- Email: [email protected]
Compartment syndrome of the foot following calcaneus fracture
IXc Ebol (IYYZI 2. 157-161 t
1992 Longman
Group tiK Ltd
Compartment syndrome of the foot following calcaneus fracture T. Saxby. M. Myerson, L. Schon Union Memorial Australia
Hospital,
Baltimore,
Mar_yland, USA, and Princess Alexandra
Hospital,
Brisbane,
SUMMA R Y. A prospective study of 74 patients with intra-articular fracture of the calcaneus and its association with compartment syndrome was undertaken. 10 patients (13%) had elevated compartment pressures greater than 40 mmHg in 1 or more compartments. Three additional patients had a compartment pressure of greater than 30 mmHg, and 15 patients (19%) had pressures ranging from lo-30 mmHg. 13 patients underwent fasciotomy, using a medial incision in 10, combined medial and dorsal incisions in 2, and with dorsal incisions only, in 1 patient. At follow-up, 11 (85%) had no evidence of myoneural ischemia, 1 patient had mild signs and in 1 patient in whom dorsal incisions only were used for fasciotomy had the classic syndrome with clawing of the toes and a stiff painful foot. Based on our clinical observations and pressure measurements, compartment syndrome of the foot does occur after calcaneus fracture. If performed correctly and expeditiously, fasciotomy is effective treatment for the prevention of the long-term sequelae of this debilitating condition.
Data collected on the 74 patients in the study included demographic information, the mechanism of injury and associated injuries. All patients were specifically examined for a compartment syndrome. The clinical features evaluated included severe, unrelenting pain, paresthesiae, numbness, and pain on passive dorsiflexion of the toes. All patients in the study had compartment pressures measured by a digital handheld monitor (Digital Quickset, Stryker, Kalamazoo, Ml) at time of presentation. The technique employed involved multistick catheterization of the interosseous, medial, lateral and central or calcaneal compartments. At the commencement of the study the division of the central compartment into a superficial and a deep (calcaneal) compartment was not recognized.2 During the first 2 years therefore, pressure measurements were made in the central compartment and later, directly in the posterior aspect of the central compartment, now referred to as the calcaneal compartment. An interstitial pressure of more than 40 mmHg in any one compartment was considered pathologic and was treated by fasciotomy. Patients with compartment pressures between 30 and 40 mmHg were carefully evaluated, and fasciotomy performed only in the presence of classic clinical findings, particularly unrelenting pain associated with numbness in the distribution of the tibia1 nerve. Patients with pressures less than 30 mmHg were not treated with fasciotomy, but carefully monitored with frequent clinical examination. Fasciotomy was performed immediately upon diagnosis of the compartment syndrome, once the patient could be taken to surgery, regardless of the decision making for fracture care. It was felt that the compartment syndrome took
Although compartment syndrome following trauma to an extremity is a well recognized entity, this complication following foot trauma has only been recently noted.‘-” Compartment syndromes of the foot are typically associated with high energy, especially where crushing of the foot occurs. The characteristic findings of this syndrome are severe, unrelenting pain associated with severe burning or tingling of the foot. tense swelling, pain on passive dorsiflexion of the toes, and occasionally sensory deficits. However, apart from a few isolated case reports, the association of compartment syndrome of the foot and calcaneus fracture has not received much attention.lp4 The consequences of untreated compartment syndrome in the foot include claw and hammer toe deformities, continued pain, stiffness, weakness, sensory changes, and atrophy of the intrinsic musculature.4.5 The aims of this study were to establish the incidence of compartment syndrome of the foot following intraarticular calcaneus fracture and to review the results of fasciotomy.
MATERIALS
AND METHODS
A prospective study of calcaneus fracture and its association with compartment syndrome was undertaken in 1987 at the Union Memorial Hospital. Between January 1987 and January 1990, 108 calcaneus fractures were treated at our institution. Compartment pressures were measured in 74 patients. The other 34 patients either presented for treatment more than 1 week after injury, or pressures were not obtained, and they were excluded from the study. 157
158
The Foot
precedence over fracture care. If the calcaneus fracture warranted open reduction and internal fixation, this could be performed simultaneously or delayed accordingly. Regional anesthesia was used in 5 and general anesthesia in 8 patients. The decision to perform regional or general anesthesia was determined by the clinical situation, patient preference, and need for additional surgery. Regional anesthesia was only used if fracture care was not simultaneously performed.
