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Foot Compartment Syndrome

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Topic updated on 08/06/16 11:24am
Introduction
  • Devastating condition where an osseofascial compartment pressure rises to a level that decreases perfusion
  • May lead to irreversible muscle and nerve damage
  • May occur anywhere that skeletal muscle is surrounded by fascia, but most commonly
    • leg
    • forearm
    • hand
    • foot (details below)
    • thigh
    • buttock
    • shoulder
    • paraspinous muscles
  • Pathophysiology
    • local trauma and soft tissue destruction> bleeding and edema > increased interstitial pressure > vascular occlusion > myoneural ischemia
  • Causes
    • trauma
      • fractures (69% of cases)
        • 5-17% of calcaneus fractures result in compartment syndrome
      • crush injuries
      • severe ankle sprains
      • gunshot wounds
    • tight casts, dressings, or external wrappings
    • burns
    • postischemic swelling
    • bleeding disorders
    • vascular injury
Anatomy
  • 9 main compartments (controversial)
    • medial
      • abductor hallucis 
      • flexor hallucis brevis 
    • lateral
      • abductor digiti minimi 
      • flexor digiti minimi brevis 
    • interosseous (x4)
    • central (x3)
      • superficial 
        • flexor digitorum brevis 
      • central
        • quadratus plantae 
      • deep
        • adductor hallucis 
        • posterior tibial neurovascular bundle
Presentation
  • Symptoms
    • pain out of proportion to injury
  • Physical exam
    • pain with dorsiflexion of toes (MTPJ) 
      • places intrinsic muscles on stretch
    • tense swollen foot
    • loss of two-point discrimination
    • pulses
      • presence of pulses does not exclude diagnosis
Evaluation
  • Radiographs
    • obtain to rule-out fracture
  • Compartment pressure measurements 
    • indications
      • polytrauma patients
      • patient not alert/unreliable
      • inconclusive physical exam findings
    • relative contraindication
      • unequivocally positive clinical findings should prompt emergent operative intervention without need for compartment measurements
    • technique
      • central compartment
        • base of first metatarsal
        • direct needle lateral and plantar through abductor hallucis
      • medial compartment
        • base of first metatarsal advancing 2cm into abductor hallucis
      • interosseous
        • second, third, and fourth webspaces
        • advance plantar 2cm to puncture extensor fascia
      • lateral
        • midshaft of fifth metatarsal 
        • advance 1cm medial and plantar
    • threshold for decompression
      • controversial, but generally considered to be
        • absolute value of 30-45 mm Hg
        • within 30 mm Hg of diastolic blood pressure (delta p)
          • intraoperatively, diastolic blood pressure may be decreased from anesthesia
            • must compare intra-operative measurement to pre-operative diastolic pressure
Treatment 
  • Nonoperative
    • observation
      • indications
        • delta p > 30 
        • exam not consistent with compartment syndrome
  • Operative
    • emergent foot fasciotomies
      • indications
        • clinical presentation consistent with compartment syndrome
        • compartment measurements with absolute value of 30-45 mm Hg
        • compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
          • intraoperatively, diastolic blood pressure may be decreased from anesthesia
            • must compare intra-operative measurement to pre-operative diastolic pressure
Surgical Technique
  • Emergent fasciotomies of all compartments
    • dual dorsal incisions (gold standard)   
      • approach
        • dorsal medial incision 
          • medial to 2nd metatarsal
          • releases 1st and 2nd interosseous, medial, and deep central compartment
        • dorsal lateral incision
          • lateral to 4th metatarsal
          • releases 3rd and 4th interosseous, lateral, superficial and middle central compartments
      • technique
        • dorsal fascia of each interosseous compartment opened longitudinally
        • strip muscle from medial fascia in first interosseous compartment
        • split adductor compartment
        • may add medial incision for decompression of calcaneal compartment
      • post-operative
        • delayed wound closure with possible skin grafting
      • pros
        • direct access to all compartments
        • provides exposure for Chopart, Lisfranc, or tarsometatarsal fractures
      • cons
        • does not provide access for fixation of calcaneus fractures
    • single medial incision
      • technique
        • single medial incision used to release all nine compartments
      • cons
        • technically challenging
Complications
  • Chronic pain and hypersensitivity
    • difficult to manage
  • Fixed flexion deformity of digits (claw toes)
    • release flexor digitorum brevis and longus at level of digits

 

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