Compartmental catheterization and fasciotomy of the foot

COMPARTMENTAL CATHETERIZATION AND FASCIOTOMY OF THE FOOT ARTHUR MANOLI II, MD, ANTON J. FAKHOURI, MD, AND TIMOTHY G. WEBER, MD

Foot compartment syndromes are becoming increasingly recognized in a number of foot injuries. Tense swelling of the involved foot is the best clinical sign, but severe pain, pain on passive stretch of the foot muscles, and sensory disturbances are sometimes observed. Once suspected, the diagnosis is best confirmed by multiple stick catheterization of the foot. It is essential to measure the pressure in the calcaneal and lateral compartments in the hindfoot as they frequently have the highest pressures. A three-incision fasciotomy with a single medial hindfoot incision and two dorsal forefoot incisions is recommended to release the foot compartments. KEY WORDS: compartment syndrome, foot, fasciotomy, compartmental catheterization

In the past few years there has been increasing interest in the foot as a site of compartment syndrome. Feet sustaining high-energy injuries are particularly prone to the development foot compartment syndromes (FCS)J Lisfranc fracture-dislocations, calcaneal fractures, multiple metatarsal and/or phalangeal fractures, and any injury with an element of crushing are particularly prone to the development of FCS. T M As feet with these injuries usually develop considerable pain and swelling, the development of a compartment syndrome is often overlooked. In fact, it may be the development of FCS that may give these injuries their reputation for the development of severe painJ s In a recent study it was found that tense swelling is the most common clinical sign of traumatized feet (Table 1). 1 Severe pain, pain with passive stretch of the affected muscles, and sensory deficits were also observed, but not in all patients. In one patient the pulses could not be felt because of the swelling in the foot. Therefore, as the clinical signs are somewhat variable, it is essential to confirm the diagnosis of FCS in suspicious cases. It has been found that catheterization of the affected compartments is essential to confirm the diagnosisJ ~ This report describes the method of catheterization of the foot compartments as well as the currently recommended technique of foot fasciotomy.

ANATOMY In the past the foot was thought to contain four compartments, the medial, central, lateral, and interosseous. 1~ A recent dyed-gelatin injection study has shown that the From the Department of Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, MI. Address reprint requests to Arthur Manoli II, MD,.Professor, Department of Orthopaedic Surgery, Wayne State University School of Medicine, Hutzel Hospital-1 South, 4707 St Antoine, Detroit, MI 48201. Copyright 9 1992 by W. B. Saunders Company 1048-6666/92/0203-0013505.00/0

foot compartmental anatomy is much more complicated than previously thought, s In fact, nine compartments were identified on the plantar aspect of the foot. Many of the previously described compartments were subdivided and renamed (Fig 1). There are three compartments that run the entire length of the foot: the medial, lateral, and superficial. The medial compartment contains the abductor hallucis and flexor haUucis brevis muscles. The lateral compartment contains the abductor digiti minirni and flexor digiti minimi brevis muscles. The superficial compartment runs along the plantar aspect of the central area of t h e foot and contains the flexor digitorum brevis muscle. In the forefoot there were found to be five compartments in the area that was previously called the "interosseous" and "central" compartmentsJ ~ The respective mterosseous muscles were found in separate compartments between the metatarsal shafts. The adductor hallucis muscle was found in a separate compartment deep on the plantar aspect of the forefoot. In the hindfoot a separate compartment was identified deep to the superficial compartment and it was called the calcaneal compartment (Figs 2 and 3). It contains the quadratus plantae muscle. Ischemic contracture of this muscle has been implicated in the development of clawtoe deformity following compartment syndrome of the foot.S, ll,x5 Because of this complex compartmental anatomy, a number of changes must be made in our procedures for diagnosing FCS, as well as the use of foot fasciotomy to treat it. is

COMPARTMENTAL CATHETERIZATION TECHNIQUE Once the clinician is suspicious that FCS may be developing, catheterization of the foot is recommended. We generally perform this under local anesthesia using the

Operative Techniques in Orthopaedics, Vol 2, No 3 (July), 1992:203-210

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TABLE 1. Clinical Signs in 12 Patients With Foot Compartment Syndromes . .

