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Compartment syndrome of the foot
EUR J FOOT ANKLESURG 1994;1:29-36
Compartment syndrome of the foot MARKUS PISAN, KAJ KLAUE
Compartment syndrome o f the f o o t has been described recently as a serious complication after crush trauma and severe fractures. I t represents a surgical emergency and corresponds to stage I o f V o l k m a n n ' s contracture. Untreated, it will lead to pain and static changes o f the f o o t with fixed claw toes and a contracted forefoot in more than 50°70 o f the cases. Percutaneous measuring o f intrinsic compartment pressure allows rapid assessment o f pathological values (more than 30 m m H g ) . Fasciotomies o f the 9 compartments o f the foot are preferentially performed through one medial and two dorsal approaches. During the last two years we have measured pathological compartment pressures in 8 traumatized patients in w h o m an acute compartment syndrome o f the foot was clinically suspected. Pressure values o f more than 100 m m H g were demonstrated. In all patients foot compartments were released immediately. Except for one patient, with a persisting hyposensihility, all patients showed a complete recovery o f the initial neuromuscular s y m p t o m s . KEY
WORDS: Foot, compartment syndrome.
o m p a r t m e n t syndromes must be feared complications after closed injuries o f the extremities and are the second most frequent complication in traumatology after thrombosis. ~As such it represents a surgical emergency case. Not only fractures or direct injuries of the vessels are responsible but also soft tissue trauma, burns and hypothermias. 22 The lower leg as well as the forearm belong to the most frequent
C
Received February 17, 1994. Accepted for publication March 25, 1994.
Address reprint requests to: K. Klaue, Department of Orthopaedic Surgery, Inselspital, University of Bern, 3010 Bern - Switzerland.
Vol. 1 - N. I
Department of Orthopaedic Surgery, lnselspital, University of Bern
localizations. Seldomly has it been diagnosed in the upper arm, the shoulder, the hand, the gluteal region and the thigh. 3 Recently, compartment syndrome of the foot has been described as a serious complication after crush trauma and its frequency is estimated on approximately 5°7o of all c o m p a r t m e n t syndromes. 4 5 V o l k m a n n described in 1881 6 ischaemic muscle paralysis and contractures after application of thigh w o u n d dressing, too long constriction o f the limbsthrough an Esmarch bandage, and also after lacerations and contusions o f large vessels and after long periods o f severe cold. These ischaemic contractures of the muscles, the so-called Volkmann's contracture, together with irreversible nerve lesions in the sense o f a demyelinisation and following fibrosis are consequences o f an untreated c o m p a r t m e n t syndrome. Increased pressure within a closed space is responsible for a compartment syndrome, whereas the limiting factor is not only the fascia of the muscle but also the epimysium, the skin and occasionnally a circular bandage or cast. 2 The h a e m a t o m a and the accumulation of interstitial fluid leads to an increase of pressure which consecutively causes a reduced perfusion o f soft tissues. 2 7 s Experimental studies demonstrated a progressive reduction of soft tissue
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perfusion within a c o m p a r t m e n t submitted to continuously increased intrinsic pressure. The critical point for complete stop of micro-circulation is reached when the diastolic blood pressure equals the intrinsic p r e s s u r e . 9-11 G e n e r a l l y , a c o m p a r t m e n t pressure within peripheral muscular groups beyond 30 m m H g is considered pathological and represents an indication for operative treatment. 4 5 12 13 The extent of damage depends directly on the time and the a m o u n t of the intracompartimental pressure. In animal experiments, a period o f 12 hours before irreversible damage of the musculature was determined. 2 However all muscular groups do not react with equal sensitivity to ischemia. 14 On the other hand, if the involved compartments are not decompressed operatively, the pathological pressures persist for approximately two days, and thereafter decrease spontaneously. 8 Most serious effects are the irreversible neuromuscular changes. 5 The compartments o f the foot are divided by strong, rigid septa and therefore are predestinated to develop a c o m p a r t m e n t syndrome after a massive t r a u m a . Together with the tibio-fibular syndesmosis the mentioned septa are directly involved in the entire statics of the foot. 15 Most c o m m o n foot injuries which cause compartment syndromes are crush t r a u m a , with or without associated fracture such as calcaneus, m i d - f o o t or metatarsal. Myerson t3 f o u n d an incidence o f compartment syndromes in respectively 17°?0 and 4.7°7o of all calcaneus fractures and in 41070 if combined with crush t r a u m a . In other studies, in more than 50°70 of well-documented, conservatively treated calcaneus fractures, plantar contractions or claw toes or both were found as a sign of a non-diagnosed comp a r t m e n t syndrome. 8 Ender and M o s e r , 12 observed in 29 o f 32 calcaneus fractures pressures within the deep plantar c o m p a r t m e n t of more than 30 m m H g . The end result o f an untreated c o m p a r t m e n t syndrome o f the foot is a foot with limited function, painful, with atrophic and contract intrinsic musculature and fixed claw toes (not h a m m e r toes) and consequently a shorted arch with a tendency to a p e s caVUS.3 15-17
Anatomy A detailed anatomic description o f the different c o m p a r t m e n t s of the foot has been presented by
30
TABLE
I.--Compartments of the foot~muscular content.
