Review: acute compartment syndrome of the foot

Republication of "Minimally Invasive Surgery Using the Circular External Fixator to Correct Neglected Severe Stiff Equinocavus Foot Deformities"

Background

Stiff equinocavus deformities of the foot are challenging to treat, often requiring extensive soft tissue dissection and bone removal. These procedures frequently yield suboptimal results and not infrequently amputation. Minimally invasive surgery using a circular external fixator potentially avoids the trauma to the soft tissue and may lead to improvement in outcomes and a lower amputation rate. The objective of this study was to evaluate the efficacy of minimally invasive surgery using a circular external fixator and limited soft tissue release to correct stiff equinocavus deformities.

Methods

The treatment outcome of 29 patients (31 feet) with stiff equinocavus deformities of the foot and ankle treated with minimally invasive surgery and circular external fixation were reviewed after a mean follow-up period of 63 months. Patients' demographics and cause of the deformities were recorded. Weight bearing radiographs of the foot were compared pre and postoperatively.

Results

Outcome was satisfactory (plantigrade foot with improvement/resolution of pain) in 21 of 31 extremities, fair in 6 of 31 extremities, and poor in 4 of 31 extremities. In the majority of patients, a significant improvement in the equinocavus deformities was achieved with a statistically significant improvement in calcaneus and navicular height. Two patients with Charcot-Marie-Tooth and severely insensate feet had a poor outcome, resulting in transtibial amputation.

Conclusion

Minimally invasive surgery with gradual correction of neglected stiff equinocavus deformities using a modular circular external fixator is a reliable initial limb salvage strategy. Minimally invasive surgery and gradual correction of neglected severe stiff equinocavus deformities using the modular circular external fixator to gradually correct neglected severe stiff equinocavus deformities, is a safe initial limb salvage strategy which may simplify secondary procedures such as arthrodesis.

Level of evidence

IV.

Minimal Percutaneous Release for Acute Compartment Syndrome of the Foot: A Case Report

CASE

A 34-year-old man had an injury which resulted in pilon fracture and acute compartment syndrome of his forefoot. The case report describes the use of a novel minimally invasive dorsal approach for decompression of the lateral, central, medial, and interosseous compartments. The release was performed through multiple small incisions on the dorsal foot. The patient had complete relief with normal function of all muscle groups at 6 weeks and is now 18 months after surgery. He has returned to full activity.

CONCLUSION

The successful decompression of the forefoot compartments through a percutaneous approach avoided known complications of muscle death, toe clawing, and secondary surgeries.

Compartment Syndrome of the Foot

Foot compartment syndrome is an uncommon condition that should be recognized by all orthopedic surgeons. The clinical presentation is often less clear than other limb compartment syndromes and requires high clinical suspicion with a low threshold for direct measurement of compartment pressure. Controversy exists regarding the number of anatomic compartments and the most effective treatment. Both acute surgical intervention and delayed management can result in significant morbidity and long-term sequelae.

Percutaneous Forefoot Decompression in a Foot Compartment Syndrome Model

Acute compartment syndrome of the foot is a controversial topic. Release of the foot has been seen as complicated because of large incisions and postoperative morbidity, and there has been debate over whether this procedure is actually effective for releasing all areas of increased pressure. New sensor technology affords the opportunity to advance our understanding of acute compartment syndrome of the foot and its treatment. The purpose of the present study was to determine whether percutaneous decompression could be performed for the treatment of compartment syndrome in a forefoot model.

Saphenous Nerve Denervation for Chronic Pain After Compartment Syndrome of the Foot

Denervation has been a recommended treatment option for a range of pathologies, including relief from chronic pain; however, literature discussing complete denervation of the distal saphenous nerve for foot pain has not been found. A case report of surgical decompression for compartment syndrome resulting in chronic, debilitating foot pain that was successfully alleviated by complete saphenous nerve denervation is presented. The predominant area of the patient's pain was on the medial aspect of the foot, where a thickened scar from a decompression fasciotomy was noted. The patient's initial pain score was reported as 10 of 10, with no relief from numerous conservative treatments attempted over an 11-year period. After a diagnostic injection of a local anesthetic to the distal saphenous nerve provided the patient with immediate, temporary relief, complete denervation of the distal saphenous nerve was performed. The patient reported significant pain reduction shortly after the procedure. This case suggests that physicians should be cognizant of the saphenous nerve and its branches, as well as its variable pathways during surgery. In addition, practitioners should be aware of its influence as a progenitor of pain in the foot that may require denervation.

Neurologic Conditions Associated with Cavus Foot Deformity

The cavus foot deformity is an often less understood deformity within the spectrum of foot and ankle conditions. The hallmark concern is the possibility of an underlying neurologic or neuromuscular disorder. Although a proportion of these deformities are idiopathic, a significant majority do correlate with an underlying disorder. The appropriate evaluation of this deformity, in coordination within the multidisciplinary scope of health care, allows for a timely diagnosis and understanding of the patient's condition. We provide an abbreviated survey of possible underlying etiologies for the patient with the cavus foot deformity as a reference to the foot and ankle surgeon.

