Compartment Syndrome of the Foot and L.G

CHAPTER 3 Compartment Syndrome Of The Foot And L.g

A. LouisJimenez, DPM. Mickey D Stapp, D,PM.

INTRODUCTION extremity and foot was recognized. A variety of conditions can lead to a compart- Compafiment syndrome is a condition in which ment syndrome, including anerial injury (iatrogenic increased tissue pressure in a closed fascial com- and traumatic), thermal burn, crush injury, arterial partment reduces capillary blood perfusion below injection, gunshot wound, osteotomy, embolec- the level necessary for tissue viability. If the pres- tomy, snakebite, fracture, and acute and chronic sure remains sufficiently elevated for several hours, exertional states. Other causes include circumfer- loss of function of muscles and nerves may occur. ential dressings and casts. Myoneural necrosis will eventually result lf treatment is not rendered. A variety of complications PATHOGENESIS can result, depending on the length of time the compartment syndrome has been present. A compartment syndrome usually results from Ischemic contractures of the lower extremity and muscle injury which causes increased pressure foot are a later finding, and can result in severe within the limited space of a myofascial compart- sequelae, ranging from a partial loss of function to ment. Muscular trauma causes bleeding, resulting a full-blown Volkmann's contracture. For this rea- in edema. As the volume within a closed compart- son, early appropriate conservative and/ot surgical ment increases, arterial circulation to tissues distal treatment should be initiated. to this site becomes compromised, resulting in a Synonyms of an acute compafiment syndrome compartment syndrome. This is a common occur- include anterior tibial syndrome and Volkmann's rence with fractures. As hematoma formation ischemia. A Volkmann's ischemic contracture is the ensues, volume increases within the closed space, residual limb deformity which represents the last thereby increasing the intracompartmental pres- stage of muscle and nele necrosis following an sure. Tissue damage will depend on the amount of acute compafiment syndrome. ischemia and duration of the event. Fracture of the A better appreciation and understanding of tibia represents the most common cause of an the histologic, biomechanic, and physiologic acute compartment syndrome. A severe soft tissue changes have been well espoused by \Thitesides, injury, or contusion without fracture is the second el al., Hargens, et al., Szaba, et a1., Heppenstall, et leading cause of an acute compartment syndrome. a\., Matsen, et al., and Mubarak, et al. The excellent Intracompartmental tissue pressure is usually work done by these groups has led to a logical and lower than the pressure of arterial blood flow. For sequential method of evaluating patients with a this reason, peripheral pulses remain intact. Digital suspected compartment syndrome. They have also capillary beds drain into extracompafimental veins, set parameters regarding the timing of, and neces- therefore digital afteriovenous gradients and blood siff for fasciotomy. flow remain intact. Thus, peripheral pulses and digitai circulation are poor indicators of the blood HISTORY flow within a compartment. Nerwes will continue to conduct impulses for The condition was first described by Von one hour after onset of total ischemia. Nerues may Volkmann in 7872 as an affliction of the upper survive after four hours of ischemia, with resultant extremity. A better understanding of the condition neuropraxic damage only. After eight hours of evolved with time, and involvement of the lower ischemia, axonotomesis ensues, resulting in irre- l0 C}IAPTER 3 versible neural damage. \7hen trauma has been the increased pain. Other symptoms include edema, a inciting incident for a suspected compartment feeling of tenseness in the involved compaftment. syndrome, trauma to a nerve may cause the neu- and paresthesias of involved nerves. The earliest rologic symptoms. The cause of these neurologic finding is a swollen, tense compartment which is symptoms must be differentiated between direct a direct result of increased intracompartmental nerve trauma and that caused by the suspected pressure. The skin may be shiny and warm. Even compaftment syndrome. though the experienced examiner cannot determine intracompartmental pressure by palpation, TISSUE HEMODYNAMICS the presence of a tense compartment throughout its boundaries suggests a compartment syn- 'When Ischemia is dependant upon the perfusion gradient drome. superficial subcutaneous edema is of the tissue, which is directly related to the present, compartment tenseness may be difficult patient's blood pressure. Traumatized tissue, in to ascertain. order to meet its metabolic demands, requires As the compartment syndrome continues and more blood flow than normal. Therefore, this tis- ischemia is prolonged, fufther paresthesias, paraly- sue has decreased resistance to ischemia. A sis, and sensory changes ensue. As tissue pressure pressure of 30-40 mm Hg below mean afierial pres- approaches diastolic pressure, capillary filling time sure, or 10-30 mm Hg below diastolic pressure, has increases. Pulselessness and pallor are rare unless been shown to cause a significant decrease in tis- significant arterial damage has occurred, or the sue perfusion, resulting in ischemia. Since ischemia artery passes through a compartment subjected to is based on the perfusion gradient of tissues, tissue pressures that approach the patient's systolic patients with a high diastolic pressure will be able blood pressure. The prime indication for fas- to withstand a higher tissue pressure before ciotomy is the presence of the characteristic clinical ischemia ensues. Based on these findings, fas- symptoms and signs of a compartment syndrome, ciotomy is indicated when: 1) The tissue pressure including deficits in neuromuscular function. is 20-30 mm below diastolic blood pressure, 2) Pressures greater than 40 mm Hg for 20-30 minutes DIAGNOSIS have been present, 3) Pressures greater than 30 mm Hg are combined with other positive clinical The differential diagnosis for a compartment syn- findings, and 4) Pressures between 30-40 mm Hg drome includes fractures and contusions, cellulitis, are not decreasing with monitoring every two to and deep vein thrombosis. Fractures and contu- three hours. sions are less of a diagnostic dilemma. Cellulitis and deep vein thrombosis may show painful SIGNS AND SYMPTOMS edema in the extremify. The former can be ruled out by signs and symptoms of infection. Deep vein Historically, pann, pallor, pulselessness, paresthe- thrombosis will exhibit calf pain and positive sias, and paralysis have been the classical findings stretch pain, but neurovascular deficits are absent. in a compartment syndrome. However, a patient Intracompartmental pressure measurements, with a compafiment syndrome may not demon- doppler studies, and venography may be needed strate all of these findings. The most impressive to make the appropriate diagnosis. symptom with an acute compafiment syndrome is When the patient is conscious and able to pain out of proportion to the primary problem respond to the physician's questions, the diagnosis (fracture, soft tissue injury, etc.). Pain initiated by is easier to make and/or monitor. However, in ischemia is not relieved by immobiTization, and patients who are incoherent or unconscious, mon- may be aggravated by a circumferential dressing or itoring of the site is extremeiy important. Tissue cast. Pain, which is aggravated by passive stretch of pressure measurement may be the only mechanism the affected tissues, is the most reliable physical by which the diagnosis can be made. In shock and finding. As tissue pressures approach 30-40 mm Hg hypotensive states, a slight increase in tissue pres- (normal: 0-4 mm Hg) below a resting diastolic sure may be the only objective means of making pressure of 70 mm Hg, passive stretch will result in the diagnosis. CHAPTER 3 II

