachial artery exploration.
- Hand compartment syndrome has its own decompressive fasciotomy code (7.38 wRVU). Do not use the high-pressure injection injury code or the Dupuytren palmar release code for compartment syndrome.
- Global period is 90 days. Delayed primary closure or skin grafting planned at the initial procedure is reported with the staged-procedure modifier. Unplanned returns for complications use the unplanned-return modifier.
- Skin grafting for fasciotomy wound closure is separately reportable by area: first 100 sq cm (9.65 wRVU) plus an add-on for each additional 100 sq cm (1.68 wRVU). Document graft area in sq cm.
- If both extremities are released, report each side with right and left designations. The bilateral rate is 150% of the unilateral fee schedule amount.
- Traumatic compartment syndrome (crush, reperfusion, cast, fracture) and nontraumatic compartment syndrome (exertional, postoperative without injury) are coded in different diagnosis families, which affects DRG grouping and payer authorization. Document the cause, the limb, and the side.