1. Medial compartment - - M. adductor hallucis - - M. flexor hallucis brevis (2 heads) 2. Superficial compartment - - Mm. flexor digitorum brevis - - tendons (of a distal share) of the flexor digitorum longus - - Mm. lumbricales 3. Lateral compartment - - M. abductor digiti minimi - - M. flexor digiti minimi brevis 4. Abductor compartment - - M. abductor hallucis 5-8. Interossei compartment - - Mm. interossei (dorsales et plantares) 9. Calcaneus compartment - - M. quadratus plantae in connection (through the long flexors of the toes) with the deep, posterior compartment of the lower leg, through the retinaculum behind the medial malleous, following the vene/nerve bundle
Sarrafian 18 and recently confirmed in an anatomic study with selective dye injections of Manoli and Weber. 3 Division of compartments are mentioned in Table I. W o r t h mentioning is that the medial, lateral and superficial c o m p a r t m e n t stretch out over the entire length o f the foot, whereas the abductor and the interossei compartments are limited to the forefoot. The calcaneus c o m p a r t m e n t is the only one that lies in the hindfoot.
Clinical signs The diagnosis of the acute compartment syndrome with the patient awake has to be done clinically. A measurement o f the c o m p a r t m e n t pressure is indicated in unconcious patients and for the objectivation o f the diagnosis. Patients with a beginning compartment syndrome after a foot t r a u m a complain about severe pain, which often persist or even increases despite analgesics. The foot is normally kept in an antalgic relaxing position, in a slight flexion-adduction (Fig. 1). The M P joints are often swollen due to the pressure of the h e m a t o m a . A functional examination o f the
EUROPEAN JOURNAL OF FOOT AND ANKLE SURGERY
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Fig. 1.--Compartment syndrome. Typical swelling and antalgic position in flexion after crush trauma.
foot is often not possible. The pain increases with passive extension o f the toes and the ankle joint. Dysesthesia or hypesthesia o f the foot is another sign o f compartment syndrome. In order not to miss this discrete sign, a thorough examination of all involved nerves is required. The capillar filling remains intact during the whole acute phase. The arteria tibialis posterior is usually palpable whereas the arteria dorsalis pedis is palpable depending the severeness o f the swelling. A ultrasonogram is sometimes indicated. Myerson, la found a lesion o f the arteria dorsalis pedis in one case out o f 14 well-documented cases. As a differential diagnosis only acute, traumatic occlusion o f one or more arteries of the foot can be mentioned. 1
TABLE I I . - - M e a s u r e m e n t s o f our pathological cases. Patients (age).
Diagnosis/Side
Findings on examination
Compartment
Pressures
Time lag Trauma-Surgery
(hour) K.A. (25)
Communitive fracture of the calcaneus, left
Swelling Hyposensibility in the lateral part of the foot
Calcaneus Interossei I/II Interossei III/IV
76 32 65
12
J.D. (24)
Communitive fracture of the calcaneus, left
Swelling Hyposensibility in the lateral part of the foot
Calcaneus
65
18
O.P. (44)
Communitive fracture of the calcaneus, right
Swelling
Calcaneus
60
17
C.A. (25)
Fracture-dislocation of the Lisfranc Fracture-dislocation of the 2nd 5th Metatarso-phalangeal joints left
Swelling Hyposensibility in the lateral part of the foot and the dorsal part of toes 1-5
Calcaneus Superficial
> 100 38
4
Z.A. (55)
Fracture-dislocation of the Lisfranc Fracture of the first cuneiform Fracture of the cuboid left
Swelling
Calcaneus Medial Superficial
61 > 100 78
R.M. (30)
Fracture of the cuboid, right
Swelling Hyposensibility of the forefoot
Calcaneus Superficial Interossei I/II Interossei Ill/IV Medial
55 54 90 39 57
20
B.J. (30)
Fracture-dislocation of the Lisfranc, left
Swelling
Interossei I/II Interossei Ill/IV Medial Calcaneus
31 32 52 32
10
S.J. (26)
Lesion of the arteria dorsal pedis, right
Swelling Hyposensibility in the dorsal part of the forefoot and toes Absense of the dorsal pedis pulse
Interossei I/II
40
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B Fig. 2 . - - P r e s s u r e m e a s u r e m e n t within the calcaneal compartment. A) Punction of the skin just above the adductor hallucis muscle, slightly distal from the base of the first metatarsal and with an angle of 45 ° to the medial column towards caudal. B) Schematic diagramm. The needle passes above the adductor and beneath the first metatarsal (M" medial compartment, S: superficial compartment, C: calcaneal compartment, L: lateral compartment).
Treatment Treatment o f the acute c o m p a r t m e n t syndrome is the release of all fascial spaces involved (fasciotomy). In some cases, indication for fasciotomy can be set based on clinical investigation alone. Fasciotomy immediately follows measurement of the compartment pressures if the latter are pathological. The foot is prepped with sterile solution. We use a m o n i t o r (Datex Cardiocap T M II, Datex/Instrumentarium Corp., Helsinki Finland [Nonlinearity 1%, 0-200 m m H g ] ) and a 20-gauge needle (20 G x 2 3 / 4 " ) . We measure each pressure twice and the mean value is documented. Measurements o f our pathological cases are indicated in Table II. The exact localization o f the different compartments with the needle is based on simple landmarks and are judged upon the depth of gauging and is technically easy. In order to assess the calcaneal compartment pressure, we suggest a punction with an angle of 45 ° to the long axis o f the foot from medial, slightly distal from the base o f the first metatarsal and just above the adductor hallucis muscle. 15 The same entry can be used for punctioning the medial
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compartment (Fig. 2A and B). The interosseous compartments are optimally measured through the second and fourth intermetatarsal space. F r o m dorsal one successively enters the interosseous and the superficial at the fourth and the a b d u c t o r c o m p a r t m e n t at the second space (Fig. 3A and B). Three surgical approaches are performed. The first a p p r o a c h is straight medial and follows the dorsal edge o f the adductor hallucis nuscle. The calcaneal compartment is opened by blunt undermining along the undersurface o f the os cuneiforme. The superficial compartment is then easily split from this approach going plantary within the sagittal plane (Fig. 4A and B). The interossei compartments are relieved b y two dorsal approaches, of approximately 5 cm situated above the second and the fourth metatarsal. The medial incision is positioned rather medial and the lateral one rather lateral for providing a wide skin bridge (Fig. 5). The incisions have to remain open. The w o u n d is either covered with f a t gauze or skin substitutes until D P C or mesh grafting (Fig. 6). In calcaneal fractures, O R I F is not r e c o m m e n d e d
EUROPEAN JOURNAL OF FOOT AND ANKLE SURGERY
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KLAUE
"
1
!
