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Recurrent compartment syndrome of foot following a calcaneal fracture
Foot and Ankle Surgery 13 (2007) 154–156 www.elsevier.com/locate/fas
Case report
Recurrent compartment syndrome of foot following a calcaneal fracture Sameer Batra *, A. McMurtrie, A.K. Sinha, S. Griffin Department Of Orthopaedics, Gwynedd Hospital, North West Wales NHS Trust, Bangor, Gwynedd, UK Received 29 June 2006; received in revised form 6 November 2006; accepted 30 January 2007
Abstract We report a rare case of a recurrent compartment syndrome following a fracture of the calcaneus in a patient who had undergone complete fasciotomies in the same foot 7 years ago. Compartment syndrome is a recognized complication following a calcaneal fracture, which if unrecognized, may result in significant contractures, claw toe deformity, sensory deficits, pain and stiffness of the foot. The complex anatomy of the foot can make the diagnosis of a compartment syndrome difficult and fasciotomy more exacting, particularly in a recurrent presentation. Timely recognition and urgent compartment fasciotomies led to a good clinical outcome in this case. # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Recurrent; Compartment syndrome; Calcaneal fracture
1. Introduction Compartment syndrome of the foot is a potentially serious complication following calcaneal fractures. This is related to the small size of the fascia-bound anatomic compartments in the foot coupled with extensive bleeding from the large cancellous bone surfaces. The complex anatomy of the foot makes the diagnosis of a compartment syndrome more complex and fasciotomy more exacting, particularly in a recurrent presentation in a foot with scars from previous operations or fasciotomies. Early recognition can influence not only the immediate prognosis, but also appropriate advice; management and surveillance may also decrease the subsequent high morbidity. There are no reported cases of recurrent compartment syndrome in the foot following compartment release. We present an unusual case of a patient who had undergone complete fasciotomies and amputation of his great toe following a crush injury to his foot 7 years ago. He subsequently sustained a fracture of the calcaneus, which led * Corresponding author at: 4, Llys Miaren, Gwynedd Hospital, Bangor LL57 2PG, UK. Tel.: +44 7915053576. E-mail address: [email protected] (S. Batra).
to recurrent compartment syndrome in the same foot. The symptoms were immediately relieved by a repeat decompression procedure.
2. Case report A 22-year man presented following a fall while rock climbing from a height of 30 ft into a river, hitting his right foot on a boulder. He had undergone fasciotomy of all the compartments of the same foot 7 years ago at another institution for a compartment syndrome associated with a crush injury to his foot culminating in an amputation of the great toe. After a negative primary trauma survey, the secondary survey revealed multiple abrasions of the left lower extremity and a markedly swollen left foot. Marked swelling encompassed the entire foot, with relative sparing of digits but no signs of compartment syndrome. Radiographs and a CT scan revealed a comminuted fracture of the calcaneus. The patient was monitored closely with elevation of the foot and the regular application of ice packs. Forty-eight hours later, he complained of increasing pain associated with numbness on the plantar aspect of his right foot despite
1268-7731/$ – see front matter # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2007.01.002
S. Batra et al. / Foot and Ankle Surgery 13 (2007) 154–156
155
Fig. 1. Medial skin incision through the previous scar along with another small incision over the ankle to drain the haematoma.
adequate analgesia. On examination, passive movement of the toes resulted in pain. The pulses were not palpable but were detectable on Doppler ultrasound evaluation. Sensation in the distribution of the posterior tibial, deep peroneal and superficial peroneal nerves was evaluated with moving twopoint discrimination, light touch and pin prick sensation. Pin prick sensation and two point discrimination was found to be diminished on the plantar aspect of foot. The compartment pressure in the four interosseous compartments was 80–84 mmHg and the diastolic blood pressure was 73 mmHg. The patient was taken to theatre immediately and fasciotomies were performed through the previous surgical incisions via a medial approach and two dorsal incisions, decompressing all nine compartments (Figs. 1 and 2). The dorsal two longitudinal incisions were centred over the second and fourth metatarsals and the medial incision made between the abductor hallucis muscle and the inferior base of the first metatarsal. In addition, a haematoma threatening the skin on the medial side of the ankle joint was drained through another small medial incision. Immediately postoperatively, the foot was placed in a well-padded splint, elevated, and intravenous antibiotics administered (cefuroxime). The fasciotomy wounds were closed secondarily over the next 5 days, however, a soft tissue defect persisted over the medial malleolar area. Ten days following the decompression the patient was transferred to a tertiary orthopaedic centre. In view of the comminuted nature of the fracture and associated skin problems, the calcaneal fracture was treated with an Ilizarov apparatus using a distraction technique and indirect reduction. He went on to make an uneventful recovery and achieved radiological union of the fracture.
