Burns 32 (2006) 284292

www.elsevier.com/locate/burns

Decompression not escharotomy in acute burns

Andrew Burd *, Frederick V. Noronha, Kawser Ahmed, Jimmy Y.W. Chan,
T. Ayyappan, S.Y. Ying, Peter Pang
Division of Plastic and Reconstructive Surgery, Department of Surgery,
The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong
Accepted 10 November 2005

Abstract
The concept of escharotomy has long been associated with acute burns care. Nevertheless the practice of escharotomy is frequently flawed
and there is considerable diversity in the teaching of the procedure. It is proposed that there should be a fundamental change in the teaching of
acute burn management and the concept of decompression should be promoted. The justification for this change comes from a review of the
present knowledge base using indexed, library and web-based information sources and also a review of a series of patients transferred to a
regional burns unit over a five-year period which revealed that 37% of patients who required surgical decompression had not been
appropriately treated prior to transfer. Based on relevant compartmental anatomy a change in the surgical decompression of limbs is proposed
to allow safer and more effective management.
# 2005 Elsevier Ltd and ISBI. All rights reserved.
Keywords: Burns; Escharotomy; Decompression; Compartment syndrome

The term escharotomy is almost universally associated

with the acute management of major burns. The principles
and practice of the procedure of escharotomy are, however,
flawed, often poorly taught, often ineffectively executed
and there is a serious need of reappraisal [1]. Controversy
regarding the concept of escharotomy is not new and one of
the first indexed papers is the classic Escharotomy in
Burns Care written by Pruitt et al. in 1968 [2]. In this paper
Pruitt reviewed the then emerging controversies regarding
escharotomy. These principally related to the number, site
and depth of releasing incisions. We have reviewed the
current knowledge base regarding escharotomy and
fasciotomy in burns patients. In addition, we have reviewed
the clinical experience in our burns centre over a five-year
period. We conclude that the procedure of escharotomy
remains fundamentally flawed and propose that it should be
abandoned and replaced with a concept of a process,
decompression.

* Corresponding author. Tel.: +852 2632 2639; fax: +852 2632 4675.
E-mail address: andrewburd@surgery.cuhk.edu.hk (A. Burd).
0305-4179/$30.00 # 2005 Elsevier Ltd and ISBI. All rights reserved.
doi:10.1016/j.burns.2005.11.017

1. Methods
In order to determine the current knowledge base we
searched the three main sources of information (excluding
expert opinion); indexed publications accessible through
Medline; non-indexed and other web-based articles accessible via Google and text books in a University Medical
School Library. For the search engines the terms burns and
escharotomy; burns and fasciotomy and burns and
compartment syndrome were used.
Textbooks covering general surgery, orthopaedics,
accident and emergency medicine, burns and plastic surgery
were searched for references to burns and escharotomy,
fasciotomy and compartment syndrome. Identified texts
were then analysed for information regarding:
(i)
(ii)
(iii)
(iv)
(v)
(vi)

indications
when and where the procedure was performed
type of anaesthesia
surgical anatomy
technical details
blood loss

A. Burd et al. / Burns 32 (2006) 284292

(vii) peri-operative monitoring

(viii) post-operative care: dressings, positioning and monitoring
For the clinical review we have looked at all complex
major burns referred to the Prince of Wales Hospital in the
five-year period August 1999July 2004. These patients
were identified by referring to burns admission to the
Intensive Care Unit. All burns admitted to the ICU required
ventilation either because of airway compromise or
extensive burns requiring acute surgical intervention. A
sub-group was identified who had been transferred from
other hospitals and the management of chest and limb
compartments was noted before and after admission.

