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AUTHOR(S): TORNETTA III, PAUL, M.D.

,
BROOKLYN, NEW YORK;
TEMPLEMAN, DAVID, M.D., MINNEAPOLIS,
MINNESOTA
An Instructional Course Lecture, The American
Academy of Orthopaedic Surgeons
J Bone Joint Surg [Am] 1996; 78-A; 1438-44
Compartment syndrome is a well recognized
complication of a fracture of the tibial shaft(3,4,6,15,31).
Despite attempts to document the pathophysiology of
compartment syndrome, the clinical recognition of
this disorder is frequently difficult. If left untreated,
compartment syndrome not only results in the loss of
nerve and muscle function but also may lead to
infection, myoglobinuria and renal failure, and even
amputation.
A closed tibial fracture is one of the conditions
most frequently associated with the development of
compartment syndrome. Compartment syndrome
occurs after both closed and open tibial fractures; the
prevalence has ranged from five (1 per cent) of 411
fractures to eighteen (9 per cent) of 198 fractures(3).
The range probably reflects the varying percentage of
high-velocity injuries seen at different medical
centers(31).
The Clinical Problem
Despite an increased sensitivity of clinicians to the
diagnosis of compartment syndrome, few criteria are
available to serve as guidelines for making the
diagnosis. The subjective criteria include pain,
sensory changes, motor function, and turgor, but the
sole objective criterion is the measurement of
intracompartmental pressures. However, even the
definition of abnormal tissue pressure is difficult, as
anatomical compartments are not homogeneous and
an equilibrium of pressure cannot be expected(18).
Heckman et al.(8) measured intracompartmental
pressures at multiple sites in patients who had a tibial
fracture. They documented localized areas of
increased tissue pressure within single compartments.
These differences were significant (p < 0.0005) at
distances of as little as five centimeters from the site
of the fracture. In twenty-four of the twenty-five
patients, the highest pressures were found in the
anterior and posterior compartments. Those authors
recommended the measurement of pressure at
multiple sites, especially at the level of the fracture,
and the careful assessment of all compartments(8).
For the clinician, the fundamental problem is the
inability to identify the pressure at which nerve and
muscle become ischemic. There is no reliable
objective method to determine when a fasciotomy is

required. Despite the development of various


techniques for the measurement of
intracompartmental pressure, it is not appropriate to
rely on this measurement only; the diagnosis of a
compartment syndrome is made from a constellation
of clinical findings. The clinician should consider
several key points when evaluating a patient for the
development of compartment syndrome: (1)
intracompartmental pressures are not a measure of
muscle and nerve ischemia; (2) the development of
muscle ischemia depends on the magnitude and
duration of the elevated pressure; and (3) the
tolerance of muscle to ischemia may vary among
patients because of associated conditions such as
shock, compensatory hypertension, or altered tone of
the resistance vessels.
Many researchers have tried to identify a critical
value for intracompartmental pressure that will lead
to the development of tissue necrosis if no treatment
is given. Probably because of the variable factors just
mentioned, different critical values have been
identified by various authors(3,7,11,15,19,23,32). There
have been two approaches to the problem of a critical
value. Some investigators have tried to identify an
absolute tissue pressure above which the risk of
tissue necrosis is great enough that a fasciotomy
should be performed. This value has been determined
to be thirty(3,7,23) or forty-five(19) millimeters of
mercury (4.00 or 6.00 kilopascals). Others have
suggested that the critical value must reflect a
decrease in tissue perfusion, which occurs when the
intracompartmental pressure approaches the
perfusion pressure, as reflected by some measurement
of the systemic blood pressure(9-11). This critical
difference between blood pressure and
compartmental pressure, or differential pressure (P
or DP), has been suggested to be thirty(11,15,32) to
forty(11) millimeters of mercury (4.00 to 5.33
kilopascals).
Diagnosis
The mechanism of injury is the first indication that
a patient may be at risk for a compartment syndrome.
Chapman(4) estimated the amount of energy
associated with various mechanisms of tibial fracture:
a fall was associated with 136 newton-meters of
energy, whereas an injury caused by the bumper of a
motor vehicle striking a pedestrian was associated
with as much as 135,600 newton-meters of energy.
According to Tscherne and Gotzen(31), the more
severe the initial soft-tissue injury, the greater the
probability that soft-tissue complications, including
compartment syndrome, will develop. Because the
development of a compartment syndrome is
unpredictable, close observation is required until the
acute swelling begins to subside. A single
examination of a patient who has a tibial fracture may
not reveal a compartment syndrome, which may
develop hours or days after the initial injury.
Severe or increasing pain, tightness in the leg, and
sensory changes are frequently the first symptoms.
All complaints should be thoroughly investigated. A
careful physical examination is necessary and should
include testing of muscle strength in the leg and foot

