Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > Compartment Syndrome of the Foot
Compartment Syndrome of the Foot
Clifford L. Jeng MD
BasicsDescription
Compartment syndrome of the foot occurs when bleeding
and interstitial edema in the muscle compartments of the foot cause a
substantial decrease in capillary perfusion, resulting in myoneural
ischemia and eventual necrosis.
and interstitial edema in the muscle compartments of the foot cause a
substantial decrease in capillary perfusion, resulting in myoneural
ischemia and eventual necrosis.
General Prevention
Prevention of the long-term sequelae of compartment syndrome requires a high level of suspicion for the diagnosis.
Epidemiology
Incidence
Occurs in up to 17% of patients with calcaneus fracture (1)
Pathophysiology
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Blood flow ceases when local tissue pressure exceeds diastolic blood pressure.
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Tissue ischemia develops.
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Myoneural necrosis results, with long-term sequelae of pain, paresthesias, stiffness, claw toes, and foot deformity.
Etiology
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Frequently occurs with calcaneus fracture, midfoot/forefoot fractures, or crush injury of the foot (1,2)
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May occur with open foot injuries
DiagnosisSigns and Symptoms
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Severe pain
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Massive swelling
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Pain with passive stretching of the toes
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Diminished sensation or pulses less reliable
Imaging
Plain radiographs of the foot and ankle are necessary
for diagnosing fractures or dislocations that may be causing the
massive swelling.
for diagnosing fractures or dislocations that may be causing the
massive swelling.
Diagnostic Procedures/Surgery
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Invasive pressure measurement of the foot compartments is helpful for diagnosing compartment syndrome.
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Needle insertion sites for compartment pressure monitoring:
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Medial (abductor) compartment: Directly inferior to the 1st metatarsal
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Deep compartment: Advance the needle from the medial compartment ~1 cm deeper under the arch of the foot
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Interosseous compartment: Dorsal foot between the 3rd and 4th metatarsals
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Lateral compartment: Plantar to the 5th metatarsal
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Compartment syndrome commonly is defined as compartment pressure >30 mm Hg (2,3).
TreatmentInitial Stabilization
No circumferential bandages should be applied to the
area while monitoring for possible compartment syndrome because doing
so may worsen the condition.
area while monitoring for possible compartment syndrome because doing
so may worsen the condition.
General Measures
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A pneumatic foot pump often is useful in decreasing foot swelling early after trauma (4).
-
Oral or intravenous diuretics may help reduce edema.
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If compartment syndrome is suspected, invasive pressure measurements of the compartments should be performed.
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Early fasciotomy is the most reliable way to avoid the complications of compartment syndrome.
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Future fixation of these fractures must be considered when selecting the fasciotomy approach.
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Activity
If massive swelling is present, a patient should be kept at bed rest with the foot at heart level.
Nursing
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Vigilant
monitoring of the patient with a traumatic foot injury is necessary;
worsening or unremitting pain should prompt request for evaluation by
physician. -
Frequent testing of the foot for pain with passive stretching of the toes
-
If any change in the condition of the foot occurs, the physician should be called to check invasive pressure measurements.
Special Therapy
Physical Therapy
Stretching exercises and desensitization may be useful in a patient who has long-term sequelae of foot compartment syndrome.
Surgery
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Perform fasciotomy (compartment release):
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Surgical emergency once diagnosis is made
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Standard technique (5,6):
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2 dorsal incisions over the 2nd and 4th metatarsals to release adjacent interosseous spaces and lateral abductor compartment
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Medial arch incision to release abductor hallucis and deep muscle compartments
-
-
Alternative technique (6):
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Single medial incision to release abductor hallucis and deep compartments
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Muscles reflected plantarly
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Interosseous compartments released through medial approach
-
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P.85
Follow-up-
Foot fasciotomy incisions usually can be closed 5–7 days after the original surgery, once severe edema has subsided.
-
Split-thickness skin graft may be required to cover the wounds if the skin edges cannot be approximated.
Issues for Referral
Patients with severe foot trauma or massive swelling of the foot should prompt urgent orthopaedic consultation.
Prognosis
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The prognosis after a missed or untreated compartment syndrome of the foot is poor.
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Such patients typically have chronic pain and stiffness that can be disabling.
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Cavus or cavovarus foot deformities can occur secondary to myonecrosis and fibrosis of intrinsic foot muscles.
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Claw toes that require surgical release may develop.
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Complex regional pain syndrome can develop after compartment syndrome or crush injury.
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Complications
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Pain
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Paresthesias
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Stiffness
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Claw toes
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Foot deformities
References
1. Myerson MS. Management of compartment syndromes of the foot. Clin Orthop Relat Res 1991;271:239–248.
2. Manoli A, II. Compartment syndromes of the foot: current concepts. Foot Ankle 1990;10:340–344.
3. Myerson M. Diagnosis and treatment of compartment syndrome of the foot. Orthopaedics 1990;13:711–717.
4. Gardner
AMN, Fox RH, Lawrence C, et al. Reduction of post-traumatic swelling
and compartment pressure by impulse compression of the foot. J Bone Joint Surg 1990;72B:810–815.
AMN, Fox RH, Lawrence C, et al. Reduction of post-traumatic swelling
and compartment pressure by impulse compression of the foot. J Bone Joint Surg 1990;72B:810–815.
5. Manoli
A, II, Weber TG. Fasciotomy of the foot: an anatomical study with
special reference to release of the calcaneal compartment. Foot Ankle 1990;10:267–275.
A, II, Weber TG. Fasciotomy of the foot: an anatomical study with
special reference to release of the calcaneal compartment. Foot Ankle 1990;10:267–275.
6. Myerson
MS. Experimental decompression of the fascial compartments of the
foot—the basis for fasciotomy in acute compartment syndromes. Foot Ankle 1988;8:308–314.
MS. Experimental decompression of the fascial compartments of the
foot—the basis for fasciotomy in acute compartment syndromes. Foot Ankle 1988;8:308–314.
Additional Reading
Myerson M, Manoli A. Compartment syndromes of the foot after calcaneal fractures. Clin Orthop Relat Res 1993;290:142–150.
MiscellaneousCodes
ICD9-CM
958.8 Compartment syndrome
FAQ
Q: What is the pathophysiology of compartment syndrome?
A:
Trauma or severe intramuscular edema causes impairment of
intracompartmental microcirculation, leading to cell ischemia,
necrosis, and intracellular fluid leakage, which propagates additional
increase in compartment pressure. Muscle and nerve tissue is
susceptible to ischemia, leading to myonecrosis and nerve injury.
Trauma or severe intramuscular edema causes impairment of
intracompartmental microcirculation, leading to cell ischemia,
necrosis, and intracellular fluid leakage, which propagates additional
increase in compartment pressure. Muscle and nerve tissue is
susceptible to ischemia, leading to myonecrosis and nerve injury.
Q: Which group of patients is especially at risk for a compartment syndrome of the foot?
A: Patients with crush injuries or calcaneal fractures are at greatest risk.