Tense swelling Severe pain Sensory deficits Pain with passive toe motion Absent pulses

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Fig 1. The compartments of the foot.

portable pressure monitor (Stryker Corp., Kalamazoo, MI). Because of the complex anatomy, a multiple-stick technique is suggested. The medial stick is performed by inserting the needle in the medial part of the hindfoot approximately 4 cm inferior to the medial malleolus (Fig 4). As the needle is advanced, it enters the medial compartment and this pressure is measured. The needle is then advanced deeper into the foot where it will pass through the medial intermuscular septum, entering the calcaneal compartment. It is critical that this compartment be monitored in all suspicious cases of FCS, as it frequently has the highest pressures. ~

Fig 2. Transverse section through the hindfoot demonstrat9 ing the calcaneal (C), medial (M), superficial (S), and lateral (L) compartments. (Reprinted with permission, e 9 by American Orthopaedic Foot Society.)

A plantar stick is made in the middle of the arch, inserting the need-l~ into the superficial compartment containing the flexor digitorum brevis muscle (Fig 5). Its pressure is recorded. A lateral stick is then made, just below the fifth meta-

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Fig 3. Sagittal section t h r o u g h the s e c o n d metatarsal demonstrating the location of the calcaneal compartment (C). (Reprinted with permission. 8 9 by American Orthopaedic Foot Society.)

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MANOLI, FAKHOURI, AND WEBER

Fig 4. The medial hindfoot stick measures the pressure in the medial and calcaneal compartments.

Fig 5. The plantar stick samples the superficial compartment.

Fig 7. A stick in the first or second interspace measures the pressure in the respective interosseous space. With deep advancement of the needle, the adductor compartment may be sampled.

tarsal shaft (Fig 6). The needle should enter the lateral compartment, and the pressure is measured. Generally, either the first or second interspace is catheterized on the dorsum of the foot (Fig 7). Although theoretically it is less dangerous to catheterize the second interspace, because of the presence of the perforating branch of the dorsal pedis artery in the first interspace,catheterization of either has not really been a problem. As the artery perforates in the extreme proximal portion of the first interspace, needle measurements done in the middle of the space will avoid this. These sticks give the pressure measurement in the respective interspace. Any or all of the four spaces may be sampled. To measure the adductor compartment, the' needle is advanced through the first or second interspace deep into the forefoot, below the metatarsal shafts (Fig 7). Here the adductor compartmental pressure can be sampled. There is considerable debate as to what the threshold of pressure should be before fasciotomy is suggested. It is

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Fig 6. Technique for catheterization of the lateral compartment. FOOT CATHETERIZATION AND FASCIOTOMY

Fig 8. The hindfoot incision begins just distal to the medial calcaneal branches of the tibial nerve. 205

important to assess the patient's general condition, particularly mental status and circulatory status (blood pressure and pulse). A clinical evaluation of the foot, examining specifically for swelling, pain, sensory deficits, pain with passive toe motion, and pulses, should be performed. The San Diego group and Rorabeck's group reco m m e n d that fasciotomy be performed at pressures greater than 30 m m Hg. 17A8 Whitesides has suggested that it be performed when the pressure is greater than 10 to 30 m m Hg below diastolic blood pressure. 19 A recent study has suggested that decompressive fasciotomy should be performed when the pressures are greater than 30 to 40 m m Hg below mean arterial pressure) 6 The amount of time after the injury, the type of injury, and the pressure trends have also been helpful in decision making. 11 When the pressures are believed to be exces-

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sive, decompressive fasciotomy should be performed to prevent the development of late contractures and sensory abnormalities. Rigid clawtoe deformities of the lesser toes appear to be the most common late sequelae of missed FCS. 8'10"12"15'20

FASCIOTOMY TECHNIQUE In the past, two dorsal forefoot incisions, or a long medial arch incision, were both recommended to decompress the foot compartments. 1~ After the complex compartmental anatomy was identified, it became apparent that certain aspects of both of these techniques were necessary. s,15 First, a 6-cm medial hindfoot incision is made, begin-

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Fig 9. (A,B) The medial c o m p a r t m e n t is released (see text).