B Fig. 3.--Pressure measurement within the interossei compartments. A) Punction of the skin from dorsal above the second and fourth intermetatarsal space. Compartment pressures of the adductor and the superficial compartments are thus measured. B) Schematic diagramm. The needle is positioned deep to the second and fourth intermetatarsal spaces (M: medial compartment, A: abductor compartment, L" lateral compartment, I: interossei compartments).
•'
.'~
~xf, '4
B Fig. 4.--Medial approach for fasciotomies of the plantar compartments (medial, calcaneal and superficial compartment). A) Clinical view of the approach. B) Schematic diagramm from the medial approach, all deep plantar compartments can be released.
at this stage because o f the swollen soft tissues. In fracture-dislocations o f the Lisfranc, reduction and fixation can be m a d e during the same procedure. Post-operatively the foot is kept within a dorsal
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plaster splint for a couple of days. The leg is positioned in a slightly raised position, the knee bent approximately 20 degrees in order to guarantee sufficient arterial pressure and venous drainage.
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Fig. 5.--Dorsal approaches. The four interossei compartments are released through two dorsal approaches above the second and the fourth metatarsal respectively. From these dorsal incisions the abductor and the lateral compartments can be released. Fig. 6.--End result afte r dorsal fasciotomies and mesh graft.
Fig. 7.--Lateral (A) and axial (B) view of a communitive fracture of the calcaneus (case 1) developing a compartment syndrome.
Own cases
F r o m July 1991 to October 1993 we have measured and d o c u m e n t e d pathological c o m p a r t m e n t pressures o f the foot in 8 traumatized patients. Three patients had calcaneus burst fractures (Fig. 7A and B), three cases a fracture--dislocation o f the Lisfranc and one patient a fracture of the cuboid. The 8th case was a traumatic lesion o f the arteria dorsalis pedis
34
by glas cut injury sustained b y a thief while breaking a shop window. Table II shows the description of the cases. The average time lag between t r a u m a and measurement and fasciotomy was 11.5 hours (4-20 hours). This long delay was most often due to a unrecognized or missed diagnosis. In all patients indication of fasciotomy was clear clinically and in none of these cases we were surprised b y the pathological pressures. O R I F of the three calcaneus burst fractures were carried out only secondarily after swelling o f the foot went down, approximately 10 days after trauma. The complex metatarsal fractures with dislocation o f the Lisfranc and M T P - j o i n t s in case 4, as well as the fracture-dislocation o f the Lisfranc in case 5 and 7 required primary care. The cuboid fracture in case 6 was treated conservatively. In two patients the dorsal incision were successfully mesh-grafted 14 days postoperatively. We have checked all patients in our clinic. The results are shown in Table III. Despite the delay between trauma and fasciotomy, the sensory disturbances disappeared completely except in one patient (case 6). In this patient a hyposensibility was persisting in the area o f the N. peroneus profundus at our examination at six months. A static disturbance o f the f o r e f o o t 7 months after O R I F of the os calcis and fasciotomy was noted in case 1 with
EUROPEAN JOURNAL OF FOOT AND ANKLE SURGERY
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KLAUE
TABLE III.--Evaluation at follow-up.
ment syndromes remain without functional consequences, s Interestingly enough, the pressure of the calcaneal compartment has not been selectively measured in the published studies, despite its logical involvement after calcaneus fractures. Pressures have been measured from an intermediate c o m p a r t m e n t on the sole o f the foot. 12 This " c o m p a r t m e n t " however, is divided in seven separate compartments: the 4 interossei, the medial, the lateral and the superficial compartments. 15 Regardless o f the exact localisation o f the probe, it seems logical to consider pathologically increased pressure as indication criteria for fasciotomy. A b o u t the fasciotomy itself, if indicated, it seems logical too, that all compartments are opened to avoid iatrogenic mismatch of compartment pressures. Nevertheless, the absolute measured compartment pressure seems not to represent the only indication critera for fasciotomy. We do not advocate systematic pressure measurements in any foot trauma, while still leaving this indication based upon clinical assessment. We did not experience any complications with the described technique of fasciotomy b u t would mention the danger of creating iatrogenic scarring a b o u t the m i d f o o t if the dissection is not carried out close to b o n y and ligamentous structures thus leading to secondary functional limitation. Fortunately we observed that even following a time of 12 hours between trauma and fasciotomy the neuromuscular symptoms were completely reversible. As shown in animal experiments, neuromuscular damage is dependent upon time and pressure. 2. It seems therefore important to also release the compartments in cases coming to delayed treatment.
Patient
Follow-up (months)
K.A.
7
J.D.
10
O.P.
4
No sensory deficit
C.A.
1
No sensory deficit Cast-immobilized, no functional examination
Z.A.
6
No sensory deficit Normal ROM at the MTP joints I-V
R.M.
4
Hyposensibility in the medial part of the forefoot Normal ROM at the MTP joints I-V
B.J.
2
Postoperative no sensory deficit Cast-immobilized
S.J.