2. Results
Table 1 shows the respective response for the three search
strategies. This reflects an increasing problem with the
explosion of information on the Internet but the lack of
control or validation. Cited journals are a source for peer
reviewed articles but the literature is not profuse
with less
than one article per year. Reviewing the descriptions of
escharotomy in a selection of text books is particularly
revealing. Sixty textbooks were identified which described
some form of tissue decompression in acute burns. The data
was unsatisfactory to the extent that few descriptions covered
all aspects of the information sought and so comparative
figures cannot be given for the overall descriptions. Table 2
shows the breakdown of available information for escharotomy mentioned in 57 (out of 60) books and fasciotomy
mentioned in 24 (out of the same 60) books.

3. Clinical experience
In the five-year study period 118 patients were admitted to
our Intensive Care Unit with serious burns. Twenty-seven
(23%) underwent a surgical decompressive procedure in the
acute phase of treatment. Within the total group of 27 patients
55 limbs and 12 chest and abdomens were decompressed.
In 17/27 (63%) the treatment was appropriate both in timing
and effect; however, in 10/27 (37%) there were problems

285

related to decompression. In five cases escharotomies had

been performed prior to transfer to our hospital and these had
to be urgently revised on admission. In all five, prior
escharotomies were converted to fasciotomies. These conversion-fasciotomies accounted for 11/55 limbs decompressed. In another five cases no decompression had been
performed prior to clinical transfer but clinical compromise
required immediate surgical intervention on admission. We
do recognize a significant problem with cross-border transfers
and in an evolving clinical situation the status at the time of
transferring a patient can be quite different from the status at
the time of receiving the patient.
In two patients dead muscle was found at the time of
primary decompression. In both cases the muscle involved
was the antero-lateral compartment of the lower limb. One
of these patients subsequently went on to have a forequarter
amputation for upper limb compartmental sepsis that
developed two weeks post burn. A third patient underwent
an above knee amputation for compartmental sepsis in the
calf. Both patients having amputations had extensive
muscle necrosis and liquefaction with a healthy perfused
periphery, hand or foot. Of note both these patients had been
admitted more than 36 h post burn to our unit because of
transfer problems. One patient self-repatriated from Mainland China during the SARS outbreak. The other patient had
ingested poison as well as self-immolated and which
complicated her pre-transfer stabilization.

4. Discussion
It is obvious that over the past 35 years since Pruitts
classic paper was published the concept of escharotomy
is still riddled with divergent opinion. A major concern is
that escharotomy is a procedure. Procedures typically refer
to technically detailed and anatomically defined interventions which are performed in a context of time with a
beginning and end. Examples are setting up an intravenous
infusion or inserting a urethral catheter. Once completed
the procedure is ticked off and the next item on the check
box addressed. What is actually required is a process. The
process is decompression and requires a continuum of
assessment and reassessment with a number of possible
interventions. The aim of decompression is to ensure the

Table 1
There has been an extraordinary rise in the number of websites picked up in the Google search engine. Whilst this will include many new sites it also reflects
improvements in a indexing and search power

Google
26/5/2004
26/5/2005
Medline
1966May 2004 (week 3)
1966May 2005 (week 3)

Burns and
escharotomy

Burns and
fasciotomy

Burns and
compartment syndrome

535
729

610
3950

4460
37800

33
38

30
37

39
40

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A. Burd et al. / Burns 32 (2006) 284292

Table 2
This table reflects the diversity of the published work which in turn is an indication of the confusion and controversy over the clinical practice
Textbooksescharotomy (total: 57 books)
Frequency

Percentage

Location

Bedside
Accident and Emergency department
Theatre

24
6
2

75
19
6

Anaesthesia

Not required
Intravenous sedation
Local anaesthetic
General anaesthetic
None

22
5
4
3
2

61
14
11
8
6

Blood loss

Minimal
Bleeding risk
Substantial

7
4
1

58
33
9

Equipment

Electrocautery device
Scalpel
Diathermy and hemostatic clips/ligature

21
14
2

57
38
5

Peri-operative monitor

Intramuscular pressure
Pulse
Capillary refill
Neurological function
Sensation
Color

22
8
4
4
2
1

54
20
10
10
4
2

Textbooksfasciotomy (total: 24 books)

Frequency
Indications

Electrical burns
Excessive compartment pressure
Compartmental pressure >30 mmHg
Escharotomy fails
Deep thermal injury
Crush injury
Skeletal trauma

Location

Theatre

microcirculation maintains adequate tissue oxygenation.