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JBJA Journal of Bone and Joint Surgery American 1996 - 1998


September 1996, Volume 78-A, Number 9
1438 Instructional Course Lectures, The American
Academy of Orthopaedic Surgeons - Compartment
Syndrome Associated with Tibial Fracture*
Instructional Course Lecture

Compartment Syndrome and Tibial Nailing


In 1971, Hamza et al.(6) reported on fifty patients
who had nailing with reaming because of a tibial
fracture; there were five neuromuscular
complications that, in retrospect, seem to have been
the consequences of a compartment syndrome. Two
patients had clawing of the toes, two had a transient
peroneal-nerve palsy, and one had an equinus
contracture. More recently, Koval et al.(14)
retrospectively reviewed the records concerning sixty
acute fractures of the tibia that had been treated with
nailing and reaming with the limb in the 9090
position on a fracture-table. The purpose of that
report was to delineate clearly the complications
associated with tibial nailing with reaming. The

average time from the injury to the operation was ten


days. The authors found that eighteen of the sixty
fractures were associated with neurological
complications, which included paresthesias in the
distribution of the peroneal nerve (eleven lower
extremities), foot drop (three lower extremities), and
combined sensory and motor deficits (four lower
extremities). Sixteen of these eighteen neurological
manifestations were transient; the foot drop persisted
in one patient and the peroneal paresthesias persisted
in another. The specific cause of these neurological
problems could not be determined, and many
probably were multifactorial. The authors implicated
several factors: the presence of soft-tissue swelling,
bleeding into the compartment as a result of reaming,
and the use of calcaneal traction. In such acute
fractures, all of these factors may lead to increased
intracompartmental pressures, resulting in
neurological damage. Alternatively, this nerve
damage may have resulted from traction or a
compression injury to the nerve during the procedure.
Several other investigators have specifically
addressed the possible association between tibial
nailing and the development of compartment
syndrome. Tischenko and Goodman(29) reported on
three patients in whom a compartment syndrome
developed immediately after tibial nailing with
reaming. They prospectively studied an additional
seven patients who had continuous monitoring of the
pressure in the deep posterior compartment during
nailing with reaming. Two peak pressures were seen:
one during reduction of the fracture and the other
during reaming. On the basis of these findings, they
recommended that intracompartmental pressure
should be monitored in patients for whom prolonged
traction is needed intraoperatively. Compartment
syndrome developed after nailing with reaming in
three patients of Mawhinney et al.(21) and in two
patients of Ho and Lau(12). The common factors in
these case reports were the use of reaming and the use
of a posterior thigh-bar for positioning of the limb for
longitudinal traction.
McQueen et al.(16) conducted a prospective study of
intracompartmental pressures during and after tibial
nailing with reaming. The pressure in the anterior
compartment was continuously monitored before,
during, and for twenty-four to thirty-six hours after
the operation in sixty-six patients (sixty-seven
fractures). In general, the pressure was seen to
increase during the operative procedure and then to
dissipate during the postoperative period. Peak
pressures of more than thirty millimeters of mercury
(4.00 kilopascals) were seen during traction and
during reaming. The pressure decreased to a mean of
twenty-three millimeters of mercury (3.07
kilopascals) within twenty-four to thirty-six hours
after the procedure. A compartment syndrome
developed in one patient postoperatively. The authors
found no significant difference between the
intracompartmental pressures that were measured
during acute nailing procedures and those that were
measured during delayed nailing procedures. There
also were no significant differences among the
intracompartmental pressures that were associated