Compartment Syndrome of the Foot: An Evidence-Based Review

Compartment syndrome of the foot (CSF) is a surgical emergency, with high risk of morbidity and poor outcome, including persistent neurologic deficits or amputation. Uncertainty remains regarding surgical approaches, pressure monitoring values, and the extent of surgical treatment. This review provides a summary of the current knowledge and reports evidence-based diagnostic and therapeutic management options for CSF. Articles describing CSF were identified from MEDLINE, PubMed, and Cochrane databases up until February 2018. Experimental and original articles, systematic and nonsystematic reviews, case reports, and book chapters, independent of their level of evidence, were included. Crush injuries are the leading cause of CSF, but CSF can present after fractures of the tarsal or metatarsal bones and dislocations of the Lisfranc or Chopart joints. CSF is often associated with persistent neurologic deficits, claw toes, amputations, and skin healing problems. Diagnosis is made after accurate clinical evaluation combined with intracompartmental pressure monitoring. A threshold value of <20 mmHg difference between the diastolic blood pressure and the intracompartmental pressure is considered diagnostic. Management consists of surgery, whereby 2 dorsal incisions are combined with a medioplantar incision to the calcaneal compartment. The calcaneal compartment can serve as an "indicator compartment," as the highest-pressure values can regularly be measured within this compartment. Appropriately powered studies of CSF are necessary to further evaluate and compare diagnostic and therapeutic options.

Acute Compartment Syndrome of the Foot Due To Frostbite: Literature Review and Case Report

Acute compartment syndrome of the foot and ankle is a relatively rare clinical finding. Lower extremity compartment syndrome is customarily due to vascular or orthopedic traumatic limb-threatening pathologic issues. Clinical correlation and measurement of intracompartmental pressure are paramount to efficient diagnosis and treatment. Delayed treatment can lead to local and systemically adverse consequences. Frostbite, a comparatively more common pathologic entity of the distal extremities, occurs when tissues are exposed to freezing temperatures. Previously found in military populations, frostbite has become increasingly prevalent in the general population, leading to more clinical presentations to foot and ankle specialists. We present a review of the published data of acute foot compartment syndrome and pedal frostbite, with pathogenesis, treatment, and subsequent sequelae. A case report illustrating 1 example of bilateral foot, atraumatic compartment syndrome, is highlighted in the present report. The patient presented with changes consistent with distal bilateral forefoot frostbite, along with gangrenous changes to the distal tuft of each hallux. At admission and evaluation, the patient had increasing rhabdomyolysis with no other clear etiology. Compartment pressures were measured in the emergency room and were >100 mm Hg in the medial compartment and 50 mm Hg dorsally. The patient was taken to the operating room urgently for bilateral pedal compartment release. Both pathologic entities have detrimental outcomes if not treated in a timely and appropriate manner, with amputation rates increasing with increasing delay.

Minimally Invasive Surgery Using the Circular External Fixator to Correct Neglected Severe Stiff Equinocavus Foot Deformities

Background:

Stiff equinocavus deformities of the foot are challenging to treat, often requiring extensive soft tissue dissection and bone removal. These procedures frequently yield suboptimal results and not infrequently amputation. Minimally invasive surgery using a circular external fixator potentially avoids the trauma to the soft tissue and may lead to improvement in outcomes and a lower amputation rate. The objective of this study was to evaluate the efficacy of minimally invasive surgery using a circular external fixator and limited soft tissue release to correct stiff equinocavus deformities.

Methods:

The treatment outcome of 29 patients (31 feet) with stiff equinocavus deformities of the foot and ankle treated with minimally invasive surgery and circular external fixation were reviewed after a mean follow-up period of 63 months. Patients’ demographics and cause of the deformities were recorded. Weight bearing radiographs of the foot were compared pre and postoperatively.

Results:

Outcome was satisfactory (plantigrade foot with improvement/resolution of pain) in 21 of 31 extremities, fair in 6 of 31 extremities, and poor in 4 of 31 extremities. In the majority of patients, a significant improvement in the equinocavus deformities was achieved with a statistically significant improvement in calcaneus and navicular height. Two patients with Charcot-Marie-Tooth and severely insensate feet had a poor outcome, resulting in transtibial amputation.

Conclusion:

Minimally invasive surgery with gradual correction of neglected stiff equinocavus deformities using a modular circular external fixator is a reliable initial limb salvage strategy. Minimally invasive surgery and gradual correction of neglected severe stiff equinocavus deformities using the modular circular external fixator to gradually correct neglected severe stiff equinocavus deformities, is a safe initial limb salvage strategy which may simplify secondary procedures such as arthrodesis.

Level of evidence:

IV.

Acute compartment syndrome of the leg due to infection following an insect bite: A case report

RATIONALE

Acute compartment syndrome is a highly aggressive condition, which needs rapid diagnosis and surgical emergency. Most cases are caused by trauma, fractures, surgeries, or vascular injury, while other causes are easily misdiagnosed.

PATIENTS CONCERNS

A 29-year-old female, with a medical history of an insect bite on the left calf but not recent trauma, was admitted to the hospital due to the swelling and pain around the bite area.

DIAGNOSES

Acute compartment syndrome of the lower leg.

INTERVENTIONS

After admission, she developed septic shock symptoms, given intravenous antibiotics treatments. However, the condition worsened with increasing pain, loss of sensation, tense swelling, and severe pain to any stretch of the tissues. Thus the patient received fasciotomy followed by repeat and thorough debridement. After the wounds healed completely, systematic rehabilitation was performed for three weeks.