Lateral plantar
ANATOMY AND METHOD OF FASCIOTOMY Classically the plantar aspect of the foot has been divided into 4 separate compartments; medial, lateral, central and interosseous. 6S7In a recent study, Manoli & Webe? identified 9 compartments; the medial and lateral compartments were as previously described. However, they found that the central compartment was divided in the hindfoot by a transverse septum into a ‘superficial’ containing flexor digitorum brevis muscle and a deep compartment which they named ‘calcaneal’ which contained the quadratus plantae muscle and the lateral plantar nerve. They also identified 4 separate compartments in what had been previously called the interosseous compartment and identified a separate compartment for the adductor hallucis muscle. The fasciotomy incision(s) were planned according to the location of the raised compartment pressures. The hindfoot fasciotomy was the primary approach utilized. This was performed via a medial incision which began 4 cm from the posterior aspect of the calcaneus and 3 cm superior to the plantar surface of the foot, (Figs 1 and 2). The incision extended distally parallel to the plantar surface for approximately 6 cm. The medial compartment was released by incision of the abductor hallucis fascia. The abductor hallucis muscle was then retracted superiorly, the medial
Fig. l-This illustration demonstrates the incision used for the hindfoot fasciotomies via a medial approach. The figure also demonstrates the position for insertion of the needle to measure the compartment pressure in the calcaneal compartment.
Fig. 2-Cross-section approach calcaneal
of the hindfoot used and the compartments or superficial.
demonstrating the in cross-section, medial,
intermuscular septum was thus revealed. This was then incised longitudinally and thereby releasing the calcaneal compartment. Great care was taken during this release as the lateral plantar neurovascular bundle lies just inferior to the septum. The superficial compartment was released via this incision by subcutaneous dissection outside the previously opened medial compartment. The flexor digitorium brevis muscle was then retracted plantarward and dissection extended laterally and posteriorly. The neurovascular structures were protected during this dissection by the superiorly placed transverse hindfoot septum. Following the hindfoot fasciotomy the pressures were remeasured. The forefoot compartments were released depending on the compartment pressures following the hindfoot fasciotomies and this was required in 2 cases. In 1 case, the dorsal approach was only used because at this time the calcaneal compartment (deep central) was not recognized and it was thought that all the compartments could be decompressed via the dorsal approach. This was accomplished by two longitudinal dorsal incisions. Each interosseous compartment was identified and released. The adductor compartment was decompressed by elevating the interosseous compartment off the medial border of the second metatarsal and retracting these muscles medially. The fasciotomy incision was left open in all patients, and treated with either daily wet to dry saline dressings or covered with porcine allograft which was changed at 2-day intervals. 10 of the wounds were closed secondarily between 5 and 8 days following fasciotomy, and the remainder closed with split-thickness skin grafts. The dorsal forefoot incisions required split-thickness skin grafts in 2 cases and in 1 case delayed primary closure was achieved. The calcaneus fracture was treated non-operatively in 4 of the 13 patients. Open reduction and internal fixation was undertaken in 7, and a primary arthrod-
Compartment
esis was performed in 2 patients. Of the 9 patients treated operatively for the fracture, 2 were performed simultaneously with the fasciotomy, and the rest between 5 and 8 days following fasciotomy. The patients were followed up and evaluated for at least 12 months following injury. They were examined specifically for the symptoms and signs of myonema1 ischemia, including sensory disturbance, loss of range of motion of the toes and toe deformity. The results of treatment of the calcaneus fracture were not evaluated in this study.
RESULTS There were 74 patients entered into the study. The 13 patients found to have elevated compartment pressures included 9 males and 4 females, with an average age of 33 years (range 19-54 years). Of these 13 patients, the pressures were > 40 mmHg in 10 patients, and ranged from 30 to 40 mmHg in 3 (Table 1). Injuries were sustained in a fall from a height in 10, and in motor vehicle accidents in 3 patients. Associated injuries included a fracture of the contralateral calcaneus (l), fractures of the metatarsals in 2, and there was 1 patient with a lumbar fracture. I 1 of the patients complained of severe pain, 6 had paresthesiae, and 8 had objective changes in sensation. This sensory loss was predominantly in the distribution of the tibia1 nerve. Pain on passive dorsiflexion of the hallux and toes was present in 11 of the 13 patients. The elevated compartment pressures were usually highest in the central or calcaneal compartments (Table 2). The average time from injury to fasciotomy Table 1. Injury
pattern
and clinical
syndrome
of the foot following
calcaneus
fracture
was 24 h with a range from 3 h to 5 days. This was largely dependent on the varied times that patients were referred to our institution. In 10 patients a medial approach for fasciotomy was used; a combined dorsal and medial approach used in 2; and in I patient the dorsal approach only was utilized. 11 of the patients had no evidence of myoneural ischemia at follow-up. One patient manifested severe forefoot deformity with fixed claw toes, intrinsic muscle atrophy, and stiffness of the forefoot. In this patient fasciotomy was performed using a dorsal approach only. A second patient who underwent fasciotomy with a medial incision at 5 days experienced stiffness of the forefoot with slight claw toe deformity of the second, third and fourth toes. The balance of the patients did not manifest any symptoms or signs which we would attribute to chronic myoneural ischemia. There were no complications associated with performing the fasciotomy.