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as well as sensory testing of the superficial and deep


peroneal nerves and the tibial nerve. Because nerve
tissue is very sensitive to ischemia, sensory changes
frequently herald the onset of decreased tissue
perfusion.
Matsen(18) created a model to explain the
development of compartment syndrome. This model
was based on the premise that when local blood flow
is unable to meet the metabolic demands of the tissue,
ischemia begins. When tissue pressure increases, the
intraluminal venous pressures within the
compartment increase. This increase in venous
pressure reduces the magnitude of the arteriovenous
pressure gradient, which in turn reduces the blood
flow to the tissues of the compartment. Both the
magnitude and the duration of increased tissue
pressure adversely affect the perfusion of the
compartment. For example, it takes longer for a lower
tissue pressure to adversely affect perfusion than it
does for a higher tissue pressure, which quickly
reduces the amount of blood flowing into the
compartment.
Although the measurement of intracompartmental
pressure is a critical step in the evaluation of a patient
who is suspected of having a compartment syndrome,
the interpretation of the results raises several points
of controversy. As already discussed, either an
absolute value of intracompartmental pressure or the
difference between the diastolic blood pressure and
the intracompartmental pressure (which is used to
identify a perfusion pressure) has been used by some
as an indication to perform a fasciotomy(3,7,11,15,19,23,
32)
. McQueen et al.(15,17) recently reported on the use
of a differential pressure of less than thirty
millimeters of mercury (4.00 kilopascals) as the
threshold for a fasciotomy. With use of this criterion,
three of 116 patients with a tibial fracture had a
fasciotomy and none of the 116 patients were
observed to have sequelae(15). Several patients had an
absolute intracompartmental pressure of greater than
forty millimeters of mercury (5.33 kilopascals) but
were simply observed because the differential
pressure was more than thirty millimeters of mercury
(4.00 kilopascals). The authors concluded that simple
observation was safe, even when the absolute
compartmental pressure was high, if the diastolic
pressure remained high enough to perfuse the
compartment(15,17).

venous return and contribute to ischemia of the leg.


Matsen et al.(20) showed that, in three normal human
subjects, elevation of the limb to the 9090 position
decreased the tolerance to external pressure by thirtyfive millimeters of mercury (4.67 kilopascals). Lastly,
hemorrhagic shock decreases the mean arterial
pressure and can be an important factor in the
development of a compartment syndrome,
particularly in a multiply injured patient. For these
same reasons, a tourniquet should not be used for a
patient who has a tibial fracture and is at risk for a
compartment syndrome(35).
These considerations should be understood by any
surgeon who is planning a tibial nailing. When a
compartment syndrome is clinically suspected,
monitoring of the pressure in the anterior
compartment near the site of the fracture may be
helpful during and even after the nailing procedure.
The indication for fasciotomy should be a pressure
that is persistently within thirty millimeters of
mercury (4.00 kilopascals) of the diastolic blood
pressure, as recommended by McQueen and CourtBrown(15). Use of this guideline will allow the
surgeon to avoid many unnecessary fasciotomies that
would be done on the basis of a raw measurement of
pressure alone. Transient elevations should not be
considered evidence of compartment syndrome, as
they are common and are not associated with
sequelae(16,17,30).
Operative Technique for Fasciotomy
To perform an adequate fasciotomy, we use
extensive incisions that approximate the proximal-todistal length of the compartment to be decompressed.
A long fasciotomy is required for reliable
decompression of an acute compartment syndrome(5).
We do not recommend the use of a short incision that
does not span the length of the compartment.
Adequate decompression of the four fascial
compartments of the leg can be achieved with either
one or two incisions.
Regardless of the approach used, all four
compartments of the leg must be thoroughly
decompressed. We recommend that all of the
compartments be decompressed at the time of the
initial fasciotomy because after one compartment has
been released, hyperemia may precipitate increased
pressures in adjacent compartments. If the anterior
tibial artery was injured at the time of the tibial
fracture, the anterior skin bridge created by the twoincision technique survives only as a fasciocutaneous
flap. Because the acceptable length-to-width ratio for
this type of flap may be exceeded, the skin bridge,
particularly if it has been injured, may be placed in
jeopardy when the two-incision technique is used.
Matsen et al.(19) modified the single lateral incision
advocated by Kelly and Whitesides(13), who
performed decompression by fibulectomy. (We do
not believe that the fibula should be removed during
the treatment of a tibial fracture.) With this modified
method(19), the incision is made from the fibular neck
to the lateral malleolus. The skin is then retracted to
expose and decompress the anterior, peroneal, and
superficial posterior compartments. The deep