TISSUE PRESSURE MEASUREMENTS

In a suspected compartment syndrome, tissue pressure measurements should not be limited to the immediate area of greatest symptoms. Tissue pres- Mercury sures need to be acquired for the entire extremity. Pressure measurements have been shown to vary significantly, both statistically and clinically, in areas as close as 5 cm apafi. Even in open fractures, trauma to tissue results in segmental pressure gradients. Even though the immediate fracture site appears normal, irreversible tissue pressure increase may ensue. This can creale segmental nerve and muscle injury, resulting in abnormal Figure 1. whiteside's Infusion Technique function distal to the fracture site. \When a fasciotomy is under consideration, tissue pressures should be acquired every one to tlvo hours while observing the patient. A comparlment syndrome may develop insidiously up to 72 hours after injury, and monitoring should be maintained for at least this period of time. Fasciotomy is performed after evaluation of a patient's signs and symptoms. If pain is progressively getting worse, in addition to fulfillment of the previously discussed criteria for fasiotomy, fasciotomy should be performed. The main objective of the fasciotomy is to create and matntain normal neuromuscular and musculoskeletal function. If a stabllizrng or decreasing pressure is noted, conselative therapy may be indicated. Even after fasciotomy, multiple

compartments must be measured to assure proper Figure 2. \7ick Catheter stabilization and lowering of intracompartmental pressufes.