1
No sensory deficit Normal ROM at the MTP joints I-V
Findings on examination No sensory deficit Shortening of the flexor hallucis longus - tendon, decreased passive extension of MTP1 Normal ROM at the MTP joints II-V No sensory deficit Normal ROM at the MTP joints I-V
a significant reduction in height o f the hindfoot, as well as a significant extension deficit o f the big toe. A corrective subtalar arthrodesis was then performed, together with a lengthening t e n o t o m y o f the flexorhallucis-longus tendon with a good end-result. The other patients showed a satisfactory result with restitutio ad integrum.
Discussion Zusammenfassung Although the c o m p a r t m e n t syndrome o f the foot has been frequently mentioned in recent literature, this complication after injuries a b o u t the foot has often been neglected. In our cases, diagnosis of compartment syndrome has not been made primarily in two out o f eight cases. Certainly the question arises what are the indication criteria for fasciotomy. If the intra-compartimental pressure is taken as the only criteria, indication for fasciotomy would be given for all calcaneal fractures, since in those, the incidence of pathologically increased pressure is very high. 12 Fortunately it seems that almost 50°70 of compart-
Vol. 1 - No. 1
D a s K o m p a r t m e n t s y n d r o m a m F u s s w i r d erst seit w e n i g e n J a h r e n als e r n s t z u n e h m e n d e K o m p l i k a t i o n n a c h C r u s h t r a u m e n u n d s c h w e r e n F r a k t u r e n des F u s s k e l e t t s b e s c h r i e b e n . Es h a n d e l t sich d a b e i u m e i n e n d r i n g l i c h e n c h r i r u r g i schen Notfall, der dem Stadium I der V o l k m a n n ' s c h e r Kont r a k t u r e n t s p r i c h t . U n b e h a n d e l t ffihrt as bei fiber 50°70 zu s c h m e r z h a f t e n S t a t i k v e r f i n d e r u n g e n des F u s s e s m i t f i x i e r t e n Krallenzehen und kontraktem Vorfuss. D u r c h p e r k u t a n e D r u c k m e s s u n g k 6 n n e n p a t h o l o g i s c h erh 6 h t e L o g e n d r u c k e fiber 30 m m H g e i n f a c h e r k a n n t w e r d e n . Die F a s z i o t o m i e n d e r 9 K o m p a r t i m e n t e des F u s s e s w e r d e n d u r c h e i n e n m e d i a l e n u n d zwei d o r s a l e Z u g f i n g e d u r c h g e ffihrt.
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W~ihrend der letzten zwei Jahren haben wir bei 8 Traumapatienten mit klinischem Verdacht auf ein akutes Komp a r t m e n t s y n d r o m a m F u s s die L o g e n d r u c k e g e m e s s e n . D a b e i
konnten Maximaldrucke von tiber 100 mmHg nachgewiesen werden. Bei allen Patienten wurden die betroffenen Kompartimente notfallm/issig fasziotomiert. Ausser bei einem Patienten, bei welchem eine Hyposensibilit/it persistierte, kam es zur vollst/indigen Erholung der initialen, neuromuskul/iren Symptome.
References 1. Schmit-Neuerburg KP. Das Compartment-Syndrom als Traumafolge. Chirurg 1988;59:713-721. 2. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop 1989;240:97-105. 3. Manoli A II, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot & Ankle 1990; 10:267-275. 4. Echtermeyer V. Das Kompartmentsyndrom des Fusses. Orthop/ide 1991;20:76-79. 5. Manoli A. Compartment syndromes of the foot. Current concepts. Foot Ankle 1990;10:340-344. 6. Volkmann R. Die isch/imischen Musckell/ihmungen und Kontrakturen. Centralbl f. Chir 1881;51:801. 7. Matsen FA III. Compartmental syndrome. A unified concept. Clin Orthop 1975;113:8-13. 8. Mittelmeier Th, M/ichler G, Lob G, Mutschler W, Bauer G, Vogl Th. Compartment syndrome of the foot after intrarticular calcaneal fracture. Clin Orthop 1991;269:241-248.
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9. Ashton H. The effect of increased tissue pressure on blood flow. Clin Orthop 1975;113:15-26. 10. Jennings AMC. Some observations of cortical dosing pressures in the peripheral circulation of anesthetized. Br J Anaesth 1964;36:683-687. 11. Rorabeck CH, Macnab I, Wadell JP. Anterior tibial compartment syndrome. A clinical and experimental review. Can J Surg 1972;15:249-254. 12. Ender HG, Moser K. Die Erh6hung des Druckes in den Logen der Sohle bei Gelenkbriichen des Fersenbeines. Unfallchirurg 1991;91:523-526. 13. Myerson M. Management of compartment syndromes of the foot. Clin Orthop 1991;271:239-248. 14. Seddon HJ. Volkmann's ischemia of the lower limb. J Bone Joint Surg 1966;48B:627-637. 15. Klaue K, Masquelet AC, Jakob RP. Soft tissue and tendon injury in the foot. Current Opinion in Orthopaedics 1991 ;2:519-528. 16. Ascenio G, Pelissier J, Enjalbert M, Berin R, Galouye P, Lopez S, Simon L. Le pied dans le syndr6me de Volkmann. In: Claustre J, Simon L, eds. Actualit6s en M6decine et Chirurgie du Pied, Vol. 4. Masson Ed, 1989:26-30. 17. Myerson M. Diagnosis and treatment of compartment syndrome of the foot. Orthopedics 1990;13:711-717. 18. Sarrafian SK. Anatomy of the foot ankle. JB Lippincott 1983. 19. Bonutti PM, Bell GR. Compartment syndrome of the foot. J Bone Joint Surg 1986;68A:1449-1451. 20. Echtermeyer V. Das Kompartment-Syndrom. Berlin: Springer, 1985. 21. Henry AK. Extensile exposure. New York: Churchill Livingstone, 1982. 22. Mubarak SJ, Hargens AR. Compartment syndrome and Volkmann's Contracture. Philadelphia: WB Saunders, 1981.