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with the various types of fractures (as classified


according to the system of Tscherne and Gotzen(31)).
McQueen et al.(17) later reported that a compartment
syndrome had developed in twenty-two (6.4 per cent)
of 342 patients who were thirty-five years old or less.
Because of the seemingly contradictory evidence in
these clinical series, objective data must be evaluated.
The development of compartment syndrome in two
patients who had been managed with nailing with
reaming prompted Moed and Strom(22) to study the
pressures in the anterior and deep posterior
compartments in dogs during and after nailing with
reaming. The intracompartmental pressures increased
during nailing with reaming and then returned to
normal after fasciotomy in two of the ten dogs in the
study group, whereas the intracompartmental
pressures did not increase in any of the ten dogs in
the control group (dogs that had a fracture but did not
have nailing). The mean pressure was significantly
higher (p < 0.05) in the anterolateral compartment of
the dogs that had had intramedullary nailing, and this
difference persisted for three hours postoperatively.
No traction devices were used during the nailing
procedures, which more strongly implicates reaming
as the cause of the high intracompartmental
pressures.
In contrast, Tornetta and French(30) studied
intracompartmental pressures during tibial nailing
without reaming and without the use of continuous
traction. They continuously monitored the pressure in
the anterior compartment in thirty patients and found
that the peak intracompartmental pressures occurred
during manual reduction and during insertion of the
nail. The pressure exceeded forty millimeters of
mercury (5.33 kilopascals) in twelve of the thirty
patients and was within thirty millimeters of mercury
(4.00 kilopascals) of the diastolic blood pressure in
fifteen. All of the increased pressures returned to
baseline levels immediately after the nail had been
inserted, and there were no residual neurological
abnormalities in any of the fifty-six patients who had
had no clinical signs of compartment syndrome when
they were first seen.
After evaluation of these studies, several
conclusions can be made. First, acute compartment
syndrome is seen after tibial nailing with reaming.
Second, efforts should be made to avoid mechanical
factors that may potentiate compartment syndrome.
The most important factors that increase the
intracompartmental pressure seem to be longitudinal
traction, reaming, and the position of the lower limb.
Shakespeare and Henderson(25) showed that, in
patients who had an acute tibial fracture, the pressure
in the deep posterior compartment increased 5.7 per
cent per kilogram of weight applied for calcaneal
traction. Wozasek et al.(34), in an experimental study
in sheep, reported that the intramedullary pressure
increased as much as tenfold during reaming. This
increased pressure may cause extrusion of blood and
marrow products through the fracture into the
compartments. The position of the limb also must be
considered. The standard 9090 position requires
countertraction with the use of a posterior thigh-bar.
The use of this bar can decrease arterial flow and