EQI.IIPMENT AND TECHN]-IQUES FOR MEASUREMENT

A variety of methods to measure compafiment pressures have been described. These include 'Wick \^t

Figure 3. Slit Catheter. 12 CHAPTER 3

LEG COMPARTMENTS

Deep Posterior Neurovascular Structures

Figure 4. Stryker S.T.I. C. Device, Figure 5. Compartments of the lower extremity.

TREATMENT one of the four leg compartments is unusual, and in fact, two or more compartments are usually Approaches for treatment will depend on whether involved. Therefore, the technique used for the patient has an incipient compartment syn- decompression should allow access to all four drome or an acute compartment syndrome. An compartments. There ate a number of surgical incipient compafiment syndrome is defined as one approaches for decompression of the lower leg, which would become a full blown compartment including: 1) Fibulectolriy, 2') Perifibular fasciotomy syndrome if steps were not taken to prevent it. as described by Davey, Rorabeck, and Fowler, and Examples include soft tissue injuries, overalse syn- 3) Double incision fasciotomy as described by dromes, closed LisFranc injuries, closed tibial Mubarak and Hargens. fractures, and patients who complain of inordinate pain under a cast in which signs of a compartment Fibulectomy syndrome are absent. Fibulectomy will undoubtediy decompress all four Non-operative steps utilized in a ful1 blown compafiments. However, a fibulectomy is a radtcal compartment syndrome include removal of tight procedure and generally not recommended. dressings and casts, maintaining systolic arterral Advocates of fibulectomy as a decompressive pro- pressure, and elevating or lowering the extremify cedure for all four compafiments of the lower to the level of the hearl. This position maximizes extremicy suggest that it is indicated in patients tissue perfusion without compromising venous with a severe compartment syndrome, particularly drainage. \7hen conselative non-operative steps with involvement of the deep posterior compart- fail to diminish signs and symptoms or reduce tis- ment. Fibulectomy is contraindicated in children sue pressures, surgical fasciotomy/decompression and in compartment syndromes secondary to frac- is performed. Rorabeck emphasizes that there is no ture of the tibia. non-operative treatment that alone will alleviate a compartment syndrome. In approaching a fas- Perifibular Fasciotomy ciotomy, proximal involvement should always be This approach has the advantage of allowing ruled out. Appropriate vascular or orthopedic con- access to a1l four compartments through a single sultations are recommended. lateral incision. From a cosmetic standpoint, it is the method of choice. The incision is made over DECOMPRESSION OF THE LOWER LEG the lateral aspect of the fibula (Fig. 6). Foilowing retraction and undermining of subcutaneous tis- Anatomically, the lower extremity is divided into four sues anteriody, access is gained to the anterior and compafiments. These include the anterior, laleral, lateral compartments. They are decompressed superficial posterior, and deep posterior compart- with individual fasciotomies. The posterior skin (Fig. ments 5). A compartment syndrome involving flap is retracted, and the fascia over the superficial CHAPTER 3 I3

incisions are made. The first incision is along the tibialis anterior, in front of the anterior intramuscular septum, and the second incision is posterior to the peroneus longus, toward the anterior intramuscular septum (Fig. 7A-C). Identification of the peroneal nelve is necessary to prevent trauma to

