Compartment Syndrome of the Foot: Difference between revisions

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== Definition/Description  ==
== Definition/Description  ==


A compartment syndrome is a condition in which there arises a swelling in the body in areas surrounded by non-expandable structures. A compartment syndrome occurs when the muscles are compressed together along with nerves and blood vessels in a compartment. This compartment syndrome and also the swelling that follows usually occurs as a result of a bone fracture in the foot or as a compression of the foot itself. The swelling that occurs causes ,in most cases, a pinching of the surrounding nerves and blood vessels and thus causes a reduction in the blood circulation of the tissues. In order to avoid the risk at losing function maintenance and damage of the tissues, there should be performed a pressure relief. <ref name="Frink M et al.">Frink M, Hildebrand F. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res. 2010 Apr; 468(4): 940-950.</ref><ref name="Abraham et al.">Abraham T Rasul Jr. Compartment syndrome. eMedicine. 11 March 2009; Level of evidence: A1</ref><br>
Compartment syndrome is a condition where bleeding or edema develops in an area of the body which is  surrounded by non-expandable structures of bone and fascia, increasing the local pressure and causing circulatory disturbance in that space. This can lead to ischaemia and necrosis if left improperly diagnosed.The cause is usually following acute trauma<ref name=":0">Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. [https://link.springer.com/article/10.1007/s11999-009-0891-x Compartment syndrome of the lower leg and foot.] Clinical Orthopaedics and Related Research 2010;468(4):940-50. </ref> or it can be due to intense or overly frequent exercise (chronic exertional compartment syndrome) or overly tight casts. Fasciotomy is usually performed although non surgical treatment is also an option.<ref name=":0" /><ref name="Abraham et al.">Medscape. Acute compartment syndrome. Available from: https://emedicine.medscape.com/article/307668-overview (accessed 06/04/2020).</ref>
 
== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


Anatomical studies of muscles and tendons show that the foot is divided into 4 large compartments (interosseous, medial, lateral, central) each including muscles, nerves and arteries. Early researches identified 9 compartments. However, it is very impractical to divide the foot into more than four compartments. That’s why most of the recent studies still refer to the foot as a whole of four compartments.<ref name="BRON 2">Haddad S L, Managing risk: compartment syndromes of the foot. American Academy of Orthopaedics Surgeons, Jan/Feb 2007 http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp (accessed on november/december 2010) Level of evidence: A1</ref><br>  
The [[Foot Anatomy|foot]] is divided into 4 large compartments (interosseous, medial, lateral, central) each including muscles, nerves and arteries, although it is debated whether there are actually 9 compartments, however, it is more practical to think of the foot in 4 compartments.<ref name="BRON 2">Ortho Info. Compartment syndrome. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/compartment-syndrome/ (accessed 04/06/2020). </ref>  


There are only three compartments such as medial, lateral and superficial that run the entire length of the foot. Later four compartments were described. Patients who develops progressive claw-toe deformities due to calcaneal fractures, are given a compartment (calcaneal compartment).  
There are three compartments, medial, lateral and superficial that run the entire length of the [[Foot Anatomy|foot]]. although a 4th, the calcaneal compartment has been described in patients who develop progressive claw-toe deformities due to [[Calcaneal Fractures|calcaneal fractures]], [[File:C3.jpg|thumb]]


The barrier between the flexor digitorum brevis and the calcaneal compartment (quadratus plantae) become incompetent at a pressure gradient of less than 10mm Hg. That means the barrier won’t impair tissue perfusion and allow an independent compartment syndrome. <ref name="Guyton et al.">Guyton GP, Shearman CM, Saltzman CL. The compartments of the foot revisited. Rethinking the validity of cadaver infusion experiments. J Bone Joint Surg Br. 2001;83:245–249.</ref><ref name="Manoli A et al.">Manoli A, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle. 1990;10:267–275.</ref>  
The boundary between flexor digitorum brevis and the calcaneal compartment ([[Quadratus Plantae|quadratus plantae]]) becomes incompetent at a pressure gradient of less than 10mm Hg, so tissue perfusion becomes insignificant, effectively creating an independent compartment syndrome.<ref name="Guyton et al.">Guyton GP, Shearman CM, Saltzman CL. [https://pdfs.semanticscholar.org/6280/3847824176a1b538fc9082ff2219d09584bf.pdf The compartments of the foot revisited: rethinking the validity of cadaver infusion experiments.] The Journal of bone and joint surgery, British volume 2001;83(2):245-9.</ref><ref name="Manoli A et al." />  