OUTCOMES

After three months of follow-up, the patient is able to walk, and moves up and down the stairs, independently.

LESSONS

Our case highlights the possibility of acute compartment syndrome caused by insect bites when the patient presents with the signs of the condition, and the importance of earlier rehabilitation interventions to improve the functional outcome post operation.

Complex Foot Injury: Early and Definite Management

Complex foot injuries occur infrequently, but are life-changing events. They often present with other injuries as the result of a high-energy trauma. After initial stabilization, early assessment should be regarding salvagability. All treatment strategies are intensive. The initial treatment includes prevention of progression ischemia/necrosis, prevention of infection, and considering salvage or amputation. Definitive treatment for salvage includes anatomic reconstruction with stable internal fixation and early soft tissue coverage followed by aggressive rehabilitation. Prognosis after complex injuries is hard to predict. The various stages of the treatment are reviewed and recommendations are made.

Complications of Intra-articular Calcaneal Fractures in Adults: Key Points for Diagnosis, Prevention, and Treatment

Calcaneal fractures are complex injuries with high complication rates and they can lead to serious disability. The proper management remains controversial and complications may occur regardless of the chosen type of treatment (operative or nonoperative). The present article reviews the studies that are related to the complications of calcaneal fractures. The incidence, the diagnosis, the prevention and the treatment of these complications were researched and analyzed, with the use of PubMed database, abstracts and original articles in English than investigate the etiology. The aim of the article is to discuss the most suitable management of the complications of calcaneal fractures and recommend a specific treatment as well as prevention methods.

LEVELS OF EVIDENCE

Level IV.

Surgical treatment of malignant tumors of the calcaneus

BACKGROUND

Amputation has been most commonly considered the only option to achieve local tumor control for calcaneal malignancies. Advances in oncologic treatment modalities and wide resection have made limb salvage increasingly possible. We retrospectively reviewed nine patients with calcaneal malignancies treated with different surgical options.

METHODS

The diagnoses included chondrosarcoma in three patients, Ewing's sarcoma in three, osteosarcoma in two, and small round cell sarcoma in one. Four patients were managed by below-the-knee amputation owing to neurovascular invasion. Five patients were managed by limb salvage procedures. Pedicled osteomyocutaneous fibular grafts were used to reconstruct the defects created after total calcanectomy in limb salvage procedures. Clinical and radiographic evaluations were performed, and functional outcomes were assessed using the Musculoskeletal Tumor Society score.

RESULTS

The patients were followed up for a mean of 42.3 months. Wide resection margins were achieved in all of the patients with limb salvage surgery. At the final follow-up, two patients had died of disease. Lung metastasis was found in two patients who were alive with disease. Five patients had no evidence of disease. No local recurrence occurred in this series. All of the fibular flaps survived, and fibula hypertrophies were observed in three patients. Average Musculoskeletal Tumor Society scores were 74.6% and 83.2% in patients with amputation and limb salvage, respectively.

CONCLUSIONS

After wide resection of a calcaneal malignancy, biological reconstruction using pedicled osteocutaneous fibular flaps has proved to be a successful limb salvage procedure, offering a satisfactory oncologic and functional outcome alternative to amputation in selected patients.

Gluteal Compartment Syndrome Following Abdominal Aortic Aneurysm Treatment: Case Report and Review of the Literature

Compartment syndrome (CS) is a pathological increase of the interstitial pressure within the closed osseous fascial compartments. Trauma is the most common cause, followed by embolization, burns, and iatrogenic injuries; it usually involves the limbs. The major issue when dealing with CS is the possibility to do an early diagnosis in order to intervene precociously, through a fasciotomy, reducing the risk of tissue, vascular and nervous damage. Although it is an infrequent condition, it is potentially life threatening. In our case report, we present a 59-year-old patient, smoker, affected by hypertension, dyslipidemia, chronic renal failure, and morbid obesity who came at our attention for a 6-cm abdominal aorta aneurysm, treated with an aorto-aortic graft. Within 24 hours from surgery, the patient presented acute ischemia of the right lower limb due to thrombosis of the common iliac artery and underwent the positioning of a kissing stent at the aortic bifurcation. In the immediate postoperative period, a relevant increase in serum creatinine, creatine phosphokinase, and myoglobin value was recorded, associated with clinical presentation of swelling in the right buttock with intense pain. The diagnosis of gluteal CS was confirmed by the measurement of the gluteal compartment pressure, which resulted of 110 mm Hg. The treatment of the CS consisted in gluteal dermofasciotomy, surgical debridement of the buttock, and positioning of negative pressure medication, associated with infusive therapy, avoiding hemodialysis. Because of the epidural anesthesia only later on it was possible to observe a persistent plegia of the right lower limb, which was solved within 1 month of neurological and physical therapy. With our experience, we can state that the CS is an extremely severe complication that can occur in vascular surgeries and it should therefore be kept in mind in the short-term postoperative period in order to guarantee a precocious diagnosis and immediate treatment.