longus muscles.
Great variation has also been found in the course of
the cutaneous branches of the superficial peroneal
nerve. Blair and Botte(2) recently reported that the
most common pattern was a single nerve that exited
the crural fascia at an average of twelve centimeters
proximal to the ankle joint and then divided into its
terminal branches approximately four centimeters
proximal to the ankle joint. In the other patterns, the
medial and intermediate dorsal cutaneous nerves
arose independently from the superficial peroneal
nerve and pierced the fascia separately; the
intermediate dorsal cutaneous nerve penetrated the
fascia at a more distal point in the leg than did the
medial dorsal cutaneous nerve (usually within about
six centimeters proximal to the ankle joint). The
intermediate dorsal cutaneous nerve may be located
anterior or posterior to the lateral malleolus and may
remain in close proximity to it.
The locations of the muscular branches of the
peroneal nerve also have been more clearly
delineated recently(26,27). In addition to its recurrent,
deep, and superficial branches, the common peroneal
nerve was found to give off several muscular
branches near the fibular neck. Most of these
branches supplied the peroneus longus and extensor
digitorum muscles. This leash of nerve fibers was
located in the anterior compartment, two to five
centimeters distal to the head of the fibula.
An important implication of these recent
anatomical studies relates to the technique used for
the release of the anterior and lateral compartments.
This can be done either by division of the deep fascia
of one compartment and then division of the
intermuscular septum for the release of the other
compartment (Fig. 1-A) or by the individual release
of each compartment through its outer fascia
(Fig. 1-B). Because of the variable location of the
superficial peroneal nerve within and crossing the
anterior compartment, the second technique is safer.
However, it must be remembered that the nerve may
lie immediately beneath the fascia and therefore may
be vulnerable to injury when this method is used.
The terminal cutaneous branches of the superficial
peroneal nerve are at risk at the distal end of the
fasciotomy after they pierce the crural fascia, most
commonly at the junction of the middle and distal
thirds of the leg, approximately twelve centimeters
proximal to the ankle. The intermediate dorsal
cutaneous nerve is at particular risk if it crosses the
fibula or lies too close to it. Likewise, care must be
taken in the proximal region of the leg to avoid
damage to the branches of the common peroneal
nerve.
Outcome of Compartment Syndrome
When the diagnosis of a compartment syndrome is
made early and a fasciotomy is performed promptly,
most patients have few sequelae. Rorabeck and
Macnab(24) documented that patients who had a
release within six hours of the diagnosis had a full
recovery, whereas those who had a release after six
hours (mean time to operation, eighteen hours) had
sequelae. In a study of the malpractice costs

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posterior compartment is exposed by retraction of the


peroneal compartment anteriorly and release of the
soleus from the fibula to reveal the fascia.
In most instances, the two-incision technique
affords better exposure of the four compartments, and
release of the soleus from the fibula is not required. A
lateral incision is made over the intermuscular
septum between the anterior and lateral compartments
to release these two compartments. The medial
incision is made two centimeters from the medial
crest of the tibial shaft. The superficial posterior
compartment is easily exposed by retraction of the
skin. After the superficial posterior compartment has
been released, the deep posterior compartment is
exposed by retraction of the superficial compartment
posteriorly. The interval between the superficial and
deep compartments is best identified in the distal onethird of the leg where the gastrocnemius-soleus unit
becomes tendinous. The deep posterior compartment
should be released throughout its entire length.
After the fasciotomy, a bulky compression dressing
and a splint are applied. The foot should be placed in
slight dorsiflexion to prevent an equinus contracture.
The incision for the fasciotomy usually can be closed
after three to five days. When two incisions have
been made and it is not possible to close both,
delayed primary closure of the medial wound should
be performed. On the lateral side, where there is good
muscle coverage over the bone, the wound may be
closed by one of several methods involving the use of
split-thickness skin grafts, relaxing incisions, or skinstretching devices. Regardless of the method,
excessive skin tension must be avoided with closure.
It is important to understand the course of the
superficial nerves, especially the divisions of the
peroneal nerve, in relation to the techniques of
fasciotomy, as these nerves can be damaged when the
lateral incision is made.
The common peroneal nerve originates from the
sciatic nerve in the thigh. It enters the leg by passing
anteriorly around the fibular head under the proximal
portion of the peroneus longus muscle(33). The nerve
then divides into the superficial and deep branches
between the peroneus longus and the fibular neck.
The deep peroneal nerve courses distally in the
anterior compartment and supplies the muscles
therein. The superficial peroneal nerve passes through
the lateral compartment and supplies the peroneus
brevis and longus muscles before it pierces the fascia
in the distal third of the leg and terminates as the
medial and intermediate dorsal cutaneous nerves of
the foot.
Recent attention has been given to the variations in
the course of the superficial peroneal nerve and its
cutaneous branches. Adkison et al.(1) studied the
nerve in eighty-five legs from cadavera. In only sixtytwo legs (73 per cent) did the nerve remain in the
lateral compartment from its origin to its exit through
the deep fascia, three to eighteen centimeters
proximal to the lateral malleolus. In twenty-two legs
(26 per cent), the nerve or one of its branches passed
through the anterior compartment. In one leg (1 per
cent), the nerve coursed directly beneath the deep
fascia and superficial to the peroneus brevis and

