SUMMARY

• Foot Compartment Syndrome is a devastating lower extremity condition where the osseofascial compartment pressure rises to a level that decreases perfusion to the foot and may lead to irreversible muscle and neurovascular damage.

• Diagnosis is made with the presence of severe and progressive foot pain that worsens with the passive motion of the toes. Firmness and decreased compressibility of the compartments is often present. Needle compartment pressures are diagnostic in cases of inconclusive physical exam findings and in sedated patients.

• Treatment is usually emergent fasciotomies.

EPIDEMIOLOGY

• Anatomic location

  • May occur anywhere that skeletal muscle is surrounded by fascia, but most commonly

    • leg 

    • forearm 

    • hand 

    • foot (details below)

    • thigh 

    • buttock

    • shoulder

    • paraspinous muscles

ETIOLOGY

• 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

IMAGING

• Radiographs

  • obtain to rule-out fracture

STUDIES

• 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

    • 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

    • absolute value of 30-45 mm Hg (controversial, historic)

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

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

        • incision is made within the arch of the foot, along the muscle body of the abductor hallucis

        • dissection is continued both dorsal and plantar to the abductor hallucis muscle, which also serves to disrupt the superficial and deep components of the central compartment and allows access to the adductor muscle belly

    • 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