Decompression has to be considered for all body
compartments where a rise in compartmental pressure
can lead to compromise of vital function.
These compartments include the intracranial and extracranial head and neck, thorax, abdomen and limbs.
Decompression of the cranium may include the use of
hyperosmolar solutions to reduce brain swelling, decompressive craniotomies, reduction of fluid input and elevation
of the upper body. Decompression of the thorax is often
inadequately done. Of particular note is that it is in this
particular procedure that text books reveal the most
inconsistency between the written description, the diagrams
and clinical photographs. Indeed in Pruitts classic paper [2]
the diagram of the chest release which has been
subsequently repeated in many publications shows a
transverse chest incision which is too high to disassociate
the ribs from the abdomen (Fig. 1). The clinical photograph
shows a patient who has been effectively decompressed
despite circumferential full-thickness burns and gross
oedema (Fig. 2). Abdominal compartment syndrome has
only relatively recently been appreciated [36]. Measure-

Percentage

12
5
4
3
3
1
1

41
17
14
10
10
4
4

100

ment of intra-abdominal hypertension by direct measurement of bladder pressure has been described by Ivy who also
presents an algorithmic approach to management beginning
with simple sedation and progressing through diuresis, if

Fig. 1. (a) Depicts the often reproduced diagram of chest decompression

that indicates a transverse release mid-way between the costal margin and
the nipple and (b) shows a release which is just below and parallel to the
costal margin. The latter release will effectively separate the abdomen and
thorax and reduce resistance to ventilation.

A. Burd et al. / Burns 32 (2006) 284292

287

only one paper related to burns [15]. Considerable attention is

addressed to establishing the diagnosis and this relies on
clinical examination and both direct and indirect measurement of compartment pressures. It is reassuring to see one text
that lists as the early finding of compartment syndrome [16]:






Fig. 2. Effective release of anterior chest skin to allow respiratory excursion

of the ribs. Note the medial left arm fasciotomy.

indicated, eschar release, paracentesis and ultimately

laparotomy [5]. It is in the context of the limbs that
decompression become a more critical issue of review with
regard to traditional practices. Whilst conventional thinking
focuses on peripheral perfusion the concern should more
appropriately be focused on the raised interstitial pressure in
the closed osteofascial compartments resulting in microvascular compromise [7]. The compartmental anatomy of
the limbs has been well described with two compartments in
the arm, three in the forearm, ten in the hand, three in the
thigh, four in the lower leg and four in the foot [812].
Within the context of this anatomy there is now a greater
appreciation of the microcirculation of the skin [13,14] and
the consequences of increasing compromise to the microcirculation of the muscles leading to muscle ischaemia.
Orthopaedic and vascular surgeons are well aware of the
concept of compartment syndromes but too often in burns
the focus appears to be on the periphery, hand or foot than
the forearm or calf.
Typically orthopaedic and vascular surgeons will
recognize two types of compartment syndrome. Type 1
occurs with a proximal arterial injury leading to a postreperfusion compartment syndrome, whereas type 2 is
caused by direct trauma and subsequent elevated pressure.
The mechanism of compartment syndrome in the acute burn
injury is rather different but the effects are the same. As
interstitial pressure rises a vicious cycle develops whereby
cell death occurs leading to further oedema and further rise
in pressure and cellular compromise. In the acute burn it is
possible to recognize an incipient phase of compartment
syndrome which preceeds the acute syndrome. The acute has
early and late stages.
4.1. Acute compartment syndrome
As acute compartment syndrome (ACS) is both life and
limb threatening it has received considerable attention
particularly in the orthopaedic and vascular literature. Tiwari
et al. present a review of ACS based on both Pubmed and
Cochrane database searches but this is notable in revealing

a palpably tense limb

palpable pulses
pain on stretching muscles
paresthesia and
a brisk capillary refill

This latter sign is frequently not mentioned.

