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Bipedal compartment syndrome following bilateral intra-articular calcaneal fractures
Foot and Ankle Surgery 10 (2004) 93–96 www.elsevier.com/locate/fas
Case report
Bipedal compartment syndrome following bilateral intra-articular calcaneal fractures H. Sharma*, B. Rana, M. Naik Department of Trauma and Orthopaedics, Monklands Hospital, Airdrie, Lanarkshire ML6 0JS, UK Received 24 September 2003; revised 22 December 2003; accepted 7 January 2004
Abstract We describe an unusual case of bipedal compartment syndrome following bilateral intra-articular calcaneal fractures. All the relevant foot compartments were released on the clinical basis and the calcaneal fractures were treated conservatively. The importance of clinical diagnosis is stressed in view of diagnosing and timely managing the foot compartment syndrome to minimise the undue late complications. q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Compartment syndrome; Calcaneus; Foot; Fracture; Calcaneal fracture
1. Introduction Foot compartment syndrome was largely unrecognised until the late 1980s. Long-term sequelae of foot compartment syndrome include sensorimotor neuropathy and deformities [1]. Approximately 10% of calcaneal fractures may develop compartment syndrome of the foot [2]. We report an unusual case of bipedal compartment syndrome following bilateral intra-articular calcaneal fractures.
2. Case report A 21 year old man was admitted following an attempted suicidal jump off a 30 ft high foot bridge. He sustained bilateral intra-articular calcaneal fractures (Fig. 1). There were no concomitant injuries in the lower extremities and spine. At the time of admission there was no clinical sign of compartment syndrome. The affected limbs were elevated and close neurovascular monitoring was observed. The diagnosis of compartment syndrome was suspected clinically because of pain in excess of the injury, excessively * Corresponding author. Address: 7 Kiltongue Cottages, Monkscourt Avenue, Airdrie, Lanarkshire ML6 0JX, UK. Tel.: þ 44-1236-758464; fax: þ 44-1236-713134. E-mail address: [email protected] (H. Sharma).
swollen feet with tense shiny skin (Fig. 2), paraesthesia, delayed capillary refill and absent pedal pulses. Surgical decompression was performed on clinical grounds within 4 h of diagnosis. Two dorsal incisions for access to forefoot compartments and one medial incision for decompression of the calcaneal, medial, superficial and lateral compartments were used for both feet. In addition, deep posterior compartment syndrome was suspected on the right leg preoperatively by a positive toe stretch sign and was released by a midposterior approach. Delayed primary closure was done on the fourth postoperative day for the fasciotomy wounds which healed uneventfully (Fig. 3). The calcaneal fractures were treated conservatively after seeking a second opinion from an orthopaedic surgeon with a special interest in calcaneal fractures at a tertiary referral centre. In view of an increased risk of soft tissue infection, calcaneal osteomyelitis and flap necrosis with calcaneal fixation in the presence of compartment syndrome, the case was treated non-operatively by immobilisation in a below knee plaster for 6 weeks. He underwent gradual transition from partial to full weight bearing mobilisation subsequently. At 6 months follow-up, he made a satisfactory recovery with full-weight bearing mobilisation and ongoing physiotherapy for persistent minimal subtalar and ankle stiffness. He had slightly broadened heels, clawing of the right lesser toes and occasional heel pain whilst walking long distances. At the time of decompression, there
1268-7731/$ - see front matter q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2004.01.004
94
H. Sharma et al. / Foot and Ankle Surgery 10 (2004) 93–96
Fig. 1. Lateral radiographs of the both calcanei revealing comminuted intra-articular calcaneal fracture.
was some muscle necrosis in the calcaneal compartment. In addition, there is a possibility of subclinical ischaemic insult to the muscle as a result of full blown compartment syndrome, which led to scarring and clawing of the lesser toes. The radiographs showed satisfactory consolidation at 6 months (Figs. 4 and 5).