Acute Compartment Syndrome of the Lower Leg: Changing Concepts

The acute limb compartment syndrome is caused by bleeding or edema in a closed muscle compartment surrounded by fascia and bone, leading to muscle and nerve ischemia. The value offasciotomy has been demonstrated in the management of acute compartment syndrome, but ifperformed after a delay of8 to 10 hours, it can prove to be a double-edged weapon, as necrotic muscle would get exposed leading to muscle infections and massive bleeding.

A prospective study of surgical outcomes and quality of life in severe foot trauma and associated compartment syndrome after fasciotomy

The purpose of the present prospective study was to analyze the predictors of outcome and review the quality of life of patients who underwent emergency fasciotomy for foot compartment syndrome after blunt trauma. A total of 14 patients were identified and followed for an average of 24 (range 14 to 33) months. The mean interval from initial presentation to decompressive fasciotomy was 5.8 (range 3 to 11) hours. The follow-up data from our patients revealed satisfactory functional and quality of life outcomes, with 11 of 14 (78.6%) able to return to work. Two (14.3%) patients developed claw-toe deformities and 3 (21.4%) patients had sensory deficits directly attributed to compartment syndrome. Finally, 4 (28.6%) patients required modified shoes or shoe inserts for comfortable ambulation. Our findings suggest that earlier fasciotomy results in better quality of life scores, American Orthopaedic Foot and Ankle Society scale scores, and visual analog scale pain scores and a greater likelihood of being able to wear all shoes comfortably, ambulate independently, and return to work. A shorter interval to fasciotomy, younger age, the absence of bony injury, the absence of other concomitant injuries, and a low velocity crush injury all tended to be predictors of good outcomes at the final review.

Midfoot crush injuries

Treatment of midfoot injuries is surgical or nonsurgical, depending on the injury, the location, and the extent of the injury. Minor injuries usually heal with casting or bracing, whereas more unstable injuries typically need surgery for stability. Whether the injury is in a weight-bearing portion of the foot is also a consideration for surgery. The importance of treating midfoot injuries adequately is shown in how the midfoot is needed for function with weight bearing and its relationship between the front and the back of the foot. It is also important to ensure that the patient is able to ambulate with a reasonably normal gait.

Compartment syndrome: diagnosis, management, and unique concerns in the twenty-first century

BACKGROUND

Compartment syndrome is an elevation of intracompartmental pressure to a level that impairs circulation. While the most common etiology is trauma, other less common etiologies such as burns, emboli, and iatrogenic injuries can be equally troublesome and challenging to diagnose. The sequelae of a delayed diagnosis of compartment syndrome may be devastating. All care providers must understand the etiologies, high-risk situation, and the urgency of intervention.

QUESTIONS/PURPOSES

This study was conducted to perform a comprehensive review of compartment syndrome discussing etiologies, risk stratification, clinical progression, noninvasive and invasive monitoring, documentation, medical-legal implication, and our step-by-step approach to compartment syndrome prevention, detection, and early intervention.

METHODS

A literature search was performed using the PubMed Database and the following search terms: "Compartment syndrome AND Extremity," "Compartment syndrome AND Gluteal," and Compartment syndrome AND Paraspinal." A total of 2,068 articles were identified. Filters allowed for the exclusion of studies not printed in English (359) and those focusing on exertional compartment syndrome (84), leaving a total of 1,625 articles available for review.

RESULTS

The literature provides details regarding the etiologies, risk stratification, clinical progression, noninvasive and invasive monitoring, documentation, medical-legal implication, and our step-by-step approach to compartment syndrome prevention, detection, and early intervention. The development and progression of compartment syndrome is multifactorial, and as complexity of care increases, the opportunity for the syndrome to be missed is increased. Recent changes in the structure of in-hospital medical care including resident work hour restrictions and the incorporation of midlevel providers have increased the frequency of "signouts" or "patient handoffs" which present opportunities for the syndrome to be mismanaged.

CONCLUSION

The changing dynamics of the health care team have prompted the need for a more explicit algorithm for managing patients at risk for compartment syndrome to ensure appropriate conveyance of information among team members.

Combined medial column primary arthrodesis, middle column open reduction internal fixation, and lateral column pinning for treatment of Lisfranc fracture-dislocation injuries

Lisfranc fracture-dislocation can be a devastating injury with significant long-term sequelae, including degenerative joint disease, progressive arch collapse, and chronic pain that can be potentiated if not effectively treated. We present a case to demonstrate our preferred surgical approach, consisting of combined medial column primary arthrodesis, middle column open reduction internal fixation, and lateral column pinning, with the primary goal of minimizing common long-term complications associated with Lisfranc injuries. We present the case of a typical patient treated according to this combined surgical approach to highlight our patient selection criteria, rationale, surgical technique, and operative pearls. A 36-year-old male who had sustained a homolateral Lisfranc fracture-dislocation injury after falling from a height initially underwent fasciotomy for foot compartment syndrome. The subsequent repair 16 days later involved primary first tarsometatarsal joint fusion, open reduction internal fixation of the second and third tarsometatarsal joints, and temporary pinning of the fourth and fifth tarsometatarsal joints. He progressed well postoperatively, exhibiting an American College of Foot and Ankle Surgeons forefoot score of 90 of 100 at 1 year after surgery with no need for subsequent treatment. Lisfranc fracture-dislocations often exhibit primary dislocation to the medial column and are conducive to arthrodesis to stabilize the tarsometatarsal complex. The middle column frequently involves comminuted intra-articular fractures and will often benefit from less dissection required for open reduction internal fixation instead of primary fusion. We propose that this surgical approach is a viable alternative technique for primary treatment of Lisfranc fracture-dislocation injuries.