EUROPEAN JOURNAL OF FOOT AND ANKLE SURGERY
April 1994
Compartment syndrome of the foot MARKUS PISAN, KAJ KLAUE
Compartment syndrome o f the f o o t has been described recently as a serious complication after crush trauma and severe fractures. I t represents a surgical emergency and corresponds to stage I o f V o l k m a n n ' s contracture. Untreated, it will lead to pain and static changes o f the f o o t with fixed claw toes and a contracted forefoot in more than 50°70 o f the cases. Percutaneous measuring o f intrinsic compartment pressure allows rapid assessment o f pathological values (more than 30 m m H g ) . Fasciotomies o f the 9 compartments o f the foot are preferentially performed through one medial and two dorsal approaches. During the last two years we have measured pathological compartment pressures in 8 traumatized patients in w h o m an acute compartment syndrome o f the foot was clinically suspected. Pressure values o f more than 100 m m H g were demonstrated. In all patients foot compartments were released immediately. Except for one patient, with a persisting hyposensihility, all patients showed a complete recovery o f the initial neuromuscular s y m p t o m s . KEY
WORDS: Foot, compartment syndrome.
o m p a r t m e n t syndromes must be feared complications after closed injuries o f the extremities and are the second most frequent complication in traumatology after thrombosis. ~As such it represents a surgical emergency case. Not only fractures or direct injuries of the vessels are responsible but also soft tissue trauma, burns and hypothermias. 22 The lower leg as well as the forearm belong to the most frequent
C
Received February 17, 1994. Accepted for publication March 25, 1994.
Address reprint requests to: K. Klaue, Department of Orthopaedic Surgery, Inselspital, University of Bern, 3010 Bern - Switzerland.
Vol. 1 - N. I
Department of Orthopaedic Surgery, lnselspital, University of Bern
localizations. Seldomly has it been diagnosed in the upper arm, the shoulder, the hand, the gluteal region and the thigh. 3 Recently, compartment syndrome of the foot has been described as a serious complication after crush trauma and its frequency is estimated on approximately 5°7o of all c o m p a r t m e n t syndromes. 4 5 V o l k m a n n described in 1881 6 ischaemic muscle paralysis and contractures after application of thigh w o u n d dressing, too long constriction o f the limbsthrough an Esmarch bandage, and also after lacerations and contusions o f large vessels and after long periods o f severe cold. These ischaemic contractures of the muscles, the so-called Volkmann's contracture, together with irreversible nerve lesions in the sense o f a demyelinisation and following fibrosis are consequences o f an untreated c o m p a r t m e n t syndrome. Increased pressure within a closed space is responsible for a compartment syndrome, whereas the limiting factor is not only the fascia of the muscle but also the epimysium, the skin and occasionnally a circular bandage or cast. 2 The h a e m a t o m a and the accumulation of interstitial fluid leads to an increase of pressure which consecutively causes a reduced perfusion o f soft tissues. 2 7 s Experimental studies demonstrated a progressive reduction of soft tissue
EUROPEAN JOURNAL OF FOOT AND ANKLE SURGERY
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perfusion within a c o m p a r t m e n t submitted to continuously increased intrinsic pressure. The critical point for complete stop of micro-circulation is reached when the diastolic blood pressure equals the intrinsic p r e s s u r e . 9-11 G e n e r a l l y , a c o m p a r t m e n t pressure within peripheral muscular groups beyond 30 m m H g is considered pathological and represents an indication for operative treatment. 4 5 12 13 The extent of damage depends directly on the time and the a m o u n t of the intracompartimental pressure. In animal experiments, a period o f 12 hours before irreversible damage of the musculature was determined. 2 However all muscular groups do not react with equal sensitivity to ischemia. 14 On the other hand, if the involved compartments are not decompressed operatively, the pathological pressures persist for approximately two days, and thereafter decrease spontaneously. 8 Most serious effects are the irreversible neuromuscular changes. 5 The compartments o f the foot are divided by strong, rigid septa and therefore are predestinated to develop a c o m p a r t m e n t syndrome after a massive t r a u m a . Together with the tibio-fibular syndesmosis the mentioned septa are directly involved in the entire statics of the foot. 15 Most c o m m o n foot injuries which cause compartment syndromes are crush t r a u m a , with or without associated fracture such as calcaneus, m i d - f o o t or metatarsal. Myerson t3 f o u n d an incidence o f compartment syndromes in respectively 17°?0 and 4.7°7o of all calcaneus fractures and in 41070 if combined with crush t r a u m a . In other studies, in more than 50°70 of well-documented, conservatively treated calcaneus fractures, plantar contractions or claw toes or both were found as a sign of a non-diagnosed comp a r t m e n t syndrome. 8 Ender and M o s e r , 12 observed in 29 o f 32 calcaneus fractures pressures within the deep plantar c o m p a r t m e n t of more than 30 m m H g . The end result o f an untreated c o m p a r t m e n t syndrome o f the foot is a foot with limited function, painful, with atrophic and contract intrinsic musculature and fixed claw toes (not h a m m e r toes) and consequently a shorted arch with a tendency to a p e s caVUS.3 15-17
Anatomy A detailed anatomic description o f the different c o m p a r t m e n t s of the foot has been presented by
30
TABLE
I.--Compartments of the foot~muscular content.