DISCUSSION We have identified the presence and general incidence of compartment syndrome of the foot following calcaneus fracture. We are still unclear as to the exact incidence of this entity, which probably depends on how the diagnosis is made. In this study a compartment pressure above 40 mmHg was considered pathologic, and was present in 13% of the patients in whom compartment pressure measurements were made. The use of 40 mmHg as the cut-off value for treating these patients with fasciotomy is controversial. Of the 13 patients treated with fasciotomy, 10 patients had pressures above 40 mmHg in 1 or
findings
Side
Age
Sex
Mechanism of injury
Associated injuries
Severe pain
Numbness
Sensation
Pain (DF Toes)
I
R
24
M
Fall 6 ft
Nil
Present
Present
Present
2
L
36
F
Fall 10 ft
Present
Present
3
R
54
M
MVA
Present
Absent
4 5
L L
23 32
M M
Fall 16 ft Fail 21 ft
Present Absent
Present Absent
L
39
F
Present
Absent
7
R
38
M
Bicycle accident Fall 18 ft
Normal Lateral plantar nerve Normal
Present Absent
6
(R) Calcaneus fracture Metatarsal and ankle fracture Nil Lumbar vert. fracture Nil
Lateral plantar nerve Medial/lateral plantar nerves Normal
Present
Absent
R R
42 21
M M
Fall 6 ft Fall 8 ft
Absent Present
Absent Present
10 II
L R
18 19
F M
MVA MVA
Present Present
Absent Present
12
L
29
M
Fall 21 ft
Nil
Present
Present
13
L
55
M
Fall down stairs
Nil
Present
Absent
Lateral plantar nerve Normal Lateral plantar nerve Normal Medial/lateral plantar nerves Lateral plantar nerve Lateral plantar nerve
Present
8 9
(L) Calcaneus fracture Nil Navicular fracture Nil Nil
No.
159
Present Present
Present
Present Present Absent Present Present Present
160 The Foot Table 2. Treatment of compartment
syndrome and calcaneus fracture
Deep talc.
Compartment pressures Interosseous Medial
Time (injury to fasciotomy)
Fasciotomy
Fracture treatment
Results
Lateral
1 2 3 4
48 88 42 36
I5 24 8 28
18 28 10 _
10 16 I5 _
5h 28 h 9h 18h
Medial Medial Medial Dorsal
Early ROM Early ROM ORIF ORIF
5 6
38 34
47 33
_ _
7 8 9 10 11 12 13
94 44 49 84 56 80 63
20 6 20 16 11 52 17
25
_ _ 28 _ 22 _ _ 55 _
6h 4h 7h 3h 5 days 36 h 48 h 24 h 6h
Medial Medial Medial/dorsal Medial Medial Medial Medial Medial/dorsal Medial
ORIF ORIF Primary fusion ORIF ORIF Early ROM Early ROM Primary fusion ORIF
No deficit No deficit No deficit Stiff foot claw toes No deficit No deficit No deficit No deficit Toes slightly stiff No deficit No deficit No deficit No deficit
No.
18 10 22 63 64
more compartments, and the other 3 had pressures between 30 and 40 mmHg. Therefore, if 30 mmHg had been used as the lower limit for the diagnosis the incidence of compartment syndrome in this series would be 18%. The exact compartment pressure at which a release is required is controversial.8-‘0 The 3 patients who had pressures between 30 and 40 mmHg had clinical features of a compartment syndrome, including severe, unrelenting, burning pain associated with neurologic deficits. Since the study protocol was to surgically decompress all patients with pressures above 40 mmHg we do not know if all these patients would have gone on to develop the late sequelae of untreated myoneural ischemia. A recent3 report however found that 7 of 11 patients with calcaneus fractures who were not treated with fasciotomy but who had compartment pressures of greater than 30 mmHg later developed claw toes. In contrast, in our series 11 out of the 13 patients had no sequelae, 1 had mild stiffness of the toes and only 1 patient had definite clawing of the toes at follow-up. This 1 patient had the decompression via the dorsal approach only, since at the time it was believed that all compartments could be decompressed through this approach. However, Manoli & Weber’ have since identified the separate calcaneal compartment, and we believe that the claw toes in this patient could be due to failure to release this compartment through the dorsal approach. The second patient who manifested mild features of chronic myoneural ischemia underwent fasciotomy at 5 days following injury. Clearly this was not the optimal time to perform fasciotomy. However, when this patient presented for treatment at 5 days, his symptoms were so severe, that with the elevated pressures, we felt that fasciotomy may still be potentially beneficial. Fractures of the calcaneus are typically associated with profound pain and considerable swelling, features which are however not pathognomonic of compartmental ischemia. I1 Pain on passive stretching of