Acute Compartment Syndrome of the Foot due to Infection After Local Hydrocortisone Injection: A Case Report

High-energy trauma associated with calcaneal fracture or Lisfranc fracture dislocation and midfoot crushing injuries are known causes of compartment syndrome in the foot. Suppurative infection in the deep osseofascial compartments can also cause compartment syndrome. We describe the case of a 29-year-old female who had developed a suppurative local infection that resulted in acute compartment syndrome after receiving a local hydrocortisone injection for plantar fasciitis. We diagnosed the compartment syndrome, and fasciotomy was promptly undertaken. After more than 2 years of follow-up, she had a satisfactory functional outcome without substantial morbidity. To our knowledge, no other report in the English-language studies has described compartment syndrome due to abscess formation after a local injection of hydrocortisone. The aim of our report was to highlight this rare, but serious, complication of a routine outpatient clinical procedure.

Isolated medial foot compartment syndrome after ankle sprain

Foot compartment syndrome is a serious potential complication of foot crush injury, fractures, surgery, and vascular injury. An acute compartment syndrome isolated to the medial compartment of the foot after suffering an ankle sprain is a rare complication. We report the case of a 31-year-old man who developed a medial foot compartment syndrome after suffering a deltoid ligament rupture at ankle while playing football. The patient underwent a medial compartment fasciotomy with resolution of symptoms. Compartment syndromes of the foot are rare and have been reported to occur after severe trauma. But, there are some reports in the literature of acute exertional compartment syndrome. In our case, the compartment syndrome appeared after an ankle sprain without vascular injuries associated.

The cavus foot

The cavus, or high-arched, foot can present in either childhood or adulthood as a function of muscle imbalance. Neurologic, traumatic, and idiopathic processes have been identified, along with residual clubfoot, as the primary causes of adult cavus foot deformity. A thorough history and physical examination is important and can help identify the underlying cause of deformity. Conservative treatment modalities are always used first, with surgical intervention reserved for refractory cases. The goal of surgery is to correct muscle imbalance, which can be achieved via tendon transfers, corrective osteotomies, and, in the most severe cases, fusion.

Delayed compartment syndrome of leg and foot due to rupture of popliteal artery pseudoaneurysm following posterior cruciate ligament reconstruction

Arthroscopic posterior cruciate ligament (PCL) reconstruction carries some risk of complications, including injury to the neurovascular structures at the popliteal region. We describe a delayed presentation of the right leg and foot compartment syndrome following rupture of popliteal artery pseudoaneurysm, which presented 9 days after an arthroscopic transtibial PCL reconstructive surgery. Fasciotomy, surgical exploration, repair of an injured popliteal vein and revascularisation of the popliteal artery with autogenous great saphenous vein interposition graft were performed. Owing to the close proximity of vessels to the tibial tunnel, special care should be taken in patients who undergo arthroscopic PCL reconstruction, especially if there is extensive scarring of the posterior capsule following previous injury. Emergency fasciotomy should not be delayed and is justified when the diagnosis of compartment syndrome is clinically made.

Foot compartment syndrome: diagnosis and management

Although uncommon, foot compartment syndrome (FCS) is a 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.

Sequelae of underdiagnosed foot compartment syndrome after calcaneal fractures

The calcaneus is the most frequently fractured tarsal bone. Compartment syndrome (CS) complicates fractures and other injuries and is most commonly described in association with the lower leg. The long-term sequelae of CS of the foot can include toe clawing, permanent loss of function, persistent pain, muscle atrophy, contracture, painful warts, weakness, and sensory disturbances. The incidence and clinical significance of untreated CS after calcaneal fractures were questioned. All compliant patients treated by us for a calcaneus fracture underwent a physical examination and medical interview: 47 (49 fractures) were included in the final cohort (36 males, 11 females, mean age 49 ± 14.5 years, mean follow-up 23 ± 16 months). Missed CS sequelae were diagnosed by the presence of claw toes and plantar sensory deficits. The functional outcome and pain at rest and during activity were scored. Five patients (10%) had missed CS, and their functional score was significantly lower than for those without CS (52 ± 21.5 versus 77.4 ± 22 for no CS, p < .05). All missed CS cases were diagnosed in patients with a Sanders type 3 or 4 fracture. Intra-articular fracture was a significant factor associated with developing CS sequelae (p = .045). Untreated CS can cause muscle and nerve injury and contribute to a poor functional outcome. Because CS is more likely to develop after highly comminuted intra-articular fractures, these patients warrant close monitoring for CS development. Early detection and treatment might result in fewer late disabling sequelae of this injury.