{| border="1" cellspacing="1" cellpadding="1" width="100%"
{| border="1" cellspacing="1" cellpadding="1" width="100%"
|-
|-
| valign="top" width="250" align="left" | '''Interosseous compartment:'''  
| valign="top" width="250" align="left" | '''Interosseous compartment'''  
*Dorsal interossei muscles  
*Dorsal interossei muscles  
*Plantar interossei muscles  
*Plantar interossei muscles  
Line 25: Line 24:
'''<br>'''  
'''<br>'''  


| valign="middle" width="250" align="left" | '''Medial compartment:'''<br>
| valign="middle" width="250" align="left" | '''Medial compartment'''
Abductor hallucis  
* Abductor hallucis  
 
* Flexor hallucis brevis  
*Flexor hallucis brevis  
*Tendon of flexor hallucis brevis  
*Tendon of flexor hallucis brevis  
*Medial plantar arteries, veins and nerves
*Medial plantar arteries, veins and nerves
<br>  
<br>  


|-
|-
| valign="top" width="250" align="left" | '''Lateral compartment:'''<br>
| valign="top" width="250" align="left" | '''Lateral compartment:'''
Abductor digiti minimi/quinti  
* [[Abductor Digiti Minimi (Foot)|Abductor digiti minimi]]/quinti  
 
* Flexor digiti minimi  
*Flexor digiti minimi  
*Opponens digiti minimi  
*Opponens digiti minimi  
*Branches of the lateral plantar artery vein and nerve
*Branches of the lateral plantar artery vein and nerve
<br>  
<br>  


| valign="top" width="250" align="left" | '''Central compartment''' '''(3 levels):'''<br>
| valign="top" width="250" align="left" | '''Central compartment''' '''(3 levels)'''
<u>First level:</u> Adductor hallucis  
* <u>First level:</u> Adductor hallucis  
 
* <u>Second level:</u> [[Quadratus Plantae|Quadratus plantae]]; lumbrical muscles; tendons of [[flexor digitorum longus]]
*<u>Second level:</u> Quadratus plantae  
*Lumbrical muscles  
*Tendons of flexor digitorum longus  
*<u>Third level:</u> Flexor digitorum brevis  
*<u>Third level:</u> Flexor digitorum brevis  
*All levels of the central compartment contain (deep) branches of the plantar lateral artery, vein and nerve<br>
*All levels of the central compartment contain (deep) branches of the plantar lateral artery, vein and nerve<br>


|}
|}
<ref name="BRON 1">Schünke M, Schulte E, Schumacher U, Voll M, Wesker K. Prometheus. Bohn Stafleu Van Loghum, Houten 2005. Pg 463</ref>
== Epidemiology /Etiology&nbsp;  ==
== Epidemiology /Etiology&nbsp;  ==


[[Image:Compartments of the foot-14E9C44BFB5786DE26D.jpg|thumb|right|300x300px]]  
[[Image:Compartments of the foot-14E9C44BFB5786DE26D.jpg|thumb|right|300x300px]]  


Compartment syndrome of the foot is a syndrome with a low incidence and means that there is a higher than normal pressure in at least one of the 9 compartments of the foot. The calcaneal compartment seems to be at higher risk for developing the compartment syndrome, whereas the interosseous compartments are possibly at lower risk. Therefore, extra attention should be directed at the calcaneal compartment.<ref name="Frink M et al.">Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment syndrome of the lower leg and foot. The Association of bone and joint surgeons. 27 may 2009</ref><ref name="Manoli A et al.">Manoli A, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle. 1990;10:267–275.</ref><ref name="Myerson et al.">Myerson, M. S. (1991). Management of compartment syndromes of the foot. Clinical orthopaedics and related research, 271, 239-248.</ref><ref name="Shereff et al.">Shereff, M. J. (1990). Compartment syndromes of the foot. Instructional course lectures, 39, 127.</ref>
Incidence of compartment syndrome of the foot is low. The calcaneal compartment seems to be at higher risk for developing compartment syndrome, whereas the interosseous compartments are usually at a lower risk.<ref name=":0" /><ref name="Manoli A et al.">Manoli A, Weber TG. [https://journals.sagepub.com/doi/abs/10.1177/107110079001000505 Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment.] Foot Ankle 1990;10:267–275.</ref><ref name="Myerson et al.">Myerson MS. [https://europepmc.org/article/med/1680591 Management of compartment syndromes of the foot.] Clinical orthopaedics and related research 1991(271):239-48.</ref><ref name="Shereff et al.">Shereff MJ. [https://europepmc.org/article/med/1970832 Compartment syndromes of the foot.] Instructional course lectures 1990;39:127-32.</ref>  
 