the involved muscles was found to be helpful in making the diagnosis, but was also not totally specific nor sensitive. Other clinical findings such as paresthesiae and altered sensation were found to present in approximately half of the patients. We believe therefore that the diagnosis of compartmental syndrome following calcaneus fracture should not be based on clinical findings alone. The only reliable means of diagnosis is by measuring the pressures in the involved compartments. It is essential to measure the central/ calcaneus compartment as this was found to consistently have the highest pressures. One never knows at what point in time following calcaneus fracture a compartment syndrome develops. Although the physiology of compartmental ischemia is such that fasciotomy should be performed within 6 h of diagnosis, this is not always attainable. Our institution is a referral center for complex foot injuries, and we evaluate many of these patients for the first time days or even weeks following their injury. If one believes that the damage is done at the time of injury as the compartment syndrome evolves, then there would be no need to perform fasciotomy later. However, we have repeatedly identified patients who are experiencing severe burning pain, associated with neurologic deficit, and who present more than 24 h following injury. We believe that these patients are suffering from an acute nerve compression syndrome, akin to an acute tarsal tunnel syndrome. These patients have experienced such dramatic and immediate relief of pain, with resolution of the neurologic deficit that we find it hard not to perform the fasciotomy under the appropriate circumstances. It is important to recognize that one converts a closed fracture into an open one after fasciotomy, creating potential problems with wound closure and subsequent operative fracture care. Traditionally, the fracture is managed operatively at 5-10 days once the swelling has resolved, and when the fasciotomy incisions are closed. This method was adopted in 7 of the 9 fractures treated operatively in this series.
Compartment
Although no infection occurred in these patients, the risk of delayed wound closure and compromise of subsequent operative fracture care is certainly present following fasciotomy. If one determines that operative treatment of the fracture is indicated we believe that the optimal time to perform this is may therefore be immediately following fasciotomy. However, the patient is rarely adequately prepared for surgery. We prefer to obtain a CAT scan prior to decision making concerning fracture care, which is rarely obtained prior to initiating care for the compartment syndrome. Nevertheless, if an open reduction and internal fixation is performed, and adequate imaging is obtained, then the fracture may be best treated at that time. Although swelling is always a concern, following fasciotomy and evacuation of the hematoma, we have not experienced problems with wound closure laterally. The medial fasciotomy incision is nevertheless left open as described. In this series, fasciotomy was performed within 6 h of diagnosis of raised compartment pressures, but ranged from 9 h to 5 days following injury. Other than the 1 patient who underwent fasciotomy at 5 days following injury there did not appear to be any correlation between the final outcome and the timing of fasciotomy. The time at which fasciotomy is no longer of benefit can not be determined from this study. Compartment syndromes of the foot occur after calcaneus fractures. The incidence in this series was 13%. Surgical decompression appears to be an effective treatment for the prevention of the long-term consequences of this condition, provided a medial fasciotomy incision is used, and decompression performed expeditiously following trauma.
I. Bonuti P M. Bell G R. Compartment
syndrome of J Bone Joint Surg 1986; 68A:
of the foot following
calcaneus
fracture
2. Manolli A, Weber T. Fasciotomy of the foot: An anatomical study with special reference to the release of the calcaneal compartment. Foot Ankle 1990: 10: 267-275. 3. Mittlmeier T, Gudrun M et al. Compartment syndrome of the foot after intraarticular calcaneus fracture. Clin Orthop 1991: 266: 97-104. 4. Starosta D. Sacchetti A, Sharkey P. Calcaneal fracture with compartment syndrome of the foot. Ann Emerg Med 1988; 17: 144. 5. Myerson M. The diagnosis and treatment of compartment syndromes of the foot. Orthopedics 1990; 13: 71 I-717. 6. Grodinsky M. A study of the fascial spaces of the feet. Surg Gynecol Obstet 1929; 49: 739-75 I. 7. Kamel R, Sakla F. Anatomic compartments of the sole of the human foot. Anatomy 1961: 140: 57-60. 8. Whitesides T, Haney T. Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop 1975: 113: 43-51. 9. Rorabeck C, Castle G, Hardie R, Logan J. Compartmental pressure measurements: an experimental investigation using siit catheter. J Trauma 1981; 21: 446-449. IO. Mubarak S, Hargens A. Acute compartment syndromes. Surg Clin North Am 1983: 63: 539.-565. 1 I, Myerson M. Management of compartment syndromes of the foot. Clin Orthop 1991: 271: 739.-248.