3. Discussion
Nine compartments are identified in the foot. These are (1) medial, (2) superficial, (3) lateral, (4) adductor, (5) – (8) four interossei and (9) calcaneal compartment. The calcaneal compartment contains the quadratus plantae muscle. A communication has been demonstrated between the calcaneal compartment and the deep posterior compartment of the leg through the retinaculum behind the medial malleolus, following the neurovascular and tendinous structures. The plantar aponeurosis, which forms the constricting fascial envelope of the plantar muscles, is
Foot compartment syndrome was largely unrecognised until the late 1980s. Long term sequelae of foot compartment syndrome include sensorimotor neuropathy and deformities [1]. Approximately 10% of calcaneal fractures may develop compartment syndrome of the foot [2]. We report an unusual case of bipedal compartment syndrome following bilateral intra-articular calcaneal fractures.
Fig. 2. Preoperative clinical photograph showing grossly swollen foot with tense shiny skin.
Fig. 3. Two weeks postoperative clinical photograph showing healed fasciotomy wounds.
H. Sharma et al. / Foot and Ankle Surgery 10 (2004) 93–96
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Fig. 4. Lateral and axial radiographs of the right calcaneus at 6 months follow-up revealing satisfactory consolidation of comminuted intra-articular calcaneal fracture.
the anatomic structure responsible for the compartment syndrome that may develop after calcaneal fracture [3]. The common deformities developed after foot compartment syndrome include claw toe deformity, equinus, enquinovarus and pes cavus. Claw toe deformity, the most common deformity following calcaneal fractures appears to be due to late contracture of the quadratus plantae muscle in the calcaneal compartment [4]. Pain with passive stretch is specific for foot compartment syndrome. A high index of clinical suspicion is needed to prevent missing a compartment syndrome following calcaneal fractures associated with excessively tense swelling and disproportionate pain. The presence of sensory
neurological deficits should be acted upon quickly. The vascular examination is unreliable as pedal pulses are usually impalpable due to swelling [5]. Foot macrocirculation, remains intact until the final stages, can be confirmed by Doppler ultrasound. Although multi-stick invasive catheterisation is recommended by some authors [1 – 3], this device in itself is quite challenging to use and pressure measurements can be influenced by a variety of factors including accuracy in depth and site, needle blockage, trauma to soft tissues (being an invasive procedure) leading to worsening of pain and swelling. Individual compartments cannot easily be isolated with clinical or compartment pressure monitoring.
Fig. 5. Lateral and axial radiographs of the left calcaneus at 6 months follow-up revealing satisfactory consolidation of comminuted intra-articular calcaneal fracture.
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There are sound reasons for performing fasciotomy for foot compartment syndrome on clinical grounds. The depth needed and accurate placement of these needles cannot be guaranteed, as it is a blind procedure. Thereby, pressure measured from an inaccurately placed needle can be misleading. There are nine compartments in the foot, which further adds to the complexity. The morbidity suffered from a timely done fasciotomy is minimal in comparison to the potential complications of a missed compartment syndrome [6]. We recommend that the threshold for considering compartment syndrome and performing emergency fasciotomy in the foot must be low to minimise late contracures.
References [1] Fulkerson E, Razi A, Tejwani N. Review: acute compartment syndrome of the foot. Foot Ankle Int 2003;24(2):180– 7. [2] Myerson M, Manoli A. Compartment syndromes of the foot after calcaneal fractures. Clin Orthop 1993;(290):142– 50. [3] Manoli 2nd A, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle 1990;10(5):267 –75. [4] Manoli 2nd A. Compartment syndromes of the foot: current concepts. Foot Ankle 1990;10(6):340–4. [5] Mittlmeier T, Machler G, Lob G, Mutschler W, Bauer G, Vogl T. Compartment syndrome of the foot after intraarticular calcaneal fracture. Clin Orthop 1991;(269):241 –8. [6] Starosta D, Sacchetti AD, Sharkey P. Calcaneal fracture with compartment syndrome of the foot. Ann Emerg Med 1988;17(8):856 –8.