Acute compartment syndrome of the limbs: current concepts and management

Acute compartment syndrome (ACS) of the limb refers to a constellation of symptoms, which occur following a rise in the pressure inside a limb muscle compartment. A failure or delay in recognising ACS almost invariably results in adverse outcomes for patients. Unrecognised ACS can leave patients with nonviable limbs requiring amputation and can also be life–threatening. Several clinical features indicate ACS. Where diagnosis is unclear there are several techniques for measuring intracompartmental pressure described in this review. As early diagnosis and fasciotomy are known to be the best determinants of good outcomes, it is important that surgeons are aware of the features that make this diagnosis likely. This clinical review discusses current knowledge on the relevant clinical anatomy, aetiology, pathophysiology, risk factors, clinical features, diagnostic procedures and management of an acute presentation of compartment syndrome.

Injury patterns causing isolated foot compartment syndrome

BACKGROUND

The true incidence and primary predictors of foot compartment syndrome remain controversial. Our aim was to better define the overall incidence of foot compartment syndrome in relation to the frequency and location of various foot injuries. We hypothesized that (1) the incidence would increase in proportion to the number of anatomic locations of injury, (2) the incidence would be higher in association with hindfoot and crush injuries compared with any other injury categories, and (3) not only would the incidence associated with calcaneal fractures be lower than the often quoted 10% but foot compartment syndrome would also be fairly uncommon after such fractures.

METHODS

The National Trauma Data Bank was used to identify patients who had undergone a fasciotomy for the treatment of isolated foot compartment syndrome. Strict inclusion and exclusion criteria were used to identify only patients with foot injuries who had undergone fasciotomy for foot compartment syndrome.

RESULTS

Three hundred and sixty-four patients with an isolated foot compartment syndrome were identified. The highest incidence of foot compartment syndrome was seen in association with a crush mechanism combined with a forefoot injury (18%, nineteen of 106), followed by an isolated crush injury (14%, twenty-three of 162). Only 1% (thirty-two) of 2481 patients with an isolated calcaneal fracture underwent fasciotomy. An increase in the number of anatomic locations of injury did not appear to correspond to an increased incidence of foot compartment syndrome.

CONCLUSION

Our results demonstrate that injuries involving a crush mechanism, either in isolation or in combination with a forefoot injury, should raise suspicion about the possibility that a foot compartment syndrome will develop.

Atraumatic compartment syndrome of the foot in a 15-year-old female

Compartment syndrome is a surgical emergency that usually occurs as a sequel to high-energy trauma. We report an uncommon presentation of atraumatic compartment syndrome of the right foot involving the abductor hallucis muscle. A 15-year-old female presented with pain and mild swelling of the right foot after taking part in a school sports activity. Compartment syndrome was diagnosed, >2 months of conservative treatment failed to improve her symptoms, and surgical release and debridement were performed. Our clinical experience demonstrates that compartment syndrome of the foot may occur after mild sports activity in physically inactive children.

Compartment syndrome: a review of the literature

Compartment syndrome is a rare but severe complication of lower extremity trauma. This article provides an extensive review of the literature, including incidence, physical examination findings, pathophysiology, compartment pressure evaluation, and surgical decompression techniques. Most of the recent compartment syndrome literature shows case reports of atypical causes of this limb-threatening disorder. Although the emphasis of this article is traumatic compartment syndrome, recent literature on chronic lower extremity compartment syndrome, secondary to exercise or activity, is also discussed.

Calcaneal fractures: update on current treatments

Calcaneal fractures represent 2% of all fractures and account for approximately 60% of all tarsal injuries. Motor vehicle collisions and falls are the major causes of these large force compression injuries, causing widening of the heel, loss of heel height, and articular surface displacement. A correlation has been shown between restoration of normal anatomy and satisfactory functional outcome. Once the basic principles of calcaneal fractures are understood, including the anatomy, the radiographic findings, and the challenges that these complicated fractures present, the physician can then be ready with the armamentarium that allows for a patient-specific and injury-specific plan.

Composite biological reconstruction following total calcanectomy of primary calcaneal tumors

BACKGROUND

Advances in oncologic treatment modalities and wide resection have made limb salvage procedures in calcaneal malignancy or aggressive benign tumor increasingly possible. However, reconstructions of the calcaneus remain a major surgical challenge because of the rarity and specific anatomy of this condition.

METHODS

we retrospectively reviewed 4 patients who had primary calcaneal tumors and underwent total calcanectomy and reconstructions with use of composite of allograft and vascularized osteocutaneous fibular grafts between 2007 and 2010. The diagnoses included chondrosarcoma in 1, fibrosarcoma in 1, aggressive osteoblastoma in 1, and giant-cell tumor in 1. Wide resection margins were achieved in all patients. The mean age at the time of the operation was 32.1 years. Patients were examined clinically and radiographically and were assessed functionally with Musculoskeletal Tumor Society (MSTS) score and American Orthopaedic Foot and Ankle Society (AOFAS) score.

RESULTS

The median duration of follow-up was 24.5 months. No local recurrence occurred in this series and all patients had no evidence of disease at the time of final follow-up. Limb salvage was achieved in all patients. Revision surgery was necessary in two patients because of complications (skin flap necrosis and infection). The average MSTS 93 score and AOFAS score were 91.7% and 87.5 at the final follow-up, respectively. All fibular flaps survived and bone unions achieved successfully. The overall mean time for bone union was 9.5 months. The mean time to full-weight bearing was 7 months.