3. Discussion Compartment syndrome of the foot is an uncommon complication of musculoskeletal trauma and has a natural history of disabling sequelae. The calcaneus is the most
Fig. 2. Two dorsal skin incisions centred over the second and fourth metatarsals through the previous fasciotomy scars.
frequently fractured tarsal bone accounting for 65% of tarsal injuries and approximately 2% of all fractures [1]. Acute compartment syndrome is a potentially devastating condition in which the pressure within an osseo-fascial compartment rises to a level that decreases the perfusion gradient across tissue capillary beds, leading to cellular anoxia, muscle ischemia, and death [2]. To our knowledge, there are only two previous accounts of recurrent acute compartment syndrome following fasciotomy. The first case described compartment syndrome of the hand where postoperative development of reflex sympathetic dystrophy with vasomotor instability leading to post ischemic swelling was hypothesized as the cause [3]. The second case reported two recurrences in the peroneal compartment following fasciotomies of all compartments in the leg [4]. There was no history of repeat trauma in either of these cases. Our case illustrates that compartment syndrome cannot be ruled out in a patient who has previously undergone a fasciotomy. The traditional concept of the foot being divided into four compartments was challenged by Manoli and Weber. They demonstrated that the foot consists of at least nine compartments with the central compartment being divided into a superficial and deep compartment (calcaneal compartment) [5]. The division of the central hindfoot compartment into separate superficial and calcaneal compartments has subsequently been challenged in infusion studies [6].
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S. Batra et al. / Foot and Ankle Surgery 13 (2007) 154–156
We believe that the original injury may have contributed to the development of recurrent compartment syndrome. Ischaemic damage is known to cause perifascicular and intra-fascicular oedema, which without treatment, leads to atrophy and necrosis of the muscle fibres. The muscle bulk in the compartment may decrease so that the healed compartment has less potential space to accommodate the swelling due to scarring and fibrosis from previous injury. Furthermore, during healing, fibrous scar tissue may grow between the two divided fascial edges resulting in a tough fibrous barrier between the compartments. A sustentacular calcaneal fragment may be associated with bleeding from the bone or from the medial calcaneal arteries into this compartment [3]. The diagnosis of compartment syndrome depends on evidence of decreased perfusion, ischemia, and elevated compartment pressures [2]. The provisional diagnosis of compartment syndrome was based on the clinical presentation of increasing pain out of proportion to the initial injury, pain on passive stretch referred to the compartment in compromise, and decreased sensation on the plantar surface of the foot and loss of sensation to the first dorsal web space. We urgently performed compartment measurements in this case due to the uncertainty of the diagnosis and the urgency of the situation. The critical level of the absolute intra-compartmental pressure remains yet undecided. In the literature, levels ranging from 30 to 50 mmHg are proposed [7,8]. Experimental studies have shown a big difference between individuals, when correlating absolute pressure levels, clinical signs, nerve function (EMG) and oxygen levels in the muscle tissue [9]. Whitesides introduced the concept of perfusion pressure ‘‘delta p’’ defined as diastolic pressure minus the intra-compartmental pressure. The most commonly cited Dp is less than or equal to 30 mmHg [9]. Fasciotomy is indicated when compartment pressure exceeds 30 mmHg, or if compartment pressure is greater than 10–30 mmHg below diastolic pressure [10]. The approaches for compartment decompression generally include two dorsal incisions for access to forefoot compartments, and one medial incision for decompression of the calcaneal, medial, superficial, and lateral compartments [11]. We could find no other report of recurrent compartment syndrome of the foot following a calcaneal fracture in a patient who had undergone adequate fasciotomies of the same foot on a previous occasion. We recommend careful assessment of all patients with compartment syndrome and point out that a history of fasciotomy does not exclude this diagnosis. Although a recurrent foot compartment syndrome is rare, onset of severe pain after severe foot injury should warrant a high index of suspicion of this condition leading to direct pressure measurements. The latter is particularly important in a patients who are unresponsive, uncooperative, unreliable, or in patients with equivocal findings, compartment measurements can be helpful in confirming the diagnosis of compartment syndrome in a foot with previous fasciotomies.