The authors Terence Saxby FRACS Princess Alexandra Hospital Ipswich Road Brisbane Australia 4102 Mark Myerson MD Lew Schon MD Union Memorial Hospital 201 E. University Parkway Baltimore Maryland 2 I2 18 USA
Correspondence
References the foot. A case report. 1449.-1451.
syndrome
to Dr M. Myerson
16
1992 Longman
Group tiK Ltd
Compartment syndrome of the foot following calcaneus fracture T. Saxby. M. Myerson, L. Schon Union Memorial Australia
Hospital,
Baltimore,
Mar_yland, USA, and Princess Alexandra
Hospital,
Brisbane,
SUMMA R Y. A prospective study of 74 patients with intra-articular fracture of the calcaneus and its association with compartment syndrome was undertaken. 10 patients (13%) had elevated compartment pressures greater than 40 mmHg in 1 or more compartments. Three additional patients had a compartment pressure of greater than 30 mmHg, and 15 patients (19%) had pressures ranging from lo-30 mmHg. 13 patients underwent fasciotomy, using a medial incision in 10, combined medial and dorsal incisions in 2, and with dorsal incisions only, in 1 patient. At follow-up, 11 (85%) had no evidence of myoneural ischemia, 1 patient had mild signs and in 1 patient in whom dorsal incisions only were used for fasciotomy had the classic syndrome with clawing of the toes and a stiff painful foot. Based on our clinical observations and pressure measurements, compartment syndrome of the foot does occur after calcaneus fracture. If performed correctly and expeditiously, fasciotomy is effective treatment for the prevention of the long-term sequelae of this debilitating condition.
Data collected on the 74 patients in the study included demographic information, the mechanism of injury and associated injuries. All patients were specifically examined for a compartment syndrome. The clinical features evaluated included severe, unrelenting pain, paresthesiae, numbness, and pain on passive dorsiflexion of the toes. All patients in the study had compartment pressures measured by a digital handheld monitor (Digital Quickset, Stryker, Kalamazoo, Ml) at time of presentation. The technique employed involved multistick catheterization of the interosseous, medial, lateral and central or calcaneal compartments. At the commencement of the study the division of the central compartment into a superficial and a deep (calcaneal) compartment was not recognized.2 During the first 2 years therefore, pressure measurements were made in the central compartment and later, directly in the posterior aspect of the central compartment, now referred to as the calcaneal compartment. An interstitial pressure of more than 40 mmHg in any one compartment was considered pathologic and was treated by fasciotomy. Patients with compartment pressures between 30 and 40 mmHg were carefully evaluated, and fasciotomy performed only in the presence of classic clinical findings, particularly unrelenting pain associated with numbness in the distribution of the tibia1 nerve. Patients with pressures less than 30 mmHg were not treated with fasciotomy, but carefully monitored with frequent clinical examination. Fasciotomy was performed immediately upon diagnosis of the compartment syndrome, once the patient could be taken to surgery, regardless of the decision making for fracture care. It was felt that the compartment syndrome took
Although compartment syndrome following trauma to an extremity is a well recognized entity, this complication following foot trauma has only been recently noted.‘-” Compartment syndromes of the foot are typically associated with high energy, especially where crushing of the foot occurs. The characteristic findings of this syndrome are severe, unrelenting pain associated with severe burning or tingling of the foot. tense swelling, pain on passive dorsiflexion of the toes, and occasionally sensory deficits. However, apart from a few isolated case reports, the association of compartment syndrome of the foot and calcaneus fracture has not received much attention.lp4 The consequences of untreated compartment syndrome in the foot include claw and hammer toe deformities, continued pain, stiffness, weakness, sensory changes, and atrophy of the intrinsic musculature.4.5 The aims of this study were to establish the incidence of compartment syndrome of the foot following intraarticular calcaneus fracture and to review the results of fasciotomy.
MATERIALS
AND METHODS
A prospective study of calcaneus fracture and its association with compartment syndrome was undertaken in 1987 at the Union Memorial Hospital. Between January 1987 and January 1990, 108 calcaneus fractures were treated at our institution. Compartment pressures were measured in 74 patients. The other 34 patients either presented for treatment more than 1 week after injury, or pressures were not obtained, and they were excluded from the study. 157
158
The Foot
precedence over fracture care. If the calcaneus fracture warranted open reduction and internal fixation, this could be performed simultaneously or delayed accordingly. Regional anesthesia was used in 5 and general anesthesia in 8 patients. The decision to perform regional or general anesthesia was determined by the clinical situation, patient preference, and need for additional surgery. Regional anesthesia was only used if fracture care was not simultaneously performed.
