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Compartment Syndrome of the Foot

- Discussion:
    - compartment syndromes can occur in the foot as in other parts of body;
    - mechanism of injury is severe local trauma, & assoc skeletal injury may be minimal;
    - classic symptoms & signs are progressive pain, numbness in toes, and decreased motion, however, these are the same symptoms that one would expect to find w/ concomitant foot fractures and injury;
            - tense tissue bulging may be the most reliable symptom;
    - compartmental pressures will be elevated;
    - note that compartment syndromes of the foot are associated w/ compartment syndromes of the deep posterior compartment;

- Anatomy:
    - the 9 compartments of the foot can be placed into 4 groups;
    - Intrinsic Compartment:
           - 4 intrinsic muscles between the 1st and 5th metatarsals;
    - Medial Compartment:
           - abductor hallucis;
           - flexor hallucis brevis;
    - Central Compartment: (Calcaneal Compartment)
           - flexor digitorum brevis;
           - quadratus plantae;
           - adductor hallucis;
    - Lateral Compartment:
           - flexor digiti minimi brevis;
           - abductor digiti minimi;

- Clinical Findings:
    - pain alone is not sufficient for diagnosis;
    - increased pain on passive dorsiflexion of metatarsophalangeal joints is key finding (indicating myoneural ischemia in intrinsic muscles);
    - poor capillary refill and absent pulses are late findings.
         - in the presence of massive swelling of the foot, which usually accompanies these injuries, pulses are usually not palpable.

- Surgical Treatment:
    - appropriate treatment for a suspected compartment syndrome of the foot is  immediate and complete fasciotomy;
    - abductor hallucis longus, central, lateral, and interosseous compartments must be released;
    - effective decompression of all 4 compartments can be accomplished thru medial longitudinal Henry approach, or through 2 parallel dorsal incision along the lengths of the second and fourth metatarsals;
    - medial approach:
          - this is usually the approach of choice;
          - can be used to decompress the medial and central compartments as well as the remaining foot compartments;
          - extends from a point below the medial malleolus (3 cm from the sole) to proximal aspect of first metatarsal;
          - once the neurovascular bundle has been retracted out of the way, the fascia overlying the abduction hallucis and FDB is released;
          - medial intermuscular septum is opened longitudinally;
          - the lateral plantar neurovascular bundle is found coursing over the quadratus plantae (central compartment) as they course laterally;
          - the remaining compartments (central, lateral, intrinsic) are entered thru blunt dissection w/ a clamp;3
          - lateral compartment is found by retracting the FDB out of the way;
    - dorsal approach:
          - often the dorsal approach is not necessary unless there is concomitant metatarsal or Lisfranc fractures;
          - accomplished through 2 dorsal incisions centered just medial to the 2nd metatarsal and just lateral to the 4th metatarsals (to maximize skin bridge);
                 - avoid injury to sensory nerves and extensor tendons;
          - superficial fascia is divided and interosseous are elevated off the metatarsals to further decompress the compartments;
          - clamp is used to bluntly dissect thru the central, medial, and lateral compartments;
          - separate medial incision may be needed to release the abductor;
          - fasciotomy incisions may be used for fracture fixation

Management of compartment syndromes of the foot.

Compartment syndrome of the foot after intraarticular calcaneal fracture.

Ankle and foot fasciotomy: an adjunctive technique to optimize limb salvage after revascularization for acute ischemia.

Compartment syndromes of the foot after calcaneal fractures.

Compartment syndrome of the foot in children [see comments].

Technique Tip: Use of “Pie Crusting” of the Dorsal Skin in Severe Foot Injury

Acute Foot Compartment Syndromes

Compartment syndrome of the foot. A case report.

Plantar fascial spaces of the foot and  proposed surgical approach.  

Experimental decompression of the fascial compartments of the foot--the basis for fasciotomy in acute compartment syndromes.

Acute compartment syndromes of the foot.

Cavus deformity of the foot after  fracture of the tibial shaft.  

The deep posterior compartmental syndrome of the leg.

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