The measurement of compartment pressures has been
well researched and there are well validated techniques
which have crossed the bridge from laboratory research
to clinical application in particular the wick catheter [17].
A non-invasive technique to objectively measure quantitative hardness of limb compartments has been described
[18] but has not found widespread clinical application.
This is an important and unresolved aspect in burns care
as the extensive nature of the injuries can present
practical limitations of individual compartment pressure
monitoring particularly when multiple limbs are involved
Table 3.
4.1.1. Relevance of raised compartment pressures
It has been well established that a compartment pressure
of greater than 30 mmHg for 8 hours or more can cause cell
death by interference with the microcirculation [19]. It has
also been well established that direct pressure on nerves can
caused reversible dysfunction and studies of the median
nerve in the carpal tunnel suggested that pressure between
40 and 50 mmHg presents a critical threshold beyond which
nerve function is acutely altered [20].
4.2. Management
Prevention is always preferable if possible and one
important aspect in management is positioning. In the
Table 3
Compartment syndrome is a progressive pathology which is reversible if
detected early
Type and stage

Characteristics

Incipient compartment
syndrome

Early period of limb

swelling but fully reversible
if appropriately treated

Acute compartment syndrome

Early

Late

Excessive compartment pressure

has occurred initiating cascade of
ischaemia, oedema and cell death
Extensive muscle and nerve
necrosis not yet present
Extensive muscle and nerve death
has occurred resulting in major
irreversible injury

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A. Burd et al. / Burns 32 (2006) 284292

patient with burn at the extremity who may be at risk of

developing compartment syndrome there is a widespread
practice to elevate the limbs. This, however, may have a
counterproductive effect by reducing mean arterial pressure
and thereby capillary flow. Conversely allowing the limb to
become dependent may increase the swelling of the tissues.
The best compromise therefore is to place the extremity at
the level of the heart. In practical terms this means resting on
one pillow [16].
Any constricting bandaging or clothing must be removed
and the haemodynamic status of the patient reviewed
particularly with regard to fluid overload. One important
aspect of fluid management is the introduction of colloid.
Although this remains a controversial issue from the
perspective of overall survival [21] the general consensus
in the burn community is that using colloid reduces total
infusion volumes [22]. This can make a significant
difference for the patient with borderline perfusion of the
microcirculation in burned extremities and even if for this
reason alone colloid infusion should be considered in burn
resuscitation.
4.2.1. Surgical management
When considering acute compartment syndrome prompt
surgical decompression is indicated. Whilst reports of late
decompression with a favourable outcome do exist these are
rare [23]. When the details of surgical technique are
reviewed it is evident that all is not well. One report
describing a clinico-anatomical perspective of a lower limb
compartment syndrome declared that current surgical
technique was poorly described in most texts [24]. This
situation seems to have improved and certainly in the
orthopaedic literature there are some excellent accounts of
limb decompression [10]. Nevertheless there are some areas
where the prudent authors do not adopt a dogmatic approach
and leave the operative surgeon with individualizing the
surgical management.

4.3. Principles of fasciotomy

In Rowlands description of upper limb fasciotomy
several principles are underlined which influence the
positioning of the skin incisions [11]. These principles
apply to fasciotomies on both upper and lower limbs.
(1)
(2)
(3)
(4)

Damage to cutaneous nerves should be avoided.

Longitudinal veins should be preserved where possible.
Straight line incisions across joints should be avoided.
Direct decompression of major nerves and/or vessels as
indicated.