Case report
Bipedal compartment syndrome following bilateral intra-articular calcaneal fractures H. Sharma*, B. Rana, M. Naik Department of Trauma and Orthopaedics, Monklands Hospital, Airdrie, Lanarkshire ML6 0JS, UK Received 24 September 2003; revised 22 December 2003; accepted 7 January 2004
Abstract We describe an unusual case of bipedal compartment syndrome following bilateral intra-articular calcaneal fractures. All the relevant foot compartments were released on the clinical basis and the calcaneal fractures were treated conservatively. The importance of clinical diagnosis is stressed in view of diagnosing and timely managing the foot compartment syndrome to minimise the undue late complications. q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Compartment syndrome; Calcaneus; Foot; Fracture; Calcaneal fracture
1. Introduction Foot compartment syndrome was largely unrecognised until the late 1980s. Long-term sequelae of foot compartment syndrome include sensorimotor neuropathy and deformities [1]. Approximately 10% of calcaneal fractures may develop compartment syndrome of the foot [2]. We report an unusual case of bipedal compartment syndrome following bilateral intra-articular calcaneal fractures.
2. Case report A 21 year old man was admitted following an attempted suicidal jump off a 30 ft high foot bridge. He sustained bilateral intra-articular calcaneal fractures (Fig. 1). There were no concomitant injuries in the lower extremities and spine. At the time of admission there was no clinical sign of compartment syndrome. The affected limbs were elevated and close neurovascular monitoring was observed. The diagnosis of compartment syndrome was suspected clinically because of pain in excess of the injury, excessively * Corresponding author. Address: 7 Kiltongue Cottages, Monkscourt Avenue, Airdrie, Lanarkshire ML6 0JX, UK. Tel.: þ 44-1236-758464; fax: þ 44-1236-713134. E-mail address: [email protected] (H. Sharma).
swollen feet with tense shiny skin (Fig. 2), paraesthesia, delayed capillary refill and absent pedal pulses. Surgical decompression was performed on clinical grounds within 4 h of diagnosis. Two dorsal incisions for access to forefoot compartments and one medial incision for decompression of the calcaneal, medial, superficial and lateral compartments were used for both feet. In addition, deep posterior compartment syndrome was suspected on the right leg preoperatively by a positive toe stretch sign and was released by a midposterior approach. Delayed primary closure was done on the fourth postoperative day for the fasciotomy wounds which healed uneventfully (Fig. 3). The calcaneal fractures were treated conservatively after seeking a second opinion from an orthopaedic surgeon with a special interest in calcaneal fractures at a tertiary referral centre. In view of an increased risk of soft tissue infection, calcaneal osteomyelitis and flap necrosis with calcaneal fixation in the presence of compartment syndrome, the case was treated non-operatively by immobilisation in a below knee plaster for 6 weeks. He underwent gradual transition from partial to full weight bearing mobilisation subsequently. At 6 months follow-up, he made a satisfactory recovery with full-weight bearing mobilisation and ongoing physiotherapy for persistent minimal subtalar and ankle stiffness. He had slightly broadened heels, clawing of the right lesser toes and occasional heel pain whilst walking long distances. At the time of decompression, there
1268-7731/$ - see front matter q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2004.01.004
94
H. Sharma et al. / Foot and Ankle Surgery 10 (2004) 93–96
Fig. 1. Lateral radiographs of the both calcanei revealing comminuted intra-articular calcaneal fracture.
was some muscle necrosis in the calcaneal compartment. In addition, there is a possibility of subclinical ischaemic insult to the muscle as a result of full blown compartment syndrome, which led to scarring and clawing of the lesser toes. The radiographs showed satisfactory consolidation at 6 months (Figs. 4 and 5).