Lateral plantar
ANATOMY AND METHOD OF FASCIOTOMY Classically the plantar aspect of the foot has been divided into 4 separate compartments; medial, lateral, central and interosseous. 6S7In a recent study, Manoli & Webe? identified 9 compartments; the medial and lateral compartments were as previously described. However, they found that the central compartment was divided in the hindfoot by a transverse septum into a ‘superficial’ containing flexor digitorum brevis muscle and a deep compartment which they named ‘calcaneal’ which contained the quadratus plantae muscle and the lateral plantar nerve. They also identified 4 separate compartments in what had been previously called the interosseous compartment and identified a separate compartment for the adductor hallucis muscle. The fasciotomy incision(s) were planned according to the location of the raised compartment pressures. The hindfoot fasciotomy was the primary approach utilized. This was performed via a medial incision which began 4 cm from the posterior aspect of the calcaneus and 3 cm superior to the plantar surface of the foot, (Figs 1 and 2). The incision extended distally parallel to the plantar surface for approximately 6 cm. The medial compartment was released by incision of the abductor hallucis fascia. The abductor hallucis muscle was then retracted superiorly, the medial
Fig. l-This illustration demonstrates the incision used for the hindfoot fasciotomies via a medial approach. The figure also demonstrates the position for insertion of the needle to measure the compartment pressure in the calcaneal compartment.
Fig. 2-Cross-section approach calcaneal
of the hindfoot used and the compartments or superficial.
demonstrating the in cross-section, medial,
intermuscular septum was thus revealed. This was then incised longitudinally and thereby releasing the calcaneal compartment. Great care was taken during this release as the lateral plantar neurovascular bundle lies just inferior to the septum. The superficial compartment was released via this incision by subcutaneous dissection outside the previously opened medial compartment. The flexor digitorium brevis muscle was then retracted plantarward and dissection extended laterally and posteriorly. The neurovascular structures were protected during this dissection by the superiorly placed transverse hindfoot septum. Following the hindfoot fasciotomy the pressures were remeasured. The forefoot compartments were released depending on the compartment pressures following the hindfoot fasciotomies and this was required in 2 cases. In 1 case, the dorsal approach was only used because at this time the calcaneal compartment (deep central) was not recognized and it was thought that all the compartments could be decompressed via the dorsal approach. This was accomplished by two longitudinal dorsal incisions. Each interosseous compartment was identified and released. The adductor compartment was decompressed by elevating the interosseous compartment off the medial border of the second metatarsal and retracting these muscles medially. The fasciotomy incision was left open in all patients, and treated with either daily wet to dry saline dressings or covered with porcine allograft which was changed at 2-day intervals. 10 of the wounds were closed secondarily between 5 and 8 days following fasciotomy, and the remainder closed with split-thickness skin grafts. The dorsal forefoot incisions required split-thickness skin grafts in 2 cases and in 1 case delayed primary closure was achieved. The calcaneus fracture was treated non-operatively in 4 of the 13 patients. Open reduction and internal fixation was undertaken in 7, and a primary arthrod-
Compartment
esis was performed in 2 patients. Of the 9 patients treated operatively for the fracture, 2 were performed simultaneously with the fasciotomy, and the rest between 5 and 8 days following fasciotomy. The patients were followed up and evaluated for at least 12 months following injury. They were examined specifically for the symptoms and signs of myonema1 ischemia, including sensory disturbance, loss of range of motion of the toes and toe deformity. The results of treatment of the calcaneus fracture were not evaluated in this study.
RESULTS There were 74 patients entered into the study. The 13 patients found to have elevated compartment pressures included 9 males and 4 females, with an average age of 33 years (range 19-54 years). Of these 13 patients, the pressures were > 40 mmHg in 10 patients, and ranged from 30 to 40 mmHg in 3 (Table 1). Injuries were sustained in a fall from a height in 10, and in motor vehicle accidents in 3 patients. Associated injuries included a fracture of the contralateral calcaneus (l), fractures of the metatarsals in 2, and there was 1 patient with a lumbar fracture. I 1 of the patients complained of severe pain, 6 had paresthesiae, and 8 had objective changes in sensation. This sensory loss was predominantly in the distribution of the tibia1 nerve. Pain on passive dorsiflexion of the hallux and toes was present in 11 of the 13 patients. The elevated compartment pressures were usually highest in the central or calcaneal compartments (Table 2). The average time from injury to fasciotomy Table 1. Injury
pattern
and clinical
syndrome
of the foot following
calcaneus
fracture
was 24 h with a range from 3 h to 5 days. This was largely dependent on the varied times that patients were referred to our institution. In 10 patients a medial approach for fasciotomy was used; a combined dorsal and medial approach used in 2; and in I patient the dorsal approach only was utilized. 11 of the patients had no evidence of myoneural ischemia at follow-up. One patient manifested severe forefoot deformity with fixed claw toes, intrinsic muscle atrophy, and stiffness of the forefoot. In this patient fasciotomy was performed using a dorsal approach only. A second patient who underwent fasciotomy with a medial incision at 5 days experienced stiffness of the forefoot with slight claw toe deformity of the second, third and fourth toes. The balance of the patients did not manifest any symptoms or signs which we would attribute to chronic myoneural ischemia. There were no complications associated with performing the fasciotomy.
