Nerves are the structure most sensitive to the effects of compartment syndrome. Animal models have delineated the time course of irreversible damage to the nerves. Regardless of peak compartment pressures, if release of pressure occurred within 4 h, nerve conduction returned to baseline. After 12 h complete irreversible ischemia occurred. Between 4 and 12 h the peak compartment pressure is significant. With exceptionally high pressures irreversible necrosis occurs at 4 h. This data suggests there is a small window for reversal of the process [6, 7].

One translational study recently investigated functional outcomes in a swine model of hemorrhagic shock, hind limb ischemia, and reperfusion with prophylactic fasciotomy at 1, 3, and 6 h of ischemia. Increasing ischemic intervals resulted in incremental increases in compartment pressure without reaching >30 mmHg. While trends were observed in sensory improvement between the 3- and 6 h groups, this was not statistically significant, nor did it translate to a notable difference in functional outcomes. While this demonstrates that the use of prophylactic fasciotomies in this particular swine model of hemorrhagic shock does not improve functional outcome, all ischemic times were 6 h or less. This suggests in short ischemic times prophylactic fasciotomies may not be beneficial [8].

There are several clinical features that are associated with an increase need for fasciotomies and presumably compartment syndrome. In a single large series, mechanism of injury is not independently associated with need for fasciotomy [9]. Arterial ligation and combined arterial-venous injuries both have increased risk of compartment syndrome. The level of the injury also plays a significant role. Popliteal injuries have a significant increase in the need for fasciotomies (61 %) vs injuries above the knee (19 %) [10]. Prolonged ischemia time of >4–6 h is also associated with an increased risk. Lastly, prolonged hypotension is associated with both the need for fasciotomies and limb loss [9, 11].

Fasciotomy, while inherently performed for limb salvage, can result in significant complications including amputation. The most feared complication is incomplete compartment release or delayed fasciotomy, resulting in a high rate of morbidity and mortality [12]. The most commonly missed compartments were the anterior and posterior deep compartments containing the main neurovascular bundles of the leg. Patients who underwent delayed fasciotomy had a 3-fold increase in mortality and twice the rate of amputation. Chronic venous insufficiency may be a result of loss of the muscle pump and deterioration of venous hemodynamics.[13]. Nerve damage and neuropathic pain have been documented in patients after fasciotomy resulting in decreased plantar flexion, dorsal extension, sensory deficits in 53–70 %, and pain in 15–26 % which increased with exertion. Approximately 7 % rate of superficial peroneal nerve injury occurs with fasciotomy [14], leading to inability to evert the foot, and loss of sensation over the dorsum of the foot. Minor but potentially lifestyle limiting complications also occur such as pain, disfiguring wounds, infection, skin changes, and recurrent ulcerations [15, 16].

Advocates of prophylactic fasciotomies stress that early fasciotomy can reduce the high morbidity associated with compartment syndrome. The largest review of prophylactic fasciotomies in patients with vascular injury is a retrospective review of the National Trauma Databank (NTDB) from 2002 to 2006. [17]. The NTDB is the largest trauma database in the US, and is comprised of voluntarily-reported patient information. Inclusion criteria were patients greater than 18 with lower extremity arterial injury, arterial repair, and fasciotomy. Patients were divided into 2 groups relative to the timing of fasciotomy – the late group had a fasciotomy performed less than 18 h after the vascular repair, while the early group was decompressed within 12 h. Outcomes were in-hospital mortality, amputation rates, complications, and length of hospital and ICU stays.