Chronic (exertional) compartment syndromes take place when athletes make too many efforts during a sport causing an overuse injury. The muscles get tired and irritated resulting in an inflammation and swelling. Sports like soccer, biking, running, tennis, gymnastics can be risk factors.<ref name="BRON 8">http://www.physioadvisor.com.au/10513350/compartment-syndrome-chronic-compartment-syndrom.htm</ref>
 
It is possible that athletes don’t have the appropriate training program so that they overstrain their muscles. Use of inappropriate footwear.<ref name="BRON 10">http://orthoinfo.aaos.org/topic.cfm?topic=a00204</ref><br>Other causes can be biomechanical faults in a person’s anatomy.<ref name="BRON 8" /> Limb length differences, muscle weakness, tightness in specific joints etc
 
Acute compartment syndromes can be produced by many different events. Crush injuries cover the majority of compartment syndromes of the foot<ref name="BRON 2" />, next to this fact one notices snake bites, burns, [[Metatarsal Fractures|metatarsal fractures]], talus or calcaneus fractures, dislocation of the Chopart and/or Lisfranc joints etc.<ref name="BRON 2" /> <ref name="BRON 3" />


Steroids: Using steroids or creatine makes the muscles increase in volume.<ref name="BRON 7">Tucker Alicia K. Chronic exertional compartment syndrome of the leg. Current Reviews in Musculoskeletal Medicine. 2 September 2010 http://ukpmc.ac.uk/articles/PMC2941579/ (accessed on november/december 2010) Level of evidence: A1</ref>&nbsp;
Chronic (exertional) compartment syndrome can develop through over exertion during sporting activity. The muscles become fatigued and irritated resulting in an inflammatory response and swelling. Sports like football, motorcross, running, tennis and gymnastics can be risk factors.<ref name="BRON 8">Physio Adviser. Compartment Syndrome (Deep Posterior). Available from: http://www.physioadvisor.com.au/10513350/compartment-syndrome-chronic-compartment-syndrom.htm (accessed 06/04/2020).</ref> Training programmes may be inappropriate or incorrect footwear could be a cause.<ref name="BRON 2" /> Other causes can be biomechanical abnormailities, limb length differences, muscle weakness or muscular tightness.<ref name="BRON 8" />
 
Bandages: If a tape, bandage or cast is too tight fitted, it may lead to a [[Compartment Syndrome|compartment syndrome]].


Crush injuries are the most common cause of compartment syndromes of the foot <ref name="BRON 2" />, as well as snake bites, burns, too tightly fitted bandages or casts, [[Metatarsal Fractures|metatarsal fractures]], [[talus]] or [[Calcaneal Fractures|calcaneus fractures]], [[Chopart fracture-dislocation|Chopart]] and/or [[Lisfranc Injuries|Lisfranc joint dislocations]],<ref name="BRON 2" /> steroid or creatine use which can cause muscles to increase in volume.<ref name="BRON 7">Tucker Alicia K. Chronic exertional compartment syndrome of the leg. Current Reviews in Musculoskeletal Medicine. 2 September 2010 http://ukpmc.ac.uk/articles/PMC2941579/ (accessed on november/december 2010) Level of evidence: A1</ref>&nbsp;
== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


As in almost any disease/injury, pain is also one of the key symptoms for the compartment syndrome of the foot. The pain will occur when the patient does active exercises, When he/she continues exercising, the pain-intensity will increase. After a resting period, the pain and tightness resolve. The most patients typically describe this kind of pain as an aching and burning pain.<ref name="Tucker Alicia K. et al.">Tucker Alicia K. Chronic exertional compartment syndrome of the leg. Current Reviews in Musculoskeletal Medicine. 2 September 2010</ref>  
Pain is one of the key symptoms for compartment syndrome, being severe and spontaneous or occurring during active exercises, often increasing in intensity as the activity continues, only resolving on rest. Typically, the pain is described as an aching and/or burning sensation.<ref name="Tucker Alicia K. et al." />  