1. Medial compartment - - M. adductor hallucis - - M. flexor hallucis brevis (2 heads) 2. Superficial compartment - - Mm. flexor digitorum brevis - - tendons (of a distal share) of the flexor digitorum longus - - Mm. lumbricales 3. Lateral compartment - - M. abductor digiti minimi - - M. flexor digiti minimi brevis 4. Abductor compartment - - M. abductor hallucis 5-8. Interossei compartment - - Mm. interossei (dorsales et plantares) 9. Calcaneus compartment - - M. quadratus plantae in connection (through the long flexors of the toes) with the deep, posterior compartment of the lower leg, through the retinaculum behind the medial malleous, following the vene/nerve bundle
Sarrafian 18 and recently confirmed in an anatomic study with selective dye injections of Manoli and Weber. 3 Division of compartments are mentioned in Table I. W o r t h mentioning is that the medial, lateral and superficial c o m p a r t m e n t stretch out over the entire length o f the foot, whereas the abductor and the interossei compartments are limited to the forefoot. The calcaneus c o m p a r t m e n t is the only one that lies in the hindfoot.
Clinical signs The diagnosis of the acute compartment syndrome with the patient awake has to be done clinically. A measurement o f the c o m p a r t m e n t pressure is indicated in unconcious patients and for the objectivation o f the diagnosis. Patients with a beginning compartment syndrome after a foot t r a u m a complain about severe pain, which often persist or even increases despite analgesics. The foot is normally kept in an antalgic relaxing position, in a slight flexion-adduction (Fig. 1). The M P joints are often swollen due to the pressure of the h e m a t o m a . A functional examination o f the
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Fig. 1.--Compartment syndrome. Typical swelling and antalgic position in flexion after crush trauma.
foot is often not possible. The pain increases with passive extension o f the toes and the ankle joint. Dysesthesia or hypesthesia o f the foot is another sign o f compartment syndrome. In order not to miss this discrete sign, a thorough examination of all involved nerves is required. The capillar filling remains intact during the whole acute phase. The arteria tibialis posterior is usually palpable whereas the arteria dorsalis pedis is palpable depending the severeness o f the swelling. A ultrasonogram is sometimes indicated. Myerson, la found a lesion o f the arteria dorsalis pedis in one case out o f 14 well-documented cases. As a differential diagnosis only acute, traumatic occlusion o f one or more arteries of the foot can be mentioned. 1
TABLE I I . - - M e a s u r e m e n t s o f our pathological cases. Patients (age).
Diagnosis/Side
Findings on examination
Compartment
Pressures
Time lag Trauma-Surgery
(hour) K.A. (25)
Communitive fracture of the calcaneus, left
Swelling Hyposensibility in the lateral part of the foot
Calcaneus Interossei I/II Interossei III/IV
76 32 65
12
J.D. (24)
Communitive fracture of the calcaneus, left
Swelling Hyposensibility in the lateral part of the foot
Calcaneus
65
18
O.P. (44)
Communitive fracture of the calcaneus, right
Swelling
Calcaneus
60
17
C.A. (25)
Fracture-dislocation of the Lisfranc Fracture-dislocation of the 2nd 5th Metatarso-phalangeal joints left
Swelling Hyposensibility in the lateral part of the foot and the dorsal part of toes 1-5
Calcaneus Superficial
> 100 38
4
Z.A. (55)
Fracture-dislocation of the Lisfranc Fracture of the first cuneiform Fracture of the cuboid left
Swelling
Calcaneus Medial Superficial
61 > 100 78
R.M. (30)
Fracture of the cuboid, right
Swelling Hyposensibility of the forefoot
Calcaneus Superficial Interossei I/II Interossei Ill/IV Medial
55 54 90 39 57
20
B.J. (30)
Fracture-dislocation of the Lisfranc, left
Swelling
Interossei I/II Interossei Ill/IV Medial Calcaneus
31 32 52 32
10
S.J. (26)
Lesion of the arteria dorsal pedis, right
Swelling Hyposensibility in the dorsal part of the forefoot and toes Absense of the dorsal pedis pulse
Interossei I/II
40
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B Fig. 2 . - - P r e s s u r e m e a s u r e m e n t within the calcaneal compartment. A) Punction of the skin just above the adductor hallucis muscle, slightly distal from the base of the first metatarsal and with an angle of 45 ° to the medial column towards caudal. B) Schematic diagramm. The needle passes above the adductor and beneath the first metatarsal (M" medial compartment, S: superficial compartment, C: calcaneal compartment, L: lateral compartment).
Treatment Treatment o f the acute c o m p a r t m e n t syndrome is the release of all fascial spaces involved (fasciotomy). In some cases, indication for fasciotomy can be set based on clinical investigation alone. Fasciotomy immediately follows measurement of the compartment pressures if the latter are pathological. The foot is prepped with sterile solution. We use a m o n i t o r (Datex Cardiocap T M II, Datex/Instrumentarium Corp., Helsinki Finland [Nonlinearity 1%, 0-200 m m H g ] ) and a 20-gauge needle (20 G x 2 3 / 4 " ) . We measure each pressure twice and the mean value is documented. Measurements o f our pathological cases are indicated in Table II. The exact localization o f the different compartments with the needle is based on simple landmarks and are judged upon the depth of gauging and is technically easy. In order to assess the calcaneal compartment pressure, we suggest a punction with an angle of 45 ° to the long axis o f the foot from medial, slightly distal from the base o f the first metatarsal and just above the adductor hallucis muscle. 15 The same entry can be used for punctioning the medial
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compartment (Fig. 2A and B). The interosseous compartments are optimally measured through the second and fourth intermetatarsal space. F r o m dorsal one successively enters the interosseous and the superficial at the fourth and the a b d u c t o r c o m p a r t m e n t at the second space (Fig. 3A and B). Three surgical approaches are performed. The first a p p r o a c h is straight medial and follows the dorsal edge o f the adductor hallucis nuscle. The calcaneal compartment is opened by blunt undermining along the undersurface o f the os cuneiforme. The superficial compartment is then easily split from this approach going plantary within the sagittal plane (Fig. 4A and B). The interossei compartments are relieved b y two dorsal approaches, of approximately 5 cm situated above the second and the fourth metatarsal. The medial incision is positioned rather medial and the lateral one rather lateral for providing a wide skin bridge (Fig. 5). The incisions have to remain open. The w o u n d is either covered with f a t gauze or skin substitutes until D P C or mesh grafting (Fig. 6). In calcaneal fractures, O R I F is not r e c o m m e n d e d
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"
1
!