Superficial posterior fasciotomy

Figure 6. Perifibular Fasciotomy. posterior compartment is incised. The plane between the peroneus longus and soleus muscles is followed down to the fibula, with care taken to avoid the peroneal ne1we. The fibular origin of the soleus muscle is released through the proximal portion of the incision. The peroneal compartment Flgure 7A. Double incision Fasciotomy, posterior-medial incision. is then retracted anteriorly. By retracting the superficial posterior compartment posteriorly, the deep posterior compartment is visualized. The fascia overlying the deep compafiment is then incised along its entire length. This is a viable technique as long as the anatomy of the extremity has not been distorted. In severe traumatic injuries where the normal anatomy has been distorted, the double incision technique is recommended. Anterior intermusculer Double Incision Approach The double incision approach uses two vertical incisions. The anterior incision allows access to both the anterior and peroneal compartments. The second incision is placed on the posterior and medial aspect of the tibia, giving access to both the superficial and deep posterior compartments. The anterior incision is placed midway between the tibia and the fibula, and courses the length of the two compartments. Following subcutaneous Flgure 78. Double incision fasciotomy, antero- dissection, the interval between the anterior and lateral incision, laleral compartments (anterior intramuscular septum) is identified, and fwo vertical fasciotomy t4 CHAPTER 3

lnterosseous

Anterolateral incision

Flgure 7C. Cross-sectional view of double incision fasciotomy. Figure 8. Compartments of the foot. this structure. Tissue pressure measurements should be The posterior medial incision is placed 2.5 cm recorded for each plantar compartment, as well as behind the posterior border of the tibia, and pro- each dorsal interosseous compartment. Decom- gresses the entire length of the compafiment. The pression is accomplished with the use of three saphenous vein and nerve are identified and incisions (Fig. 9). Two dorsal incisions are used to protected. The fascia overlying the gastrocnemius- release two interosseous compafiments each. soleus complex is initially incised and the muscle Access to the plantar compafiments can be accom- is retracted. Deep to this layer lies the flexor digi- plished using either Henry's Approach, a curuilinear torum longus muscle. The fascia overlying it is medial incision, or a standard medial incision. incised, thus completing the fasciotomy of the Henry's approach stafts at the medial aspect deep posterior compartment of the leg. of the first metatarsophalangeal joint, courses The advantage of this technique is that it is sim- toward the first metatarsocuneiform joint, and then ple to perform and there are yery few neurovasculaq culves plantarly over the talonavicular joint. This muscular, or tendinous structures that can be injured, incision allows the surgeon to divide the foot into except for the saphenous vein medially and the per- four layers. Henry's approach may also be oneal nerves laterally. It allows selective extended proximally for release of the tarsal decompression of one or two compafiments as tunnel" The alternate approach to the medial com- needed, with minimal soft tissue dissection. partment is through the use of a straight linear incision. Following subcutaneous dissection, the DECOMPRESSION OF THE FOOT abductor hallucis muscle belly is mobilized from the plantar aspect of the first metatarsal, navicular, The foot is anatomically divided into four compart- and underlying fibers of the flexor hallucis brevis. ments. The medial compartment contains the The Master Knot of Henry is exposed and incised. abductor hallucis and the flexor hallucis brevis Care is taken to not injure the medial and lateral muscles. The central compartment contains the neurovascular bundles. After release of the Master adductor hallucis, quadratus plantae, flexor digito- Knot of Henry, the entire deep anatomy of the foot rum brevis muscles, as well as the tendons of the may be visualized. The first, second, and third lay- flexor digitorum longus and flexor hallucis longus ers of the foot may be retracted plantarly so as to muscles. The lateral compaftment contains the follow the route of the medial and lateral plantar flexor digiti minimi and abductor digiti minimi arteries and nerves (on the dorsal side of the third muscles. The fourth compafiment, which is the layer, Fig. 10). After pTantar retraction of the third interosseous compafiment, contains both the dor- layer, the inferior fascia overlying the interosseous sal and plantar interossei. A fifth compafiment has compaftment may be visualized and decom- been reported, which includes the quadratus plan- pressed. Interosseous release from the dorsal side, tae which is in communication with the deep however, is preferred, as it allows easier access posterior compartment of the lower leg (Fig. 8). to and visualization of each of the individual CHAPTER 3 l5

IIOITA i'\)ll)'

DoBal lnErola@us m. \ui { /t4, \\/ lnbrmueule sePtum Platu mBt&rE I sry Flsxor dlgiii minimi brevfu m. ft' tuducb. hallucla il. \:),

Figure !. Incision placement for decompression of the foot. Flgure 10. Decompression of the foot via the medial approach. A. Standard medial incision, B. Henry's or curuilinear medial incision.

necrotic muscle is removed. The late result of secondary wound closure and skin grafting is quite satisfactory from a cosmetic standpoint of view.

