Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Compartment Syndrome of the Foot

Basics
Description
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.
 
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
 
Pathophysiology
  • Blood flow ceases when local tissue pressure exceeds diastolic blood pressure.
  • Tissue ischemia develops.
  • Myoneural necrosis results, with long-term sequelae of pain, paresthesias, stiffness, claw toes, and foot deformity.
Etiology
  • Frequently occurs with calcaneus fracture, midfoot/forefoot fractures, or crush injury of the foot
  • May occur with open foot injuries
Diagnosis
Signs and Symptoms
  • Severe pain
  • Massive swelling
  • Pain with passive stretching of the toes
  • 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.
 
Diagnostic Procedures/Surgery
  • Invasive pressure measurement of the foot compartments is helpful for diagnosing compartment syndrome.
  • Needle insertion sites for compartment pressure monitoring:
    • Medial (abductor) compartment: Directly inferior to the 1st metatarsal
    • Deep compartment: Advance the needle from the medial compartment ~1 cm deeper under the arch of the foot
    • Interosseous compartment: Dorsal foot between the 3rd and 4th metatarsals
    • Lateral compartment: Plantar to the 5th metatarsal
  • Compartment syndrome commonly is defined as compartment pressure >30 mm Hg  .
Treatment
Initial Stabilization
No circumferential bandages should be applied to the area while monitoring for possible compartment syndrome because doing so may worsen the condition.
 
General Measures
  • A pneumatic foot pump often is useful in decreasing foot swelling early after trauma .
  • Oral or intravenous diuretics may help reduce edema.
  • If compartment syndrome is suspected, invasive pressure measurements of the compartments should be performed.
  • Early fasciotomy is the most reliable way to avoid the complications of compartment syndrome.
    • Future fixation of these fractures must be considered when selecting the fasciotomy approach.
Activity
If massive swelling is present, a patient should be kept at bed rest with the foot at heart level.
 
Nursing
  • 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
  • Perform fasciotomy (compartment release):
    • Surgical emergency once diagnosis is made
    • Standard technique:
      • 2 dorsal incisions over the 2nd and 4th metatarsals to release adjacent interosseous spaces and lateral abductor compartment
      • Medial arch incision to release abductor hallucis and deep muscle compartments
    • Alternative technique :
      • Single medial incision to release abductor hallucis and deep compartments
      • Muscles reflected plantarly
      • Interosseous compartments released through medial approach
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
  • The prognosis after a missed or untreated compartment syndrome of the foot is poor.
    • Such patients typically have chronic pain and stiffness that can be disabling.
    • Cavus or cavovarus foot deformities can occur secondary to myonecrosis and fibrosis of intrinsic foot muscles.
    • Claw toes that require surgical release may develop.
    • Complex regional pain syndrome can develop after compartment syndrome or crush injury.
Complications
  • Pain
  • Paresthesias
  • Stiffness
  • Claw toes
  • Foot deformities
Miscellaneous
Codes
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.

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.

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