B Fig. 3.--Pressure measurement within the interossei compartments. A) Punction of the skin from dorsal above the second and fourth intermetatarsal space. Compartment pressures of the adductor and the superficial compartments are thus measured. B) Schematic diagramm. The needle is positioned deep to the second and fourth intermetatarsal spaces (M: medial compartment, A: abductor compartment, L" lateral compartment, I: interossei compartments).
•'
.'~
~xf, '4
B Fig. 4.--Medial approach for fasciotomies of the plantar compartments (medial, calcaneal and superficial compartment). A) Clinical view of the approach. B) Schematic diagramm from the medial approach, all deep plantar compartments can be released.
at this stage because o f the swollen soft tissues. In fracture-dislocations o f the Lisfranc, reduction and fixation can be m a d e during the same procedure. Post-operatively the foot is kept within a dorsal
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plaster splint for a couple of days. The leg is positioned in a slightly raised position, the knee bent approximately 20 degrees in order to guarantee sufficient arterial pressure and venous drainage.
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Fig. 5.--Dorsal approaches. The four interossei compartments are released through two dorsal approaches above the second and the fourth metatarsal respectively. From these dorsal incisions the abductor and the lateral compartments can be released. Fig. 6.--End result afte r dorsal fasciotomies and mesh graft.
Fig. 7.--Lateral (A) and axial (B) view of a communitive fracture of the calcaneus (case 1) developing a compartment syndrome.
Own cases
F r o m July 1991 to October 1993 we have measured and d o c u m e n t e d pathological c o m p a r t m e n t pressures o f the foot in 8 traumatized patients. Three patients had calcaneus burst fractures (Fig. 7A and B), three cases a fracture--dislocation o f the Lisfranc and one patient a fracture of the cuboid. The 8th case was a traumatic lesion o f the arteria dorsalis pedis
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by glas cut injury sustained b y a thief while breaking a shop window. Table II shows the description of the cases. The average time lag between t r a u m a and measurement and fasciotomy was 11.5 hours (4-20 hours). This long delay was most often due to a unrecognized or missed diagnosis. In all patients indication of fasciotomy was clear clinically and in none of these cases we were surprised b y the pathological pressures. O R I F of the three calcaneus burst fractures were carried out only secondarily after swelling o f the foot went down, approximately 10 days after trauma. The complex metatarsal fractures with dislocation o f the Lisfranc and M T P - j o i n t s in case 4, as well as the fracture-dislocation o f the Lisfranc in case 5 and 7 required primary care. The cuboid fracture in case 6 was treated conservatively. In two patients the dorsal incision were successfully mesh-grafted 14 days postoperatively. We have checked all patients in our clinic. The results are shown in Table III. Despite the delay between trauma and fasciotomy, the sensory disturbances disappeared completely except in one patient (case 6). In this patient a hyposensibility was persisting in the area o f the N. peroneus profundus at our examination at six months. A static disturbance o f the f o r e f o o t 7 months after O R I F of the os calcis and fasciotomy was noted in case 1 with
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TABLE III.--Evaluation at follow-up.
ment syndromes remain without functional consequences, s Interestingly enough, the pressure of the calcaneal compartment has not been selectively measured in the published studies, despite its logical involvement after calcaneus fractures. Pressures have been measured from an intermediate c o m p a r t m e n t on the sole o f the foot. 12 This " c o m p a r t m e n t " however, is divided in seven separate compartments: the 4 interossei, the medial, the lateral and the superficial compartments. 15 Regardless o f the exact localisation o f the probe, it seems logical to consider pathologically increased pressure as indication criteria for fasciotomy. A b o u t the fasciotomy itself, if indicated, it seems logical too, that all compartments are opened to avoid iatrogenic mismatch of compartment pressures. Nevertheless, the absolute measured compartment pressure seems not to represent the only indication critera for fasciotomy. We do not advocate systematic pressure measurements in any foot trauma, while still leaving this indication based upon clinical assessment. We did not experience any complications with the described technique of fasciotomy b u t would mention the danger of creating iatrogenic scarring a b o u t the m i d f o o t if the dissection is not carried out close to b o n y and ligamentous structures thus leading to secondary functional limitation. Fortunately we observed that even following a time of 12 hours between trauma and fasciotomy the neuromuscular symptoms were completely reversible. As shown in animal experiments, neuromuscular damage is dependent upon time and pressure. 2. It seems therefore important to also release the compartments in cases coming to delayed treatment.
Patient
Follow-up (months)
K.A.
7
J.D.
10
O.P.
4
No sensory deficit
C.A.
1
No sensory deficit Cast-immobilized, no functional examination
Z.A.
6
No sensory deficit Normal ROM at the MTP joints I-V
R.M.
4
Hyposensibility in the medial part of the forefoot Normal ROM at the MTP joints I-V
B.J.
2
Postoperative no sensory deficit Cast-immobilized
S.J.
1
No sensory deficit Normal ROM at the MTP joints I-V
Findings on examination No sensory deficit Shortening of the flexor hallucis longus - tendon, decreased passive extension of MTP1 Normal ROM at the MTP joints II-V No sensory deficit Normal ROM at the MTP joints I-V
a significant reduction in height o f the hindfoot, as well as a significant extension deficit o f the big toe. A corrective subtalar arthrodesis was then performed, together with a lengthening t e n o t o m y o f the flexorhallucis-longus tendon with a good end-result. The other patients showed a satisfactory result with restitutio ad integrum.
