Review Article Foot Compartment Syndrome: Diagnosis and Management Abstract Andrew Dodd, MD Although uncommon, foot compartment syndrome (FCS) is a Ian Le, MD, FRCSC distinct clinical entity that typically results from high-energy fractures and crush injuries. In the literature, the reported number of anatomic compartments in the foot has ranged from 3 to 10, and the clinical relevance of these compartments has recently been investigated. Diagnosis of FCS can be challenging because the signs and symptoms are less reliable indicators than those of compartment syndrome in other areas of the body. This may lead to a delay in diagnosis. The role of fasciotomy in management of FCS has been debated, but no high-level evidence exists to guide decision making. Nevertheless, emergent fasciotomy is commonly recommended with the goal of preventing chronic pain and deformity. Surgical intervention may also be necessary for the correction of secondary deformity. oot compartment syndrome patients with isolated calcaneal frac- F(FCS) is relatively uncommon.1,2 tures and suspected FCS underwent a Although isolated foot injuries result fasciotomy. in FCS in only 2% of cases,3 ortho- Stiffness, chronic disability, defor- paedic surgeons must remain aware mity, and pain are some of the com- of this clinical entity because it can plications associated with untreated result in negative sequelae. FCS ac- FCS2,4-8,10-13,15,16 (Table 1). Necrosis of counts for <5% of limb compart- the intrinsic muscles of the foot can ment syndrome cases.4 lead to ischemic contractures that Typically, FCS is the result of high- may result in claw toe, hammer toe, From the Section of Orthopaedic energy injuries to the foot such as and pes cavus. Neurovascular injury Surgery, University of Calgary, can also cause chronic pain and an Calgary, Alberta, Canada. crush injuries, Lisfranc fracture- dislocations, midfoot and forefoot insensate foot with secondary neuro- Neither of the following authors nor trauma, and calcaneal fractures.2,3,5-14 pathic pathology (eg, chronic ulcer- any immediate family member has 2,5-8,10,12,13,15 received anything of value from or FCS can also develop after a tibial ation, joint destruction). has stock or stock options held in a fracture secondary to the communi- commercial company or institution cation between the deep posterior related directly or indirectly to the subject of this article: Dr. Dodd and compartment of the leg and the cal- Pathophysiology 7 Dr. Le. caneal compartment of the foot. J Am Acad Orthop Surg 2013;21: The most commonly cited etiology is Compartment syndrome is caused by 657-664 a high-energy fracture of the calca- increasing pressure secondary to neus, which results in FCS in up to hemorrhage or edema within an ana- http://dx.doi.org/10.5435/ 3,10,12,15 JAAOS-21-11-657 10% of cases. However, data tomic compartment bound by inelas- from a study by Thakur et al3 sug- tic fibrous tissue. Pressures rise until Copyright 2013 by the American Academy of Orthopaedic Surgeons. gest that this patient population may capillary perfusion pressure is ex- be undertreated because only 1% of ceeded, resulting in ischemia, soft- November 2013, Vol 21, No 11 657 Foot Compartment Syndrome: Diagnosis and Management Table 1 ported high rates of sensory distur- the anatomic compartments of the bance and pain at rest in patients foot using high-resolution MRI. The Potential Complications Associated With Untreated Foot treated for lower limb compartment authors found a 10th compartment Compartment Syndrome syndrome. To our knowledge, no in addition to the 9 compartments studies have examined the prevalence described by Manoli and Weber.26 Chronic pain or natural history of neuropathic The 10th compartment is bounded Insensate foot pain in the setting of acute FCS. by the skin and contains the extensor Foot and ankle stiffness digitorum brevis and the extensor Claw toe deformity hallucis brevis in a newly described Hammer toe deformity Anatomy dorsal compartment. Cavus foot deformity In a cadaver study of the myofas- Neuropathic pain Understanding of the myofascial cial compartments of the foot, Ling Neuropathic ulceration compartments of the foot continues and Kumar8 dissected 13 feet and to evolve. Early reports identified found three vertical fibrous septae in four fascial compartments: medial, the hindfoot that, along with the tissue compromise, and subsequent lateral, central, and interosseous.22-24 plantar aponeurosis, form the com- necrosis followed by fibrosis and Myerson25 described methods for partments of the foot (Figure 1). contracture of the compartment’s surgical decompression of these com- These results were substantially dif- contents.2,4 partments. ferent from those of prior studies. Claw toe is the most common se- Manoli and Weber26 performed in- The septae bound compartments quela of FCS and develops when the fusion studies and reported that the identified as medial, intermediate, extrinsic musculature overpowers foot could be divided into nine ana- and lateral. Skin