IATE COMPLICATIONS

DoEd inlerossmug m, The degree of post-compartment syndrome com- plication is related to the time before diagnosis and lntermuacule sePfum treatment, and the compartment involved. The Fl6xor digiti minlmi brevi3 m. greater the nerwe and muscle damage, the worse Adducbr hallucis m. Itrrh6cul{ 6eptum the prognosis. Vithout decompression or with incomplete decompression in a compafiment syndrome, fibrosis of muscle occurs. Residual muscle function and deformily are directly related to the Figure 11. Decompression of the foot via the dorsal approach. degree of muscle fibrosis. interosseous compartments (Fig. 11). A variery of residual deforrnities from a com- In open traumatic wounds, appropriate pafiment syndrome may be seen, depending on lavage and debridement is first performed. Skin the compartment(s) affected. In deep posterior and soft tissue margins which are not viabie are compafiment involvement, deformities can range removed. Individual lacerations of the wound may from miid digital and metatarsophalangeal contrac- the then be used as a site of access for decompression. tures to talipes equinovarus. Sensory ioss to This will eliminate the need for additionally plantar aspect of the foot and loss of inneruation to placed incisions. the intrinsic musculature may result from tibial nerve damage. POSTOPERATIVE CARE Anterior compartment syndrome may result in a dropfoot. An equinus deformity may be seen superficial posterior compartment involve- Postoperatively, the fasciotomy sites are packed with ment. Lateral compartment involvement may result open with sterile gauze, foilowed by a soft bulky in contracture of the peroneus longus, resulting in dressing, placing the foot p0 degrees to the leg and a plantarflexed first ray and heel varus. Loss of the at the level of the heart. Delayed primary closure peroneus brevis will a11ow overpowering of the with or without split thickness skin grafting is per- antagonistic tibialis posterior muscle, and con- formed 48-72 hours later. 'When the compartment tribute to a cavlrs foot deformity. has necrotic muscle or muscle of questionable via- A true Volkmann's or Dupuyren's contracture bility, the patient is returned to the operating room may result from tissue fibrosis caused by neuro- for debridement. The process is repeated until all I6 CHAPTER 3 muscular damage associated with a compartment Halpern AA, Nagel DA: Anterior compaftment pressures in patients with tibia fractures, J Trauma 20t786, 7980. syndrome. Treatment of such contractures centers Hargens AR, Schmidt DA, Evans KL, et al: Quantitation of skeletal around daily spiinting and stretching exercises, muscle necrosis in a model compartment syndrome. J BoneJoillt surg 63At631, 7987. bracing, orthotics, and shoe modifications. Surgical Hasman L: Volkmann's Ischemic Contracture. ACTA Chirug Plast, interyention may be necessary to correct severe 27;26-41., 1985. contractural deformities. Each involved compart- Hayden .f\(r: Compartment syndromes: Early recognition and treatment. Postgraduate Medicine, 7 4:191,-202, 1983. ment is explored, and necrotic and fibrotic tissue is Heckman MM, Grewe SR, Whitesides TE: Comparlment syndromes of excised in its entirety. Neurolysis, as well as tendi- the foot, In Gould JS (ed): Operatiue Foot Surgery. Philadeiphia, \X{B Saunders, pp. 568-)78,1991. nous and osseous stabilizing procedures, are Heckman MM, \X/hitesides, TE, Grewe SRr Spatial relationships of com- performed as necessary. In cases of a severe partment syndromes in lower extremity trauma. Orthop Transactions, J Boneloint Surg 1.1.:537, 1987. uncontrollable deformity or an insensate foot, Henry AK: Extensile ExPosure, 2nd