4. Conclusion Previous complete fasciotomies of foot do not preclude the development of a foot compartment syndrome. Heightened suspicion for an acute foot compartment syndrome is warranted in these patients suffering from lower extremity trauma. The classic physical findings of compartment syndrome, such as pain with passive extension, paresthesias, pulselessness and a tense compartment may be less reliable in these patients. Therefore, early, multiple foot compartment pressure readings are warranted. Timely surgical intervention allows the best chance of a good clinical outcome.
Conflicts of interest statement All authors hereby state that no financial and personal relationships with other people, or organisations, that could inappropriately influence (bias) this work, all within 3 years of beginning the work submitted, exists.
Acknowledgement We sincerely acknowledge the contribution of Mr. Royston, Consultant Orthopaedic Surgeon who provided the details of follow up treatment of the patient.
References [1] Lim EV, Leung JP. Complications of intraarticular calcaneal fractures. Clin Orthop Relat Res 2001;391:7–16. [2] Myerson M, Manoli A. Compartment syndromes of the foot after calcaneal fractures. Clin Orthop Relat Res 1993;290:142–50. [3] Chokshi BV, Lee S, Wolfe SW. Recurrent compartment syndrome of the hand: a case report. J Hand Surg [Am] 1998;23(1):66–9. [4] Kotak BP, Bendall SP. Recurrent acute compartment syndrome. Injury 2000;31(1):66–7. [5] Manoli II 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. [6] Bibbo C, Lin SS, Cunningham FJ. Acute traumatic compartment syndrome of the foot in children. Pediatr Emerg Care 2000;16(4): 244–8. [7] Allen M, Stirling A, Crawshaw C, Barnes M. Intracompartmental pressure monitoring of leg injuries. An aid to management. J Bone Joint Surg 1985;67:53–7. [8] Mubarak S, Hargens A. Acute compartment syndromes. Surg Clin North Am 1983;63:539–65. [9] Whitesides T, Haney T, Morimoto K, Hirada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop 1975;113:43. [10] Fulkerson E, Razi A, Tejwani N. Acute compartment syndrome of the foot. Foot Ankle Int 2003;24(2):180–7. [11] Mittlmeier T, Machler G, Lob G, Mutschler W, Bauer G, Vogl T. Compartment syndrome of the foot after intraarticular calcaneal fracture. Clin Orthop Relat Res 1991;269:241–8.
Case report
Recurrent compartment syndrome of foot following a calcaneal fracture Sameer Batra *, A. McMurtrie, A.K. Sinha, S. Griffin Department Of Orthopaedics, Gwynedd Hospital, North West Wales NHS Trust, Bangor, Gwynedd, UK Received 29 June 2006; received in revised form 6 November 2006; accepted 30 January 2007
Abstract We report a rare case of a recurrent compartment syndrome following a fracture of the calcaneus in a patient who had undergone complete fasciotomies in the same foot 7 years ago. Compartment syndrome is a recognized complication following a calcaneal fracture, which if unrecognized, may result in significant contractures, claw toe deformity, sensory deficits, pain and stiffness of the foot. The complex anatomy of the foot can make the diagnosis of a compartment syndrome difficult and fasciotomy more exacting, particularly in a recurrent presentation. Timely recognition and urgent compartment fasciotomies led to a good clinical outcome in this case. # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Recurrent; Compartment syndrome; Calcaneal fracture
1. Introduction Compartment syndrome of the foot is a potentially serious complication following calcaneal fractures. This is related to the small size of the fascia-bound anatomic compartments in the foot coupled with extensive bleeding from the large cancellous bone surfaces. The complex anatomy of the foot makes the diagnosis of a compartment syndrome more complex and fasciotomy more exacting, particularly in a recurrent presentation in a foot with scars from previous operations or fasciotomies. Early recognition can influence not only the immediate prognosis, but also appropriate advice; management and surveillance may also decrease the subsequent high morbidity. There are no reported cases of recurrent compartment syndrome in the foot following compartment release. We present an unusual case of a patient who had undergone complete fasciotomies and amputation of his great toe following a crush injury to his foot 7 years ago. He subsequently sustained a fracture of the calcaneus, which led * Corresponding author at: 4, Llys Miaren, Gwynedd Hospital, Bangor LL57 2PG, UK. Tel.: +44 7915053576. E-mail address: [email protected] (S. Batra).
to recurrent compartment syndrome in the same foot. The symptoms were immediately relieved by a repeat decompression procedure.