Overview
A compartment syndrome of the leg may be a
devastating complication of a tibial fracture.
Meticulous and repeated examinations of the patient
who has such a fracture are needed to ensure that the
diagnosis is not missed. In patients who are
conscious, sensory changes usually occur before
motor changes. Pain on passive stretching of the
muscles in a given compartment may be the earliest
clinical indicator(24). In patients who are obtunded or
anesthetized, objective criteria must be used to make
the diagnosis. Intracompartmental pressure is the sole
objective measurement and constitutes an indirect
measurement of muscle and nerve ischemia. We
believe that the most reliable measurement is the
difference between the diastolic blood pressure and
the intracompartmental pressure (differential
pressure, or P), and we consider a differential
pressure of less than thirty millimeters of mercury
(4.00 kilopascals) to be indicative of compartment
syndrome. Patients who are managed with tibial
nailing are at particular risk, especially if reamers and
prolonged traction are used(22,29). In these situations,
monitoring of the pressure in the anterior
compartment is a judicious step. If the nail is inserted
without the use of continuous traction or reaming,
incidental but short-lived increases in pressure will
occur, but continuous monitoring is not needed(30).
Once a compartment syndrome has been diagnosed,
emergent fasciotomy is needed to avoid permanent
neurological sequelae(24). Many techniques are
available, but regardless of the method chosen, all
four compartments must be released throughout their
entire extent. A delay of more than six hours in the
diagnosis or the fasciotomy usually leads to
permanent weakness. The surgeon must have a high
index of suspicion for compartment syndrome for all
patients who have a tibial fracture.

1.

2.

3.

4.

5.

6.

7.

8.

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10.

11.

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13.

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Blair, J. M.; and Botte, M. J.: Surgical
anatomy of the superficial peroneal nerve in
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305:229-238.
Blick, S. S.; Brumback, R. J.; Poka, A.;
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Compartment syndrome in open tibial
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Chapman, M. W.: Fractures of the tibial and
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Gaspard, D. J.; and Kohl, R. D., Jr.:
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Hamza, K. N.; Dunkerley, G. E.; and Murray,
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Hargens, A. R.; Romine, J. S.; Sipe, J. C.;
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Heckman, M. M.; Whitesides, T. E., Jr.;
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Kelly, R. P.; and Whitesides, T. E., Jr.:
Transfibular route for fasciotomy of the leg

Redistribution of this article permitted only in accordance with the publishers copyright provisions.

associated with a missed diagnosis of compartment


syndrome in eight patients(28), the average indemnity
was nearly $280,000. The sequelae included
amputation and complete loss of function of the
lower extremity. The costs were high because the
patients were young (average age, sixteen years), with
an average work-life expectancy of thirty years; thus,
the loss of productivity in these patients was severe.
Two factors were found to contribute to the missed
diagnosis. First, intracompartmental pressure had not
been measured in any of the patients. This points to
the need for early diagnosis of a compartment
syndrome and the timely measurement of
intracompartmental pressure. Second, some patients
had been evaluated by more than one physician as the
syndrome evolved over a period of time. This
demonstrates the need for improved communication
between health-care providers in the assessment and
observation of patients who are at risk for the
development of a compartment syndrome.

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[abstract] J. Bone and Joint Surg. July 1967;


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McQueen, M. M.; and Court-Brown, C. M.:
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The pressure threshold for decompression. J.
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Fig. 1-B: Illustration showing the individual release


of each compartment through its outer fascia (the
preferred technique).

Redistribution of this article permitted only in accordance with the publishers copyright provisions.

Fig. 1-A: Illustration showing release of the


compartments by division of the deep fascia of the
anterior compartment first and then division of the
intermuscular septum for release of the lateral
compartment.

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