'''Pain during certain movements:<ref name="Tucker Alicia K. et al.">Tucker Alicia K. Chronic exertional compartment syndrome of the leg. Current Reviews in Musculoskeletal Medicine. 2 September 2010</ref><ref name="Frink M et al.">Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment syndrome of the lower leg and foot. The Association of bone and joint surgeons. 27 may 2009</ref><ref name="Ulmer T. et al.">Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder?&amp;amp;amp;amp;amp;amp;amp;amp;nbsp;J Orthop Trauma.&amp;amp;amp;amp;amp;amp;amp;amp;nbsp;2002;16:572–577. doi: 10.1097/00005131-200209000-00006.</ref><ref name="Abraham T. et al.">Abraham T Rasul Jr. Compartment syndrome. eMedicine. 11 March 2009</ref>'''
'''Movement usually eliciting pain:'''<ref name=":0" /><ref name="Abraham et al." /><ref name="Tucker Alicia K. et al." /><ref name="Ulmer T. et al.">Ulmer T. [https://journals.lww.com/jorthotrauma/Abstract/2002/09000/The_Clinical_Diagnosis_of_Compartment_Syndrome_of.6.aspx The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder?] Journal of orthopaedic trauma 2002;16(8):572-7. </ref>  


*Pain with passive stretching  
*Pain with passive stretching  
*Pain during active (dorsi)flexion of the foot
*Pain during active dorsiflexion of the [[Ankle Joint|ankle]]
*Enlarged soreness caused by moving the toes  
*Increased soreness caused by moving the toes  
*Pain while palpating or squeezing the affected compartments<ref name="Schünke M. et al.">Schünke M, Schulte E, Schumacher U, Voll M, Wesker K. Prometheus. Bohn Stafleu Van Loghum, Houten 2010.</ref>
*Pain on palpation or compressing the affected compartments


'''Other relevant sings:<ref name="Tucker Alicia K. et al.">Tucker Alicia K. Chronic exertional compartment syndrome of the leg. Current Reviews in Musculoskeletal Medicine. 2 September 2010</ref><ref name="Frink M et al.">Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment syndrome of the lower leg and foot. The Association of bone and joint surgeons. 27 may 2009</ref><ref name="Ulmer T. et al.">Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder?&amp;amp;amp;amp;amp;amp;amp;amp;nbsp;J Orthop Trauma.&amp;amp;amp;amp;amp;amp;amp;amp;nbsp;2002;16:572–577. doi: 10.1097/00005131-200209000-00006.</ref><ref name="Abraham T. et al.">Abraham T Rasul Jr. Compartment syndrome. eMedicine. 11 March 2009</ref>'''
'''Other relevant signs:'''<ref name=":0" /><ref name="Abraham et al." /><ref name="Tucker Alicia K. et al." /><ref name="Ulmer T. et al." />  


*Swelling and tightness  
*Swelling and tightness  
*Pale skin on the spot of tissue damage  
*Pale skin in the area of tissue damage  
*Sensory deficits caused by neurological deficits<ref name="Vaillancourt C. et al.">Vaillancourt C, Shrier I, Vandal A, Falk M, Rossignol M, Vernec A, Somogyi D. Acute compartment syndrome: How long before muscle necrosis occurs? CJEM. 2004;6:147–154.</ref>  
*Sensory deficits caused by neurological injury<ref name="Vaillancourt C. et al.">Vaillancourt C, Shrier I, Vandal A, Falk M, Rossignol M, Vernec A, Somogyi D. [https://www.cambridge.org/core/journals/canadian-journal-of-emergency-medicine/article/acute-compartment-syndrome-how-long-before-muscle-necrosis-occurs/0BC7916DBCB088647ED7266A772D48CF Acute compartment syndrome: how long before muscle necrosis occurs?] Canadian Journal of Emergency Medicine 2004;6(3):147-54.</ref>  
*Firmness of the involved compartments<ref name="Tucker Alicia K. et al.">Tucker Alicia K. Chronic exertional compartment syndrome of the leg. Current Reviews in Musculoskeletal Medicine. 2 September 2010</ref>  
*Firmness of the involved compartments<ref name="Tucker Alicia K. et al." />  
*Muscle weakness with the intrinsic foot muscles<ref name="Tucker Alicia K. et al.">Tucker Alicia K. Chronic exertional compartment syndrome of the leg. Current Reviews in Musculoskeletal Medicine. 2 September 2010</ref> <br>
*Muscle weakness of the intrinsic foot muscles<ref name="Tucker Alicia K. et al.">Tucker AK. [https://link.springer.com/article/10.1007/s12178-010-9065-4 Chronic exertional compartment syndrome of the leg.] Current reviews in musculoskeletal medicine 2010;3(1-4):32-7.</ref>  