Discussion Zusammenfassung Although the c o m p a r t m e n t syndrome o f the foot has been frequently mentioned in recent literature, this complication after injuries a b o u t the foot has often been neglected. In our cases, diagnosis of compartment syndrome has not been made primarily in two out o f eight cases. Certainly the question arises what are the indication criteria for fasciotomy. If the intra-compartimental pressure is taken as the only criteria, indication for fasciotomy would be given for all calcaneal fractures, since in those, the incidence of pathologically increased pressure is very high. 12 Fortunately it seems that almost 50°70 of compart-
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D a s K o m p a r t m e n t s y n d r o m a m F u s s w i r d erst seit w e n i g e n J a h r e n als e r n s t z u n e h m e n d e K o m p l i k a t i o n n a c h C r u s h t r a u m e n u n d s c h w e r e n F r a k t u r e n des F u s s k e l e t t s b e s c h r i e b e n . Es h a n d e l t sich d a b e i u m e i n e n d r i n g l i c h e n c h r i r u r g i schen Notfall, der dem Stadium I der V o l k m a n n ' s c h e r Kont r a k t u r e n t s p r i c h t . U n b e h a n d e l t ffihrt as bei fiber 50°70 zu s c h m e r z h a f t e n S t a t i k v e r f i n d e r u n g e n des F u s s e s m i t f i x i e r t e n Krallenzehen und kontraktem Vorfuss. D u r c h p e r k u t a n e D r u c k m e s s u n g k 6 n n e n p a t h o l o g i s c h erh 6 h t e L o g e n d r u c k e fiber 30 m m H g e i n f a c h e r k a n n t w e r d e n . Die F a s z i o t o m i e n d e r 9 K o m p a r t i m e n t e des F u s s e s w e r d e n d u r c h e i n e n m e d i a l e n u n d zwei d o r s a l e Z u g f i n g e d u r c h g e ffihrt.
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W~ihrend der letzten zwei Jahren haben wir bei 8 Traumapatienten mit klinischem Verdacht auf ein akutes Komp a r t m e n t s y n d r o m a m F u s s die L o g e n d r u c k e g e m e s s e n . D a b e i
konnten Maximaldrucke von tiber 100 mmHg nachgewiesen werden. Bei allen Patienten wurden die betroffenen Kompartimente notfallm/issig fasziotomiert. Ausser bei einem Patienten, bei welchem eine Hyposensibilit/it persistierte, kam es zur vollst/indigen Erholung der initialen, neuromuskul/iren Symptome.
References 1. Schmit-Neuerburg KP. Das Compartment-Syndrom als Traumafolge. Chirurg 1988;59:713-721. 2. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop 1989;240:97-105. 3. Manoli A II, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot & Ankle 1990; 10:267-275. 4. Echtermeyer V. Das Kompartmentsyndrom des Fusses. Orthop/ide 1991;20:76-79. 5. Manoli A. Compartment syndromes of the foot. Current concepts. Foot Ankle 1990;10:340-344. 6. Volkmann R. Die isch/imischen Musckell/ihmungen und Kontrakturen. Centralbl f. Chir 1881;51:801. 7. Matsen FA III. Compartmental syndrome. A unified concept. Clin Orthop 1975;113:8-13. 8. Mittelmeier Th, M/ichler G, Lob G, Mutschler W, Bauer G, Vogl Th. Compartment syndrome of the foot after intrarticular calcaneal fracture. Clin Orthop 1991;269:241-248.
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9. Ashton H. The effect of increased tissue pressure on blood flow. Clin Orthop 1975;113:15-26. 10. Jennings AMC. Some observations of cortical dosing pressures in the peripheral circulation of anesthetized. Br J Anaesth 1964;36:683-687. 11. Rorabeck CH, Macnab I, Wadell JP. Anterior tibial compartment syndrome. A clinical and experimental review. Can J Surg 1972;15:249-254. 12. Ender HG, Moser K. Die Erh6hung des Druckes in den Logen der Sohle bei Gelenkbriichen des Fersenbeines. Unfallchirurg 1991;91:523-526. 13. Myerson M. Management of compartment syndromes of the foot. Clin Orthop 1991;271:239-248. 14. Seddon HJ. Volkmann's ischemia of the lower limb. J Bone Joint Surg 1966;48B:627-637. 15. Klaue K, Masquelet AC, Jakob RP. Soft tissue and tendon injury in the foot. Current Opinion in Orthopaedics 1991 ;2:519-528. 16. Ascenio G, Pelissier J, Enjalbert M, Berin R, Galouye P, Lopez S, Simon L. Le pied dans le syndr6me de Volkmann. In: Claustre J, Simon L, eds. Actualit6s en M6decine et Chirurgie du Pied, Vol. 4. Masson Ed, 1989:26-30. 17. Myerson M. Diagnosis and treatment of compartment syndrome of the foot. Orthopedics 1990;13:711-717. 18. Sarrafian SK. Anatomy of the foot ankle. JB Lippincott 1983. 19. Bonutti PM, Bell GR. Compartment syndrome of the foot. J Bone Joint Surg 1986;68A:1449-1451. 20. Echtermeyer V. Das Kompartment-Syndrom. Berlin: Springer, 1985. 21. Henry AK. Extensile exposure. New York: Churchill Livingstone, 1982. 22. Mubarak SJ, Hargens AR. Compartment syndrome and Volkmann's Contracture. Philadelphia: WB Saunders, 1981.
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