DISCUSSION We have identified the presence and general incidence of compartment syndrome of the foot following calcaneus fracture. We are still unclear as to the exact incidence of this entity, which probably depends on how the diagnosis is made. In this study a compartment pressure above 40 mmHg was considered pathologic, and was present in 13% of the patients in whom compartment pressure measurements were made. The use of 40 mmHg as the cut-off value for treating these patients with fasciotomy is controversial. Of the 13 patients treated with fasciotomy, 10 patients had pressures above 40 mmHg in 1 or
findings
Side
Age
Sex
Mechanism of injury
Associated injuries
Severe pain
Numbness
Sensation
Pain (DF Toes)
I
R
24
M
Fall 6 ft
Nil
Present
Present
Present
2
L
36
F
Fall 10 ft
Present
Present
3
R
54
M
MVA
Present
Absent
4 5
L L
23 32
M M
Fall 16 ft Fail 21 ft
Present Absent
Present Absent
L
39
F
Present
Absent
7
R
38
M
Bicycle accident Fall 18 ft
Normal Lateral plantar nerve Normal
Present Absent
6
(R) Calcaneus fracture Metatarsal and ankle fracture Nil Lumbar vert. fracture Nil
Lateral plantar nerve Medial/lateral plantar nerves Normal
Present
Absent
R R
42 21
M M
Fall 6 ft Fall 8 ft
Absent Present
Absent Present
10 II
L R
18 19
F M
MVA MVA
Present Present
Absent Present
12
L
29
M
Fall 21 ft
Nil
Present
Present
13
L
55
M
Fall down stairs
Nil
Present
Absent
Lateral plantar nerve Normal Lateral plantar nerve Normal Medial/lateral plantar nerves Lateral plantar nerve Lateral plantar nerve
Present
8 9
(L) Calcaneus fracture Nil Navicular fracture Nil Nil
No.
159
Present Present
Present
Present Present Absent Present Present Present
160 The Foot Table 2. Treatment of compartment
syndrome and calcaneus fracture
Deep talc.
Compartment pressures Interosseous Medial
Time (injury to fasciotomy)
Fasciotomy
Fracture treatment
Results
Lateral
1 2 3 4
48 88 42 36
I5 24 8 28
18 28 10 _
10 16 I5 _
5h 28 h 9h 18h
Medial Medial Medial Dorsal
Early ROM Early ROM ORIF ORIF
5 6
38 34
47 33
_ _
7 8 9 10 11 12 13
94 44 49 84 56 80 63
20 6 20 16 11 52 17
25
_ _ 28 _ 22 _ _ 55 _
6h 4h 7h 3h 5 days 36 h 48 h 24 h 6h
Medial Medial Medial/dorsal Medial Medial Medial Medial Medial/dorsal Medial
ORIF ORIF Primary fusion ORIF ORIF Early ROM Early ROM Primary fusion ORIF
No deficit No deficit No deficit Stiff foot claw toes No deficit No deficit No deficit No deficit Toes slightly stiff No deficit No deficit No deficit No deficit
No.
18 10 22 63 64
more compartments, and the other 3 had pressures between 30 and 40 mmHg. Therefore, if 30 mmHg had been used as the lower limit for the diagnosis the incidence of compartment syndrome in this series would be 18%. The exact compartment pressure at which a release is required is controversial.8-‘0 The 3 patients who had pressures between 30 and 40 mmHg had clinical features of a compartment syndrome, including severe, unrelenting, burning pain associated with neurologic deficits. Since the study protocol was to surgically decompress all patients with pressures above 40 mmHg we do not know if all these patients would have gone on to develop the late sequelae of untreated myoneural ischemia. A recent3 report however found that 7 of 11 patients with calcaneus fractures who were not treated with fasciotomy but who had compartment pressures of greater than 30 mmHg later developed claw toes. In contrast, in our series 11 out of the 13 patients had no sequelae, 1 had mild stiffness of the toes and only 1 patient had definite clawing of the toes at follow-up. This 1 patient had the decompression via the dorsal approach only, since at the time it was believed that all compartments could be decompressed through this approach. However, Manoli & Weber’ have since identified the separate calcaneal compartment, and we believe that the claw toes in this patient could be due to failure to release this compartment through the dorsal approach. The second patient who manifested mild features of chronic myoneural ischemia underwent fasciotomy at 5 days following injury. Clearly this was not the optimal time to perform fasciotomy. However, when this patient presented for treatment at 5 days, his symptoms were so severe, that with the elevated pressures, we felt that fasciotomy may still be potentially beneficial. Fractures of the calcaneus are typically associated with profound pain and considerable swelling, features which are however not pathognomonic of compartmental ischemia. I1 Pain on passive stretching of