'''Considering the 5 P’s''': '''P'''ain, '''P'''allor, '''P'''aresthesia, '''P'''aralysis, '''P'''ulselessness<ref name="BRON 1" /><br>  
The 5 P’s may be considered when diagnosing compartment syndrome: '''P'''ain, '''P'''allor, '''P'''aresthesia, '''P'''aralysis, '''P'''ulselessness <ref name="BRON 1">Schünke M, Schulte E, Schumacher U, Voll M, Wesker K. Prometheus. Bohn Stafleu Van Loghum, Houten 2005. Pg 463</ref>  


== Differential diagnosis ==
== Differential Diagnosis ==


The compartment syndrome is characterized by an increase of the interstitial pressure with severe pain and pain associated with passive stretching of the muscles as a result. Other consequences consist of a reduced supply of blood and fluid supply to tissues. Invasive measurement wherein a needle is placed in the body is considered to be a safe and quick method to determine compartment syndrome.<ref name="Frink M et al.">Frink M, Hildebrand F. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res. 2010 Apr; 468(4): 940-950.</ref>  
Compartment syndrome is characterised by an increase of the interstitial pressure with severe pain and pain associated with passive stretching of the muscles as a result. Other consequences consist of a reduced supply of blood and fluid supply to tissues.<ref name=":0" />  


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


In order to diagnose a compartment syndrome there should be an awareness of the signs and symptoms specific to this syndrome as described above by the surgeon. There should also be appropriate clinical examination.<ref name="Frink M et al.">Frink M, Hildebrand F. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res. 2010 Apr; 468(4): 940-950.</ref><br>If a compartment syndrome is suspected, frequent examination will be needed in the acute phase.<br>Some studies proofs that serial examinations that has to been taken at least every hour, are essential. This is due to muscle necrosis that occurs within 3 hours.<ref name="Vaillancourt C. et al.a">Vaillancourt C, Shrier I, Vandal A, Falk M, Rossignol M, Vernec A, Somogyi D. Acute compartment syndrome: How long before muscle necrosis occurs? CJEM. 2004;6:147–154.</ref>  
Awareness of the signs and symptoms specific to this syndrome are key to an accurate diagnosis, alongside an appropriate clinical examination.<ref name=":0" /> Where compartment syndrome is suspected, frequent examination is required in the acute phase, sometimes hourly, as muscle necrosis can occur within 3 hours.<ref name="Vaillancourt C. et al." />  


A quick and safe procedure to diagnose a compartment syndrome is invasive measurement.<ref name="Whitesides et al.">Whitesides TE, Jr, Haney TC, Harada H, Holmes HE, Morimoto K. A simple method for tissue pressure determination. Arch Surg. 1975;110:1311–1313.</ref> It is also the only valuable test to diagnose this syndrome.&nbsp;Otherwise known as [[Compartment Syndrome|Intracompartmental pressure monitoring]] (ICP).&nbsp;<br>
A quick and safe procedure to diagnose compartment syndrome is invasive measurement.<ref name="Whitesides et al.">Whitesides TE, Haney TC, Harada H, Holmes HE, Morimoto K. [https://jamanetwork.com/journals/jamasurgery/article-abstract/581027 A simple method for tissue pressure determination.] Archives of Surgery 1975;110(11):1311-3.</ref> where a needle is placed into the area, the only valuable test to diagnose this syndrome, otherwise known as [[Compartment Syndrome|intracompartmental pressure monitoring]].&nbsp;  


== Outcome measures  ==
== Outcome measures  ==


The american orthopaedic foot and ankle society scale and the Visual analog scale have been used to measure quality of life after fasciotomy.<ref name="Han F. et al.">Han, F., Daruwalla, Z. J., Shen, L., &amp;amp;amp;amp;amp;amp;amp;amp;amp; Kumar, V. P. (2015). A prospective study of surgical outcomes and quality of life in severe foot trauma and associated compartment syndrome after fasciotomy. The Journal of Foot and Ankle Surgery, 54(3), 417-423.</ref>  
Foot and Ankle visual analog scale from the American Orthopaedic Foot and Ankle Society measures the quality of life after fasciotomy.<ref name="Han F. et al.">Han F, Daruwalla ZJ, Shen L, Kumar VP. [https://www.sciencedirect.com/science/article/pii/S106725161400444X A prospective study of surgical outcomes and quality of life in severe foot trauma and associated compartment syndrome after fasciotomy.] The Journal of Foot and Ankle Surgery 2015;54(3):417-23.</ref>  