5. Relevance of fasciotomy to escharotomy

The classical teaching in burns management is that limb
escharotomies should be performed when the distribution
and depth of the burn actually or potentially compromises
tissue perfusion. Advice is given, or should be given, that the
patient needs subsequent monitoring to assess the adequacy
of tissue perfusion and that if there is evidence of continuous
compromise particularly of muscle perfusion in closed
compartment, that these should be decompressed. The major
concern is how the limb that has been initially treated with
an escharotomy should be further decompressed? Many
texts will simply say that if there is continuing evidence of
vascular compromise the escharotomy incisions should be
deepened to include the deep fascia. This often repeated
dictum is fundamentally wrong, and is particularly
dangerous when applied to the lower limb which is the
limb most affected by permanent vascular compromise and
amputation after burn.
The cross section of the calf (Fig. 4) shows the position
of the conventionally recommended escharotomy incisions.
It can be seen that by extending these through the deep
fascia will still leave the anterior and deep posterior

Table 4
Decompression is a continual process and does not depend on clearly defined and quantifiable parameters. Judgment is needed particularly in the late
presentation. On balance it is perhaps better to err on the side of decompression in the early presentation (<12 h post burn) and against decompression in the late
presentation (>24 h post burn)
Decompression
Remove
Positioning
Fluids
Surgery strongly indicated irrespective of signs and symptoms
Surgery must be considered (even in non-burned limbs)
If full thickness
Skin incision

Rings, tight clothing, tight bandages

Level of the heart
Consider colloids from 1224 h
Circumferential full and deep partial thickness burns
Extensive burns with large volume resuscitation even in non-circumferential burns
Consider fasciotomy
Consider as far fasciotomy

Optimum Conditions

In theatre
GA
Aseptic Technique
Coagulating diathermy
Consider practicality and feasibility
Again. Again. Again.
Consider leaving limb undecompressed if periphery viable

Monitoring
Clinic assessment
Late presentation > 24 h

A. Burd et al. / Burns 32 (2006) 284292

compartments unreleased. It is of course possible to

emphasise that all four compartments should be released
but it is our thesis that the best way in which to achieve this is
to repeatedly stress the process of decompression rather
than the procedure of escharotomy. It follows then that if the
process of decompression is followed along a clinical
course with intervention, observation and response that the
spectrum of possible interventions should be reviewed in
order to plan the sequence of interventions. In this respect
the final surgical act of decompression is going to be the
release of the fascial compartments (although this is
admittedly not often necessary in burns). It would therefore
be logical and reasonable to suggest that the earlier
interventions, that is to say the escharotomy should be
performed through the same skin incisions advocated for

289

the fasciotomy although pending further clinical evaluation

the deep fascia would be spared.
5.1. Late presentation
One aspect of decompression that has received scant
attention in the Burns literature is what to do with the
patient who presents late, particularly with well established features of acute compartment syndrome. Decompression in this situation will undoubtedly open up a
compartment of necrotic muscle which is an excellent
culture medium for infection. This supports the conventional wisdom that if acute compartment syndrome has
been missed with a delay of 2448 h it is best to refrain
from extensive decompression and allow dead muscle to

Fig. 3. X-section of upper limb anatomy depicting the escharotomy incision (red arrow) and the fasciotomy incision (dashed line).

290

A. Burd et al. / Burns 32 (2006) 284292

resorb with some scarring. Whilst this may still result in

significant functional loss it may prevent an amputation or
even death from invasive sepsis. This is obviously an area
that needs more attention from Burns surgeons whilst
orthopaedic surgeons are already grappling with the
dilemma [25].