the involved muscles was found to be helpful in making the diagnosis, but was also not totally specific nor sensitive. Other clinical findings such as paresthesiae and altered sensation were found to present in approximately half of the patients. We believe therefore that the diagnosis of compartmental syndrome following calcaneus fracture should not be based on clinical findings alone. The only reliable means of diagnosis is by measuring the pressures in the involved compartments. It is essential to measure the central/ calcaneus compartment as this was found to consistently have the highest pressures. One never knows at what point in time following calcaneus fracture a compartment syndrome develops. Although the physiology of compartmental ischemia is such that fasciotomy should be performed within 6 h of diagnosis, this is not always attainable. Our institution is a referral center for complex foot injuries, and we evaluate many of these patients for the first time days or even weeks following their injury. If one believes that the damage is done at the time of injury as the compartment syndrome evolves, then there would be no need to perform fasciotomy later. However, we have repeatedly identified patients who are experiencing severe burning pain, associated with neurologic deficit, and who present more than 24 h following injury. We believe that these patients are suffering from an acute nerve compression syndrome, akin to an acute tarsal tunnel syndrome. These patients have experienced such dramatic and immediate relief of pain, with resolution of the neurologic deficit that we find it hard not to perform the fasciotomy under the appropriate circumstances. It is important to recognize that one converts a closed fracture into an open one after fasciotomy, creating potential problems with wound closure and subsequent operative fracture care. Traditionally, the fracture is managed operatively at 5-10 days once the swelling has resolved, and when the fasciotomy incisions are closed. This method was adopted in 7 of the 9 fractures treated operatively in this series.
Compartment
Although no infection occurred in these patients, the risk of delayed wound closure and compromise of subsequent operative fracture care is certainly present following fasciotomy. If one determines that operative treatment of the fracture is indicated we believe that the optimal time to perform this is may therefore be immediately following fasciotomy. However, the patient is rarely adequately prepared for surgery. We prefer to obtain a CAT scan prior to decision making concerning fracture care, which is rarely obtained prior to initiating care for the compartment syndrome. Nevertheless, if an open reduction and internal fixation is performed, and adequate imaging is obtained, then the fracture may be best treated at that time. Although swelling is always a concern, following fasciotomy and evacuation of the hematoma, we have not experienced problems with wound closure laterally. The medial fasciotomy incision is nevertheless left open as described. In this series, fasciotomy was performed within 6 h of diagnosis of raised compartment pressures, but ranged from 9 h to 5 days following injury. Other than the 1 patient who underwent fasciotomy at 5 days following injury there did not appear to be any correlation between the final outcome and the timing of fasciotomy. The time at which fasciotomy is no longer of benefit can not be determined from this study. Compartment syndromes of the foot occur after calcaneus fractures. The incidence in this series was 13%. Surgical decompression appears to be an effective treatment for the prevention of the long-term consequences of this condition, provided a medial fasciotomy incision is used, and decompression performed expeditiously following trauma.
I. Bonuti P M. Bell G R. Compartment
syndrome of J Bone Joint Surg 1986; 68A:
of the foot following
calcaneus
fracture
2. Manolli A, Weber T. Fasciotomy of the foot: An anatomical study with special reference to the release of the calcaneal compartment. Foot Ankle 1990: 10: 267-275. 3. Mittlmeier T, Gudrun M et al. Compartment syndrome of the foot after intraarticular calcaneus fracture. Clin Orthop 1991: 266: 97-104. 4. Starosta D. Sacchetti A, Sharkey P. Calcaneal fracture with compartment syndrome of the foot. Ann Emerg Med 1988; 17: 144. 5. Myerson M. The diagnosis and treatment of compartment syndromes of the foot. Orthopedics 1990; 13: 71 I-717. 6. Grodinsky M. A study of the fascial spaces of the feet. Surg Gynecol Obstet 1929; 49: 739-75 I. 7. Kamel R, Sakla F. Anatomic compartments of the sole of the human foot. Anatomy 1961: 140: 57-60. 8. Whitesides T, Haney T. Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop 1975: 113: 43-51. 9. Rorabeck C, Castle G, Hardie R, Logan J. Compartmental pressure measurements: an experimental investigation using siit catheter. J Trauma 1981; 21: 446-449. IO. Mubarak S, Hargens A. Acute compartment syndromes. Surg Clin North Am 1983: 63: 539.-565. 1 I, Myerson M. Management of compartment syndromes of the foot. Clin Orthop 1991: 271: 739.-248.
The authors Terence Saxby FRACS Princess Alexandra Hospital Ipswich Road Brisbane Australia 4102 Mark Myerson MD Lew Schon MD Union Memorial Hospital 201 E. University Parkway Baltimore Maryland 2 I2 18 USA
Correspondence
References the foot. A case report. 1449.-1451.
syndrome
to Dr M. Myerson
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