== Physical examination ==
== Physical Examination ==


The physical examination starts with the inspection. The physical therapist makes the comparison of the affected foot to the unaffected foot. In this phase of the examination, special attention needs to be paid to the specific symptoms which are described above. After inspection the therapist should examine the pain level by performing palpation and motion tests on the patient.  
Awareness of the complication, an appropriate clinical examination, comparison of the affected foot to the unaffected foot with attention to the syndrome's specific symptoms are most important. Pain levels are assessed through palpation and active and passive range of motion tests on the patient.  


'''Physical relevant findings that may occur for compartment syndrome:<ref name="Guyton et al.">Guyton GP, Shearman CM, Saltzman CL. The compartments of the foot revisited. Rethinking the validity of cadaver infusion experiments. J Bone Joint Surg Br. 2001;83:245–249.</ref><ref name="Frink M et al.">Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment syndrome of the lower leg and foot. The Association of bone and joint surgeons. 27 may 2009</ref>'''
'''Physically relevant findings that may occur for compartment syndrome:'''<ref name=":0" /><ref name="Guyton et al." />  


*Weakness of dorsiflexion (anterior compartment)  
*Weak dorsiflexion (anterior compartment)  
*Weakness of eversion (lateral compartment)  
*Weak eversion (lateral compartment)  
*Weakness of plantar flexion (posterior compartment)
*Weak plantar flexion (posterior compartment)


Although diagnostic devices are commercially available a complete and careful examination of patients suspected for compartment syndrome is necessary. However, the most important step in diagnosing a compartment syndrome is the surgeon’s awareness of this complication and appropriate clinical examination.<ref name="Frink M et al.">Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment syndrome of the lower leg and foot. The Association of bone and joint surgeons. 27 may 2009</ref> <br>
== Medical Management  ==


Although this physical examination gives us a lot information, it isn’t enough to diagnose the compartment syndrome. Therefore a complete and careful clinical examination needs to be carried out by a doctor.  
It is necessary to immediately carry out a fasciotomy in order to remove the excess pressure. A cast or brace can be used, but they should be left open for patients with severe pain and/or excess pressure in the affected compartment. Affected limbs should not be raised in order to not affect the already impaired blood flow any further.<ref name=":0" />


== Medical Management <br>  ==
Emergency&nbsp;decompressive fasciotomy is conducted with an acute compartment syndrome.&nbsp;


After determinating a compartment syndrome it is necessary to immediately carry out a fasciotomy in order to remove the excess pressure. A cast or brace can be used, but they should be left open for patients with severe pain and/or excess pressure in the affected compartment. Affected limbs should not be lifted in order to not affect the already impaired blood flow any more. (level of evidence 3b)<ref name="Frink M et al.">Frink M, Hildebrand F. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res. 2010 Apr; 468(4): 940-950.</ref>
*'''Indication: '''when the intracompartmental pressure measurement has an absolute value of 30-45 mm Hg.  
 
Emergency&nbsp;decompressive fasciotomy is being conducted in acute compartment syndrome.&nbsp;
 
*'''Indication: '''decompressive fasciotomy is indicated when the intracompartmental pressure measurement with absolute value of 30-45 mm Hg.  
*'''Techniques: '''  
*'''Techniques: '''  
**Dual dorsal incision is a gold standard technique, in which dorsal medial and lateral incision approach is being applied to release the compartments.  
**Dual dorsal incision is the  gold standard technique. A dorsal medial and lateral incision is made to release the compartments.  
**Single medial incision is applied through medial approach to release all compartments but it is technically challenging.  
**A single medial incision is used to release all compartments, but it is technically more challenging.  
*'''Complications:''' following fasciotomy care must be taken, otherwise chronic pain and hypersensitivity are the complications difficult to manage. Sometimes claw toes (fixed flexion deformity of digits) develops.<ref name="kardsheh M">Karadsheh M. Foot Compartment Syndrome. http://www.orthobullets.com (accessed 27 December 2016).</ref>
**'''Complications:''' chronic pain and hypersensitivity are possible complications and can be difficult to manage. Sometimes claw toes develops.<ref name="kardsheh M">Ortho Bullets. Foot Compartment Syndrome. Available from: https://www.orthobullets.com/trauma/1065/foot-compartment-syndrome (accessed 27/12/2016).</ref>  
 