6. Recommendations
When teaching and describing the management of the
acute, severe, burn the prioritization of life threatening
intervention is listed as:

A. for airway (plus cervical spine)

B. for breathing
C. for circulation
We recommend that D should be for decompression.
Establishing this concept as a feature of fundamental
importance is the key to redefining the misguided emphasis
of burns care that results from teaching E for escharotomy.
There is an absolute difference between decompression a
process and escharotomy a procedure. Decompression
must be taught in the context of the unfolding pathophysiological response of a severe burn injury and involves a
range of possible interventions spanning from loosening
bandages; appropriate positioning of limbs (heart level);

Fig. 4. X-section of lower limb anatomy depicting the escharotomy incision (red arrow) and the fasciotomy incision (dashed line).

A. Burd et al. / Burns 32 (2006) 284292

avoiding fluid overload; to escharotomy and fasciotomy

(Table 4). Incision for the escharotomy should be both safe
and effective and capable of being easily extended in depth
to allow safe and effective fasciotomies to be performed. It is
beyond the scope of this paper to provide an extensive
review of fasciotomy incisions but Figs. 3 and 4 indicates the
association of classical escharotomy incisions, fasciotomy
incisions and limb compartments.
Surgical decompression should be performed in a clean
environment preferably an operating room. The burn
wound should be cleaned by antiseptic solution and the
patient covered as appropriate with surgical drapes. The
incision line should be marked on the skin with the body in
the anatomical position. Note that it is possible to lose
orientation once the limb is moved particularly when
supinating and pronating the forearm. The skin incision
should be made using the needle point unipolar diathermy
set on coagulation mode. If there is difficulty in penetrating
the superficial eschar cutting mode can be used initially.
Coagulation mode should be maintained as the initial
incision is extended through the subcutaneous fat and
superficial fascia. In the absence of clinical or direct
measurement of raised muscle compartment pressures the
limb release can be restricted to opening the eschar and
dividing the superficial fascia. The release can be extended
to but not through the deep fascia. Care should be taken to
preserve intact superficial veins and cutaneous nerves. The
wound should be loosely dressed with a non-adherent
gauze such as Bactigras (Smith and Nephew Healthcare
Ltd) and the limb dressed according to standard unit
protocols. Special care should be taken to avoid
constrictive bandaging and the limb position at the level
of the heart usually by resting it on one or two pillows.
Regular charting of parameters of peripheral perfusion
should be performed hourly with a low threshold for further
clinical evaluation.
When the decompression has been performed under the
ideal conditions in an operating theatre it is a matter of
clinical judgment whether to extend the incisions to include
the deep fascia and decompress the limb muscle compartments. Under such conditions the risk of introducing
infection should be minimized whilst the completeness of
decompression obviates the need for time consuming and
potentially misleading monitoring such as invasive compartment pressure studies. This is obviously another
contentious area of debate with the accuracy, reliability
and interpretation of an invasive monitoring technique
being weighed against perhaps unnecessary surgery. On the
other hand, it is important to avoid simply extending the
procedural mindset and suggest that since once a full
decompression has been performed and no further surgical
procedure can be performed that monitoring is no longer
necessary. It is perhaps more a question of the emphasis on
monitoring as the full decompressed limb is more at risk of
direct invasive infection and should be appropriately
monitored to detect any early signs of such an eventuality.

291

These will include, fever and purulent drainage or fever,

swelling and erythema in unburned skin, i.e. signs of
intracompartmental sepsis [26]. Two further points are
worth considering. In the isolated limb burn and when
logistics allow, more extensive burns, escharectomy can
provide both a release of constriction to the limb but also
decrease the continuing influx of vasoactive products.
Finally, if a fasciotomy has been performed in the acute
stage consideration should be given to formally closing this
when the oedema subsides.

7. Summary
Decompression is a process which requires assessment,
measurement and monitoring. Positioning of limbs and
qualitative and quantitative fluid resuscitation are important
considerations. Surgical intervention should ideally be
performed in an operating room environment with strict
adherence to aseptic technique. The depth, extent and
placement of incisions should be based on anatomical
considerations that allow for the safe and effective conversion
of an eschar release to a fascial release if indicated.

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