Ed, New York, Churchill amputation may be the treatment of choice. Livingstone, 1P82. Heppenstall RB, Sapega AA, Scott R, et al: The compartment syndrome: An experimental and clinical study of muscular energy SUMMARY metabolism using phosphorus nuclear magnetic resonance spec- troscopy. Clin Ofibop 225:155, 7988. Heppenstall RB, Scott R, Sapega d{, et al; A comparative study of the A compartment syndrome is a condition which tolerance of skeletal muscle to ischemia: Tourniquet application compared with acute compaftment syndrome. J Bone Joint Surg the podiatric physician infrequently encounters. 68A:820, 1986. However, as more lta:uma and sports injuries are Lee BY, Brancato RF, Park IH, Shaw -W\7: Management of treated the podiatric physician, this condition Compartment Syndrome: Diagnostic and Surgical Considerations. by AmJ Surg 148:383-388, 1984. will be encountered more often. Manoli, A II: Compartment Syndromes of the Foot: Current Concepts. Pain out of proportion to the involved surgery Foot Ankle 10:310-314, 1990. Matsen FA III: Compartmental Syndromes, New York, Gr-une and or trauma, and stretch pann, are the most reliable Stratton, pp. 86-93, 1980. clinical signs and symptoms of a compaftment syn- Matsen FA III: A practical approach to compartmental syndromes. Part I Definition, theory, and pathogenesis. A-AOS Instr Collrse Lect, drome. Paresthesias, paralysis, and sensory changes 32:88-92, 1.983. are relatively late findings. Pulses are generally pal- Matsen FA III, Clawson DK: The deep posterior compartmental syndromes ol the teg. / BoneJoinl Surg 7-7A:34. l9-5. pable, and pallor is not generally present, in an Matsen FA III, Winquist RA, Krugmire RB: Diagnosis and management ensuing or shofi-lived compartment syndrome. of compartment syndromes, J Bone Joint Surg 62N28, 7980. extremely podiatric McDermott AGP, Marble AE, Yabsley RH: Monitoring acute compart- It is important that the ment pressures with the s.t.i.c. catheter. Clin Orthop 790:192, physician be familiar with the different methods of 1.984. measuring intracompartmental pressures. The deci- Meyerson MD: Experimental decompression of tl're fascia of the foot - the basis of fasciotomy in acute compartment syndrome. Fool sion of whether or not to perform foot andlor leg Ankle 6308-314. 1988. decompression willbe based upon a sound under- Mubarak SJ, Carroll NC: Volkmann's contracture in children-etiology and prevention. J Bone Joint Surg 61A:285, 1979. standing and evaluation of clinical signs and Mubarak SJ, Hargens AR: Acute Compafiment Syndromes. Surg Clin of symptoms. Objective tissue pressure measurements, N Am 63-3:539-565, 1983. Mubarak SJ, Hargens ARt Compartruent Syndromes and Volkmann's although not necessary to render emergency Contrdcture. Philadelphia,'WB Saunders, pp. 100-101, 1981. decompression, are a vahnble study in helping to X4ubarak SJ, Hargens AR, Owen CA, et al: The wick technique for determine the timing and necessity of fasciotomy. measurement of intramuscular pressure. J Bone Joint Surg 58A1701.6. 1976. Mubarak SJ, Owen CA: Double incision fasciotomy of the leg for decompression in compaftment syndromes, J Bone Joint Surg 59A:784. 1977. BIBLIOGRAPITY Mubarak SJ, Owen CA, Hargens AR, et al: Acute compartment syndromes. Foot Ankle 6:308-314, 1988. -{/Hi Mubarak SJ, Owen CA, Hargens AR, Garetto LP, Akeson Acute Amendola A, Rorabeck CH, Vellett D, Vezina \7, Rutt B, Nott L: The compartment syndromes: diagnosis and treatment rn'ith the aid of use of magnetic resonance imaging in exertional compartment the wick catheter. J Bone Joint Sury 60A;1.091, 7978. syndromes. AmJ Sports Mecl 18:29-34, 1990. 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