== Physical Therapy Management <br>  ==
 
Overall nonoperative treatment has been generally unsuccessful.<ref name="BRON 13">Matthew R. Bong, M.D., Daniel B. Polatsch, M.D., Laith M. Jazrawi, M.D. and Andrew S. Rokito, M.D. Chronic Exertional Compartment Syndrome. Diagnosis and Management. Bulletin, Hospital for joint diseases. Volume 62, N° 3, 4. 2005 Level of evidence: B</ref>&nbsp; After undergoing an operation the patient gets the advice to use ice packs and anti-inflammatory medication to reduce the swelling and to get enough rest. A physiotherapist can provide postoperative exercises to improve the muscle weakness and stimulate proprioceptive sensors. (Level of evidence 1b)  
 
'''Soft tissue massage '''<ref name="BRON 8" />
 
*Effleurages, petrissages
*Lymphatic drainage
 
'''Passive mobilization of the ankle joint, the metatarsals and phalanges&nbsp;'''<ref name="BRON 8" /> <br>
 
*Tractions
 
'''Use of orthotics&nbsp;'''<ref name="BRON 8" />&nbsp;<ref name="BRON 10" /><br>To correct biomechanical defaults<br>For example: orthopedic soles for pronated feet, flat feet etc.
 
'''Stretch exercises to improve flexibility&nbsp;'''<ref name="BRON 9">http://www.physioadvisor.com.au/8047989/ankle-flexibility-exercises-ankle-sprains-ankle.htm</ref>
 
*Dorsal and plantar flexion - Let the patient move the feet up and down as far as possible. Repeating 10-20 times. <br>
*2.Inversion and eversion - Let the patient move the feet in and out as far as possible. Repeating 10-20 times.&nbsp;
*3. Rotation - Let the patient move the feet in circles as large as possible. Repeating 10-20 times.<br>


'''Strength exercises for intrinsic foot muscles'''
== Physiotherapy Management  ==


*Toe curl: Place a towel beneath the feet of the patient; he must pull the towel towards him by curling his toes into the towel. <ref name="BRON 11" />  
Non-operative treatment is generally not successful.<ref name="BRON 13">Bong MR, Polatsch DB, Jazrawi LM, Rokito AS. [https://pdfs.semanticscholar.org/e36f/04d74152ef531e43a1828b1075a79003ee20.pdf Chronic Exertional Compartment Syndrome.] Bulletin of the NYU Hospital for Joint Diseases 2005;62. </ref>&nbsp;Post-operatively, patients are advised to use ice and anti-inflammatory medication to reduce swelling and to rest. An exercise programme is given to improve muscle weakness and to stimulate [[Proprioception|proprioceptive]] sensors.
*&nbsp;Picking up marbles or other small objects: The patient has to claw his toes to be able to pick up the object from the floor.  
*Walking: Early postoperative exercises involve walking with crutches. Once the patient can painless put weight on his foot and is comfortable in proper shoes, he/she may start to walk.  
*Toe squeeze: Put some soft objects between the toes of the patient. Now he/she has to squeeze the toes and hold for 5 seconds, repeating 10 times.  
*Toe raises, toe curls: to improve dorsal and plantar flexion of the toes, the patient can actively move the toes up and down. This exercise can be performed dynamic or static.  
*Strength exercise for plantar flexion: rotations of the feet (feet must be kept together during the exercise) <ref name="BRON 11" />  
*Strength exercise for dorsal flexion: cycling in the air, feet must unroll properly.<ref name="BRON 11" />
*Resistance band exercise: the patient can practice dorsal and plantar flexion, inversion and eversion. <ref name="BRON 9" />


'''A low-key return to activities <ref name="BRON 13" />'''
[[Massage|Soft tissue massage]]<ref name="BRON 8" /> may be used to provide lymphatic drainage. Passive mobilisation of the ankle joint, the metatarsals and phalanges<ref name="BRON 8" /> is useful for increased range of motion and mobility of joints along with lower limb stretches.