CONCLUSIONS

Vascularized fibular flaps in combination with massive allografts provide an excellent option for biological reconstruction after total calcanectomy in tumor situation and have proven to be a successful limb salvage procedure, which result in earlier patient recovery and return of function.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Treatment algorithm for complex injuries of the foot in paediatric patients

BACKGROUND

Complex injuries of the foot in the paediatric population present difficult treatment challenges. While standardised protocols exist for the adult population to achieve an optimal result in the treatment of such injuries, therapy in paediatric patientsmust be managed without a firm treatment algorithm.

METHODS

Medical records of all patients with a complex trauma of the foot treated at our Department over a period of 13 years were evaluated. A complex trauma of the foot was defined using the scoring system developed by Zwipp et al. (1997).24 Treatment and outcome were analysed. Additionally, our treatment algorithm of complex injuries of the foot in paediatric patients is presented.

RESULTS

Twenty-nine patients were included in the study (79%m; 21% f, average age 12.1 years, ranging 2–16 years). Traffic accidents were the most common mechanism (n = 14; 48.3%), followed by a fall from a height in five patients (17.2%). Lawnmower injuries were found in another 3 patients (10.3%) and other mechanisms of injury in 7 patients (24.2%). The mean score according to Zwipp et al. (1997)24 was 5.8 points (range 5–8 points). While closed fractures were diagnosed in 20 (69%) patients, 9 patients (31%) presented open fractures. Operative intervention was necessary in 24 patients (82.8%). Fracture stabilisation could be realised using K-wires in 13 cases (54.2%), screws in 3 cases (12.5%) and plate fixation in 1 case (4.2%). Combined techniques including external fixation were applied in another 7 (29.1%) cases. The mean time between injury and latest follow-up examination was 5.7 years (range 13 months to 13 years). The mean functional outcome was 47.6 (29–56) points for the OAFQ, 15.1 (0–69) points for the FFI and 82.3 (59–100) points for the AOFAS Score.

DISCUSSION

To regard the maxims in treating complex injuries and open fractures in the growing skeleton we developed a simple treatment algorithm for complex foot injuries in order to provide preservation of the soft tissue envelope, avoidance of infection, restoration of the axis and the articular surface.

CONCLUSION

A complex trauma of the paediatric foot is a rare and challenging injury. Avoidance of infection, preservation of the soft tissue envelope and fracture healing will provide good functional outcome despite the severity of trauma. Long time follow-up is essential to detect complications.

Spontaneous compartment syndrome of the foot

Compartment syndrome of the foot is usually associated with trauma, and if untreated may result in deformity and loss of function. We report a case of spontaneous compartment syndrome of the foot presenting with severe unremitting pain. The diagnosis was supported by measurements of compartment pressures and the symptoms resolved after surgical decompression. Spontaneous compartment syndrome in the leg has been described in a small number of cases, but there has been no previous report involving the foot. We believe that this case highlights the importance of suspecting a spontaneous compartment syndrome of the foot if the appropriate symptoms are present but there is no clear cause. We also believe that compartment pressure measurement assists in the decision to undertake surgical decompression.

Salvage of foot with extensive giant cell tumour with transfer of vascularised fibular bone graft

Though giant cell tumor is not uncommon in young adults, simultaneous involvement of multiple mid-foot bones is very uncommon and very difficult to treat. For reconstruction of large segmental bony defects following tumour excision, free vascularized bone graft is an excellent surgical option. We report a case with extensive involvement of all the tarsal bones and metatarsal bases in a young adult. After excision his foot was reconstructed with vascularised bone flap. We were able to save his foot after a wide local excision and reconstruction with free fibula graft. Graft united early and showed excellent remodelling because of good vascularity. We feel that this method deserves consideration as a last attempt to salvage functional foot in disease like this.

Acute exertional medial compartment syndrome of the foot after playing basketball

Compartment syndrome of the foot is an uncommon event. The most common cause of compartment syndrome of the foot is a crush injury. Exceedingly rare is acute compartment syndrome of the foot occurring in the absence of trauma. We describe the clinical scenario involving a 23-year-old healthy male who developed acute exertional compartment syndrome isolated to the medial compartment of the foot after playing basketball. The patient had no evidence of injury nor trauma, and the diagnosis was made based on physical exam, magnetic resonance imaging (MRI), and compartment pressure measurements. The patient did undergo successful fasciotomy on the day of presentation to the emergency department and has since completely recovered. We found four cases reported in the literature of acute exertional medial compartment syndrome of the foot in the absence of trauma or injury. This is the second case reported after playing basketball, while the others occurred after aerobics, a long distance run, and football. The most recent case was reported by Miozzari et al. [Am J Sports Med. 36(5):983-6, 2008] and involved a marathon runner who developed an isolated medial compartment syndrome of the foot. We would like to increase awareness of this uncommon clinical presentation in the absence of trauma and present the dramatic radiographic findings.

Hallux varus as complication of foot compartment syndrome

Hallux varus can present as a congenital deformity or it can be acquired secondary to trauma, surgery, or neuromuscular disease. In the present report, we describe the presence of hallux varus as a sequela of calcaneal fracture with entrapment of the medial plantar nerve in the calcaneal tunnel and recommend that clinicians be wary of this when they clinically, and radiographically, evaluate patients after calcaneal fracture.