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Fig 10. (A) As the abductor hallucis muscle is retracted superiorly, (B) the medial i n t e r m u s c u l a r septum can be observed.

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MANOLI, FAKHOURI, AND WEBER

ning 4 cm from the posterior aspect of the heel and 3 cm from the plantar surface (Fig 8). The incision extends distally, parallel to the plantar aspect of the foot. Directly in line with the incision, the fascia overlying the abductor hallucis muscle is incised longitudinally, releasing the medial compartment (Fig 9). The inferior portion of the abductor hallucis muscle is stripped from its surrounding fascia and retracted superiorly. One then encounters the very thick dense white medial intermuscular septum of the foot (Fig 10). This is opened longitudinally. Great care is needed here, as the lateral plantar neurovascular bundle lies just deep to the septum and can be damaged (Fig 11). W h e n the septum is opened, the quadratus plantae muscle is observed as the calcaneal compartment is released. The medial plantar nerve lies just distal to the incision and at times it is in the medial intermuscular septum or the calcaneal compartment and should be avoided. 21 Dissection then continues inferiorly, in the subcutaneous tissue outside of the medial compartment. On the plantar aspect of the foot, the superficial compartment is

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encountered and o p e n e d longitudinally, showing the flexor digitorum brevis muscle (Fig 12). This muscle is then stripped from the fascia which lies just superior to it (the transverse septum of the hindfoot). 21 As the flexor digitorum brevis muscle is retracted plantarward deep in the foot, the lateral compartment is encountered sweeping medially in the hindfoot area (Fig 13). The lateral compartment is then opened longitudinally (Fig 14). This is best done from the posterior to anterior direction. Two dorsal forefoot incisions are then made, just medial to the second metatarsal shaft and just lateral to the fourth metatarsal shaft. Placing t h e m in this location will ensure as wide a skin bridge as possible. The four respective interosseous compartments are released, lying between the metatarsal shafts (Fig 15A, C). To reach the adductor compartment, the muscles are stripped off of the medial portion of the second metatarsal shaft and retracted medially. Deep in the first interspace, the fascia overlying the adductor compartment is then opened carefully longitudinally (Fig 15B,C). The w o u n d s are all left opened and covered with a

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Fig 11. The lateral plantar neurovascular bundle lies just deep to the sepo tum (A), in the calcaneal compartment (B).

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Fig 12. (A) The superficial compartment is identified on the plantar aspect of the foot. (B) W h e n it is released, the flexor dlgitorum brevis muscle can be observed.

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Fig 13. The flexor digitorum brevis muscle is retracted plantarward (A), showing the lateral compartment (B).

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/J sterile dressing. At 3 to 5 days after fasciotomy, an attempt is made to close the w o u n d s on a delayed basis. Approximately three quarters of the w o u n d s can be closed primarily. 1 In the other patients, a split-thickness skin graft will be needed for closure. At the time of fasciotomy, the two forefoot incisions may be used to internally fix any existing forefoot fractures or dislocations (Fig 16). 9"]~ A calcaneus fracture may be operatively repaired through a lateral approach on a late basis, after the w o u n d s are closed, h a s

DISCUSSION FCS has been only very recently recognized as a true entity in foot trauma, with 90% of the cases being reported in the last 3 years. The consequences of a ne-

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Fig 14. (A,B) The lateral compartment is opened.

glected FCS are usually rigid, progressive clawing of the lesser toes that become apparent from 8 to 13 months after the injury, s At least 9% to 10% of the fractures of the calcaneus have significantly elevated compartmental pressures, n and 10% of calcaneal fractures develop clawtoes. 2~ These problems are usually less dramatic than those observed in the forearm and leg, but they are nonetheless difficult to treat w h e n established 8As and are best avoided. As concurrent foot and leg compartment syndromes have also been reported, 8"15it is important for the clinician to be aware of the difficulties with establishing the diagnosis of FCS when either the foot or leg is traumatize,d. A ~ t h e clinical signs may be confusing in the traumatized foot, we recommend performing multiple-stick invasive catheterization of the foot in injuries of the foot or leg that develop tense swelling, particularly if the injuries

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Fig 15. (A) The two dorsal forefoot incisions allow for the interosseous compartments to be released individually. (B) The interosseous muscles of the first interspace are stripped from the medial aspect of the second metatarsal, showing the adductor compartment, which is then opened longitudinally. (C) Cross section of A and B.

have been caused by high-energy trauma. If the pressures are significantly elevated in view of the clinical condition of the patient, then foot fasciotomy should be performed.