2. Case report A 22-year man presented following a fall while rock climbing from a height of 30 ft into a river, hitting his right foot on a boulder. He had undergone fasciotomy of all the compartments of the same foot 7 years ago at another institution for a compartment syndrome associated with a crush injury to his foot culminating in an amputation of the great toe. After a negative primary trauma survey, the secondary survey revealed multiple abrasions of the left lower extremity and a markedly swollen left foot. Marked swelling encompassed the entire foot, with relative sparing of digits but no signs of compartment syndrome. Radiographs and a CT scan revealed a comminuted fracture of the calcaneus. The patient was monitored closely with elevation of the foot and the regular application of ice packs. Forty-eight hours later, he complained of increasing pain associated with numbness on the plantar aspect of his right foot despite
1268-7731/$ – see front matter # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2007.01.002
S. Batra et al. / Foot and Ankle Surgery 13 (2007) 154–156
155
Fig. 1. Medial skin incision through the previous scar along with another small incision over the ankle to drain the haematoma.
adequate analgesia. On examination, passive movement of the toes resulted in pain. The pulses were not palpable but were detectable on Doppler ultrasound evaluation. Sensation in the distribution of the posterior tibial, deep peroneal and superficial peroneal nerves was evaluated with moving twopoint discrimination, light touch and pin prick sensation. Pin prick sensation and two point discrimination was found to be diminished on the plantar aspect of foot. The compartment pressure in the four interosseous compartments was 80–84 mmHg and the diastolic blood pressure was 73 mmHg. The patient was taken to theatre immediately and fasciotomies were performed through the previous surgical incisions via a medial approach and two dorsal incisions, decompressing all nine compartments (Figs. 1 and 2). The dorsal two longitudinal incisions were centred over the second and fourth metatarsals and the medial incision made between the abductor hallucis muscle and the inferior base of the first metatarsal. In addition, a haematoma threatening the skin on the medial side of the ankle joint was drained through another small medial incision. Immediately postoperatively, the foot was placed in a well-padded splint, elevated, and intravenous antibiotics administered (cefuroxime). The fasciotomy wounds were closed secondarily over the next 5 days, however, a soft tissue defect persisted over the medial malleolar area. Ten days following the decompression the patient was transferred to a tertiary orthopaedic centre. In view of the comminuted nature of the fracture and associated skin problems, the calcaneal fracture was treated with an Ilizarov apparatus using a distraction technique and indirect reduction. He went on to make an uneventful recovery and achieved radiological union of the fracture.
3. Discussion Compartment syndrome of the foot is an uncommon complication of musculoskeletal trauma and has a natural history of disabling sequelae. The calcaneus is the most
Fig. 2. Two dorsal skin incisions centred over the second and fourth metatarsals through the previous fasciotomy scars.
frequently fractured tarsal bone accounting for 65% of tarsal injuries and approximately 2% of all fractures [1]. Acute compartment syndrome is a potentially devastating condition in which the pressure within an osseo-fascial compartment rises to a level that decreases the perfusion gradient across tissue capillary beds, leading to cellular anoxia, muscle ischemia, and death [2]. To our knowledge, there are only two previous accounts of recurrent acute compartment syndrome following fasciotomy. The first case described compartment syndrome of the hand where postoperative development of reflex sympathetic dystrophy with vasomotor instability leading to post ischemic swelling was hypothesized as the cause [3]. The second case reported two recurrences in the peroneal compartment following fasciotomies of all compartments in the leg [4]. There was no history of repeat trauma in either of these cases. Our case illustrates that compartment syndrome cannot be ruled out in a patient who has previously undergone a fasciotomy. The traditional concept of the foot being divided into four compartments was challenged by Manoli and Weber. They demonstrated that the foot consists of at least nine compartments with the central compartment being divided into a superficial and deep compartment (calcaneal compartment) [5]. The division of the central hindfoot compartment into separate superficial and calcaneal compartments has subsequently been challenged in infusion studies [6].