3. Discussion
Nine compartments are identified in the foot. These are (1) medial, (2) superficial, (3) lateral, (4) adductor, (5) – (8) four interossei and (9) calcaneal compartment. The calcaneal compartment contains the quadratus plantae muscle. A communication has been demonstrated between the calcaneal compartment and the deep posterior compartment of the leg through the retinaculum behind the medial malleolus, following the neurovascular and tendinous structures. The plantar aponeurosis, which forms the constricting fascial envelope of the plantar muscles, is
Foot compartment syndrome was largely unrecognised until the late 1980s. Long term sequelae of foot compartment syndrome include sensorimotor neuropathy and deformities [1]. Approximately 10% of calcaneal fractures may develop compartment syndrome of the foot [2]. We report an unusual case of bipedal compartment syndrome following bilateral intra-articular calcaneal fractures.
Fig. 2. Preoperative clinical photograph showing grossly swollen foot with tense shiny skin.
Fig. 3. Two weeks postoperative clinical photograph showing healed fasciotomy wounds.
H. Sharma et al. / Foot and Ankle Surgery 10 (2004) 93–96
95
Fig. 4. Lateral and axial radiographs of the right calcaneus at 6 months follow-up revealing satisfactory consolidation of comminuted intra-articular calcaneal fracture.
the anatomic structure responsible for the compartment syndrome that may develop after calcaneal fracture [3]. The common deformities developed after foot compartment syndrome include claw toe deformity, equinus, enquinovarus and pes cavus. Claw toe deformity, the most common deformity following calcaneal fractures appears to be due to late contracture of the quadratus plantae muscle in the calcaneal compartment [4]. Pain with passive stretch is specific for foot compartment syndrome. A high index of clinical suspicion is needed to prevent missing a compartment syndrome following calcaneal fractures associated with excessively tense swelling and disproportionate pain. The presence of sensory
neurological deficits should be acted upon quickly. The vascular examination is unreliable as pedal pulses are usually impalpable due to swelling [5]. Foot macrocirculation, remains intact until the final stages, can be confirmed by Doppler ultrasound. Although multi-stick invasive catheterisation is recommended by some authors [1 – 3], this device in itself is quite challenging to use and pressure measurements can be influenced by a variety of factors including accuracy in depth and site, needle blockage, trauma to soft tissues (being an invasive procedure) leading to worsening of pain and swelling. Individual compartments cannot easily be isolated with clinical or compartment pressure monitoring.
Fig. 5. Lateral and axial radiographs of the left calcaneus at 6 months follow-up revealing satisfactory consolidation of comminuted intra-articular calcaneal fracture.
96
H. Sharma et al. / Foot and Ankle Surgery 10 (2004) 93–96
There are sound reasons for performing fasciotomy for foot compartment syndrome on clinical grounds. The depth needed and accurate placement of these needles cannot be guaranteed, as it is a blind procedure. Thereby, pressure measured from an inaccurately placed needle can be misleading. There are nine compartments in the foot, which further adds to the complexity. The morbidity suffered from a timely done fasciotomy is minimal in comparison to the potential complications of a missed compartment syndrome [6]. We recommend that the threshold for considering compartment syndrome and performing emergency fasciotomy in the foot must be low to minimise late contracures.
References [1] Fulkerson E, Razi A, Tejwani N. Review: acute compartment syndrome of the foot. Foot Ankle Int 2003;24(2):180– 7. [2] Myerson M, Manoli A. Compartment syndromes of the foot after calcaneal fractures. Clin Orthop 1993;(290):142– 50. [3] Manoli 2nd A, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle 1990;10(5):267 –75. [4] Manoli 2nd A. Compartment syndromes of the foot: current concepts. Foot Ankle 1990;10(6):340–4. [5] Mittlmeier T, Machler G, Lob G, Mutschler W, Bauer G, Vogl T. Compartment syndrome of the foot after intraarticular calcaneal fracture. Clin Orthop 1991;(269):241 –8. [6] Starosta D, Sacchetti AD, Sharkey P. Calcaneal fracture with compartment syndrome of the foot. Ann Emerg Med 1988;17(8):856 –8.