REFERENCES

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Fig 16. Summary of the surgical approach. Two dorsal forefoot incisions and one medial hindfoot incision are used to decompress the foot compartments. (Reprinted with permission. 8 9 by American Orthopaedic Foot Society.)

FOOT CATHETERIZATIONAND FASCIOTOMY

1. Fakhouri AJ, Manoli A II: Compartment syndrome after highenergy injury to the foot. Orthop Trans 14:661, Fall, 1990. 2. Arntz CT, Veith RG, Hansen ST, Jr: Fractures and fracturedislocations of the tarsometatarsal joint. J Bone Joint Surg [Am] 70A:173-181, 1988 3. Bonutti PM, Bell GR: Compartment syndrome of the foot. J Bone Joint Surg [Am] 68A:1449-1451, 1986 4. Goldman FD, Dayton PD, Hanson CJ: Compartment syndrome of the foot. J Foot Surg 29:37-43, 1990 5. Gissane W: A dangerous type of fracture of the foot. J Bone Joint Surg [Br] 33B:535-538, 1951 6. Heckman JD, Champine MJ: New techniques in the management of foot trauma. Clin Orthop 240:105-114, 1989 7. Kym MR, Worsing RA: Compartment syndrome in the foot after an inversion injury to the ankle. J Bone Joint Surg [Am] 72A:138-139, 1990 8. Manoli A I I , Weber TG: Fasciotomy of the foot--An anatomical study with special reference to release of the calcaneal compartment. Foot Ankle 10:267-275, 1990 9. Myerson MS: Split-thickness skin excision: Its use for immediate wound care in crush injuries of the foot. Foot Ankle 10:54-60, 1989 10. Myerson MS: Diagnosis and treatment of compartment syndrome of the foot. Orthopedics 13:711-717, 1990 11. Myerson MS, Manoli A II: Compartment syndromes of the foot foUowing calcaneal fractures. Clin Orthop (in press, May 1993) 12. Shereff MJ: Compartment syndromes of the foot, in Greene WB (ed): Instructional Course Lectures, vol 39. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1990, pp 127-132 13. Starosta D, Sacchetti AP, Sharkey P: Calcaneal fracture with compartme_nt'syndrome of the foot. Ann Emerg Med 17:856-858, 1988 14. Ziv I, Mosheiff R, Zeligowski A, et al: Crush injuries of the foot with compartment syndrome: Immediate one-stage management. Foot Ankle 9:185-189, 1989

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15. Manoli A Ih Compartment syndromes of the foot: Current concepts. Foot Ankle 10:340-344, 1990 16. Schneck S, Sapega A, Dobrasz J, et ah The metabolic stages in an evolving compartment syndrome. Transactions of the annual meeting, Orthopaedic Research Society, 15:261, 1990 17. Bourne RB, Rorabeck CH: Compartment syndromes of the lower leg. Clin Orthop 240:97-104, 1989 18. Hargens AR, Akeson WH, Mubarak SJ, et al: Tissue fluid pressures:

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From basic research tools to clinical applications. J Orthop Res 7: 902-909, 1989 19. Whitesides TE, Haney TC, Morimoto R, et al: Tissue pressure measurements as a determinant for the need of fasdotomy. Clin Orthop 113:43-51, 1975 20. Lindsay WRN, Dewar FP: Fractures of the os calcis. Am J Surg 95:555-576, 1958 21. Martin BF: Observations on the muscles and tendons of the medial aspect of the sole of the foot. J Anat 98:437-453, 1964

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