156
S. Batra et al. / Foot and Ankle Surgery 13 (2007) 154–156
We believe that the original injury may have contributed to the development of recurrent compartment syndrome. Ischaemic damage is known to cause perifascicular and intra-fascicular oedema, which without treatment, leads to atrophy and necrosis of the muscle fibres. The muscle bulk in the compartment may decrease so that the healed compartment has less potential space to accommodate the swelling due to scarring and fibrosis from previous injury. Furthermore, during healing, fibrous scar tissue may grow between the two divided fascial edges resulting in a tough fibrous barrier between the compartments. A sustentacular calcaneal fragment may be associated with bleeding from the bone or from the medial calcaneal arteries into this compartment [3]. The diagnosis of compartment syndrome depends on evidence of decreased perfusion, ischemia, and elevated compartment pressures [2]. The provisional diagnosis of compartment syndrome was based on the clinical presentation of increasing pain out of proportion to the initial injury, pain on passive stretch referred to the compartment in compromise, and decreased sensation on the plantar surface of the foot and loss of sensation to the first dorsal web space. We urgently performed compartment measurements in this case due to the uncertainty of the diagnosis and the urgency of the situation. The critical level of the absolute intra-compartmental pressure remains yet undecided. In the literature, levels ranging from 30 to 50 mmHg are proposed [7,8]. Experimental studies have shown a big difference between individuals, when correlating absolute pressure levels, clinical signs, nerve function (EMG) and oxygen levels in the muscle tissue [9]. Whitesides introduced the concept of perfusion pressure ‘‘delta p’’ defined as diastolic pressure minus the intra-compartmental pressure. The most commonly cited Dp is less than or equal to 30 mmHg [9]. Fasciotomy is indicated when compartment pressure exceeds 30 mmHg, or if compartment pressure is greater than 10–30 mmHg below diastolic pressure [10]. The approaches for compartment decompression generally include two dorsal incisions for access to forefoot compartments, and one medial incision for decompression of the calcaneal, medial, superficial, and lateral compartments [11]. We could find no other report of recurrent compartment syndrome of the foot following a calcaneal fracture in a patient who had undergone adequate fasciotomies of the same foot on a previous occasion. We recommend careful assessment of all patients with compartment syndrome and point out that a history of fasciotomy does not exclude this diagnosis. Although a recurrent foot compartment syndrome is rare, onset of severe pain after severe foot injury should warrant a high index of suspicion of this condition leading to direct pressure measurements. The latter is particularly important in a patients who are unresponsive, uncooperative, unreliable, or in patients with equivocal findings, compartment measurements can be helpful in confirming the diagnosis of compartment syndrome in a foot with previous fasciotomies.
4. Conclusion Previous complete fasciotomies of foot do not preclude the development of a foot compartment syndrome. Heightened suspicion for an acute foot compartment syndrome is warranted in these patients suffering from lower extremity trauma. The classic physical findings of compartment syndrome, such as pain with passive extension, paresthesias, pulselessness and a tense compartment may be less reliable in these patients. Therefore, early, multiple foot compartment pressure readings are warranted. Timely surgical intervention allows the best chance of a good clinical outcome.
Conflicts of interest statement All authors hereby state that no financial and personal relationships with other people, or organisations, that could inappropriately influence (bias) this work, all within 3 years of beginning the work submitted, exists.
Acknowledgement We sincerely acknowledge the contribution of Mr. Royston, Consultant Orthopaedic Surgeon who provided the details of follow up treatment of the patient.
References [1] Lim EV, Leung JP. Complications of intraarticular calcaneal fractures. Clin Orthop Relat Res 2001;391:7–16. [2] Myerson M, Manoli A. Compartment syndromes of the foot after calcaneal fractures. Clin Orthop Relat Res 1993;290:142–50. [3] Chokshi BV, Lee S, Wolfe SW. Recurrent compartment syndrome of the hand: a case report. J Hand Surg [Am] 1998;23(1):66–9. [4] Kotak BP, Bendall SP. Recurrent acute compartment syndrome. Injury 2000;31(1):66–7. [5] Manoli II 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. [6] Bibbo C, Lin SS, Cunningham FJ. Acute traumatic compartment syndrome of the foot in children. Pediatr Emerg Care 2000;16(4): 244–8. [7] Allen M, Stirling A, Crawshaw C, Barnes M. Intracompartmental pressure monitoring of leg injuries. An aid to management. J Bone Joint Surg 1985;67:53–7. [8] Mubarak S, Hargens A. Acute compartment syndromes. Surg Clin North Am 1983;63:539–65. [9] Whitesides T, Haney T, Morimoto K, Hirada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop 1975;113:43. [10] Fulkerson E, Razi A, Tejwani N. Acute compartment syndrome of the foot. Foot Ankle Int 2003;24(2):180–7. [11] Mittlmeier T, Machler G, Lob G, Mutschler W, Bauer G, Vogl T. Compartment syndrome of the foot after intraarticular calcaneal fracture. Clin Orthop Relat Res 1991;269:241–8.