and subcutaneous the weak or scarred intrinsic foot tomic compartments, with the cen- tissue compose the medial border of muscles, whereas cavus deformity is tral compartment divided into super- the medial compartment. As such, the result of scarred and contracted ficial central and deep central (or only the intermediate and lateral plantar structures.2 In the setting of calcaneal) compartments. They also compartments are rigidly bound by intra-articular calcaneal fracture, increased the number of interosseous fascia on all sides. The authors found claw toe develops after the fracture compartments from one to four, add- no evidence of a thick fascial layer hematoma in the deep central com- ing a compartment for the adductor between the previously described su- partment of the foot raises pressures hallucis muscle. New decompression perficial central and deep central and compresses the medial and lat- techniques using multiple incisions (calcaneal) compartments, finding eral plantar neurovascular bun- were recommended based on the in- only a thin and often incomplete dles.12,15 This results in ischemic in- creased number of compartments.26 filmy layer of tissue instead. They sult to the interosseous muscles and Guyton et al27 questioned the va- concluded that the intermediate and quadratus plantae muscle, which de- lidity of previous gelatin infusion lateral compartments are the only rive their blood supply from the me- studies in defining anatomic com- compartments that need surgical de- dial and lateral plantar arteries. partments and accurately measuring compression and recommended a Acute compartment syndrome can them without image guidance. The single plantar-based surgical ap- also cause ischemic neuropathy and authors performed infusion studies proach to do so. These findings con- chronic neuropathic pain.17 Periph- using CT guidance with simultane- flict with those of Stotts et al29 who eral nerves may undergo irreversible ous compartment pressure monitor- reported on an isolated medial com- damage after 4 to 6 hours of isch- ing, focusing on the distinction be- partment syndrome in the foot that emia.17 Symptoms of neuropathic tween the superficial and deep required surgical decompression, pain include numbness, spontaneous central compartments. They demon- which suggests that the medial com- pain, allodynia, and hyperalgesia.18 strated active fluid communication partment is capable of developing Neuropathic pain is associated with between the two compartments as pressures sufficient to warrant de- poor general health and a decrease in pressures rose above 10 mm Hg. In compression. many quality of life measurements.19 addition, they commented on the dif- Ling and Kumar8 attempted to Management of neuropathic pain is ficulty of inserting an infusion needle qualify the clinical importance of the difficult and the outcomes are gener- into the superficial central compart- foot compartments with regard to ally poor. Multimodal drug therapy ment even with CT guidance. surgical decompression and con- is often necessary.20 Frink et al21 re- Reach et al28 further investigated cluded that only two rigidly bound 658 Journal of the American Academy of Orthopaedic Surgeons Andrew Dodd, MD, and Ian Le, MD, FRCSC Figure 1 tense swelling. Other authors agree that although the presence of tense swelling is not necessarily diagnostic, it is suggestive of FCS.11-13,31 Substan- tial pain with passive dorsiflexion of the toes is a common physical find- ing, but it may be present in the ab- sence of compartment syn- drome.1,2,11,13,30 Passive dorsiflexion of the toes decreases the volume of the interosseous compartments, which exacerbates pain.2 Sensory changes can be nonspecific, with the most sensitive findings being de- creased two-point discrimination and decreased light touch on the plantar aspect of the foot and toes. Decreased pin-prick sensation is a less sensitive finding.1,2,11,13,30,31 Motor strength and the presence or absence of palpable pulses are poor indica- Illustration demonstrating the anatomic structures of the foot, including the tors of a developing compartment 2 three vertical septae (medial, intermediate, and lateral) that form the two syndrome. Serial examinations are major compartments of the foot described by Ling and Kumar.8 (Reproduced helpful to observe changes in pain with permission from Ling ZX, Kumar VP: The myofascial compartments of patterns and sensory findings.2 the foot: A cadaver study. J Bone Joint Surg Br 2008;90[8]:1114-1118.) Compartment Pressure compartments exist, which may sug- high-energy fractures and severe Monitoring gest that the clinical sequelae of FCS crush injuries to the foot are at risk are a result of injury to the medial of developing FCS and should be FCS can be difficult to diagnose 1,2 and lateral plantar arteries and monitored serially. Open fractures based on physical findings; therefore, nerves that traverse the newly termed and wounds do not result in reliable most authors agree that compart- intermediate compartment.