[Fractures of the forefoot]

Fractures of the forefoot are common and comprise approximately two thirds of all foot fractures. Forefoot fractures are caused by direct impact or the effect of indirect force. The forces exerted can range from repetitive minor load (stress fractures) to massive destructive forces (complex trauma). The clinical course in forefoot fractures is typically more favourable than in fractures of the mid- and hindfoot. The incidence of complications like infection or pseudarthrosis is low. Exceptions are rare fractures of the proximal shaft of the fifth metatarsal and the sesamoids with higher pseudarthrosis rates. Malunited metatarsal fractures can cause painful conditions that should even be treated operatively. Differences in structure and function of the different forefoot areas and specific fracture types require an adapted management of these special injuries.

A hypothesis for the cause of complex regional pain syndrome-type I (reflex sympathetic dystrophy): pain due to deep-tissue microvascular pathology

Complex regional pain syndrome-type I (CRPS-I; reflex sympathetic dystrophy) is a chronic pain condition that usually follows a deep-tissue injury such as fracture or sprain. The cause of the pain is unknown. We have developed an animal model (chronic post-ischemia pain) that creates CRPS-I-like symptomatology. The model is produced by occluding the blood flow to one hind paw for 3 hours under general anesthesia. Following reperfusion, the treated hind paw exhibits an initial phase of hyperemia and edema. This is followed by mechano-hyperalgesia, mechano-allodynia, and cold-allodynia that lasted for at least 1 month. Light microscopic analyses and electron microscopic analyses of the nerves at the site of the tourniquet show that the majority of these animals have no sign of injury to myelinated or unmyelinated axons. However, electron microscopy shows that the ischemia-reperfusion injury produces a microvascular injury, slow-flow/no-reflow, in the capillaries of the hind paw muscle and digital nerves. We propose that the slow-flow/no-reflow phenomenon initiates and maintains deep-tissue ischemia and inflammation, leading to the activation of muscle nociceptors, and the ectopic activation of sensory afferent axons due to endoneurial ischemia and inflammation. These data, and a large body of clinical evidence, suggest that in at least a subset of CRPS-I patients, the fundamental cause of the abnormal pain sensations is ischemia and inflammation due to microvascular pathology in deep tissues, leading to a combination of inflammatory and neuropathic pain processes. Moreover, we suggest a unifying idea that relates the pathogenesis of CRPS-I to that of CRPS-II. Lastly, our hypothesis suggests that the role of the sympathetic nervous system in CRPS-I is a factor that is not fundamentally causative, but may have an important contributory role in early-stage disease.

Acute compartment syndrome of the foot following fixation of a pilon variant ankle fracture

Acute traumatic compartment syndrome of the foot is a serious potential complication after fractures, crush injuries, or reperfusion injury after vascular repair. Foot compartment syndrome in association with injuries to the ankle is rare. This article presents a case of acute compartment syndrome of the foot following open reduction and internal fixation of an ankle fracture. A 16-year-old girl presented after sustaining a left ankle injury. Radiographs demonstrated a length-stable posterior and lateral malleolar ankle fracture. Initial treatment consisted of a bulky splint and crutches pending the improvement of her swelling. Over the course of a week, the soft tissue environment of the distal lower extremity improved, and the patient underwent open reduction and internal fixation of both her fibula and distal tibia through 2 approaches. Approximately 2 hours from the completion of surgery, the patient reported worsening pain over the medial aspect of her foot and into her calcaneus. Physical examination of the foot demonstrated a swollen and tense abductor hallicus and heel pad. Posterior tibial and dorsalis pedis pulses were palpable and her sensation was intact throughout her foot. Emergently, fasciotomy of both compartments was performed through a medial incision. Postoperatively, the patient reported immediate pain relief. At 18-month follow-up, she reported no pain and had returned to all of her preinjury athletic activities.

Accuracy of medial foot compartment pressure testing: a comparison of two techniques

BACKGROUND

Foot compartment syndrome is diagnosed with intracompartmental pressure measurements. The purpose of this study was to determine the ability of two techniques to accurately place a needle tip within the medial foot compartment and to compare the proximity of the needle tip to the medial foot compartment neurovascular structures between the two techniques.

MATERIALS AND METHODS

This was a laboratory study using ten unembalmed cadaveric ankle-foot specimens. Two 18-gauge side-ported needles were placed into the medial foot compartments of each cadaveric specimen utilizing two separate techniques (Mollica and Reach techniques). Ultrasound was used to confirm needle tip placement within the medial foot compartment and needle proximity to the neurovascular structures.

RESULTS

Both needle placement techniques accurately placed the needle tip within the medial foot compartment. However, the distance between the needle tip and the neurovascular structures of the medial foot compartment was significantly closer (p = 0.037) using the Mollica technique (mean = 3.9 mm ± 2.2 mm) than the Reach technique (mean = 10.9 mm ± 5.2 mm). Neither needle placement technique perforated the medial foot neurovascular structures.

CONCLUSION

While both medial foot compartment pressure techniques accurately placed the needle tip within the medial foot compartment, the needle tip was significantly further from the medial foot neurovascular structures using the Reach technique than the Mollica technique. The Reach technique involves inserting the needle 6 cm below the distal tip of the medial malleolus, and advancing it 1 cm in a medial to lateral direction.