*Walking
Orthotics<ref name="BRON 2" /><ref name="BRON 8" /> can be prescribed where there are biomechanical defaults. <br>


How far can the patient rely on his feet?<br>In case of immobilization, the patient learns to walk with two crutches (no support on foot), with 1 crutch and eventually walk without crutches.
'''Recommended strength exercises for the intrinsic foot muscles:'''


*When the patient can walk pain free, he/she can start constructive running.
*Toe curl:  Place a towel beneath the feet of the patient and ask them to pull the towel towards them by curling the toes into the towel.
*Once the patient can run pain free, he/she may participate other sports.
*Picking up marbles or other small objects:  The patient has to claw their toes to be able to pick up the object from the floor.
*Walking:  Early post-operative exercises include mobilising with [[crutches]], gradually progressing to full weight bearing 
*Toe squeeze:  Soft objects are squeezed between the toes and held for 5 seconds
*Toe raises, toe curls 
*Dorsal and plantar flexion, inversion and eversion using a resistance band<ref name="BRON 9">Physio Adviser. Ankle stretches. Available from:http://www.physioadvisor.com.au/8047989/ankle-flexibility-exercises-ankle-sprains-ankle.htm (accessed 06/04/2020).</ref>


'''''Important!''&nbsp;'''If pain or swelling occurs during or after exercise, elevate the foot and use ice packs to reduce the swelling.<br>
If pain or swelling occurs during or after exercise, elevate the foot and use ice to reduce the swelling.  
 
<u><div class="researchbox"></div></u>


== Clinical Bottom Line  ==
== Clinical Bottom Line  ==


A compartment syndrome needs an immediate surgical treatment. Patients with severe postoperative pain, must be completely opened their tissue, to release extracorporal pressure. A diagnosed compartment syndrome needs immediate fasciotomy to release pressure from the affected compartment.<ref name="Frink M et al.">Frink M, Hildebrand F. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res. 2010 Apr; 468(4): 940-950.</ref>  
Compartment syndrome needs immediate surgical treatment to avoid ischemia, possible functional impairment and/or potential nerve damage of the foot.<ref name=":0" />  
 
== References<br> ==


<references /><br>
== References  ==


[[Category:Vrije_Universiteit_Brussel_Project]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]] [[Category:Foot]] [[Category:Foot_and_Ankle_Conditions]]
<references />[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]
[[Category:Foot]]
[[Category:Conditions]]
[[Category:Foot - Conditions]]
[[Category:Sports Medicine]]
[[Category:Acute Care]]

Latest revision as of 17:16, 6 April 2020

Original Editors - Jessie Tourwe

Top Contributors - Jessie Tourwe, Scott Cornish, Admin, Shaimaa Eldib, Tomer Yona, Rachael Lowe, Kim Jackson, Samrah khan, Karen Wilson, Leana Louw, Kevin Vandebroucq, Wanda van Niekerk, 127.0.0.1 and Sigrid Bortels  

Definition/Description[edit | edit source]

Compartment syndrome is a condition where bleeding or edema develops in an area of the body which is surrounded by non-expandable structures of bone and fascia, increasing the local pressure and causing circulatory disturbance in that space. This can lead to ischaemia and necrosis if left improperly diagnosed.The cause is usually following acute trauma[1] or it can be due to intense or overly frequent exercise (chronic exertional compartment syndrome) or overly tight casts. Fasciotomy is usually performed although non surgical treatment is also an option.[1][2]

Clinically Relevant Anatomy[edit | edit source]

The foot is divided into 4 large compartments (interosseous, medial, lateral, central) each including muscles, nerves and arteries, although it is debated whether there are actually 9 compartments, however, it is more practical to think of the foot in 4 compartments.[3]

There are three compartments, medial, lateral and superficial that run the entire length of the foot. although a 4th, the calcaneal compartment has been described in patients who develop progressive claw-toe deformities due to calcaneal fractures,

C3.jpg

The boundary between flexor digitorum brevis and the calcaneal compartment (quadratus plantae) becomes incompetent at a pressure gradient of less than 10mm Hg, so tissue perfusion becomes insignificant, effectively creating an independent compartment syndrome.[4][5]

Interosseous compartment
  • Dorsal interossei muscles
  • Plantar interossei muscles
  • Plantar lateral artery, vein and nerve

Medial compartment
  • Abductor hallucis
  • Flexor hallucis brevis
  • Tendon of flexor hallucis brevis
  • Medial plantar arteries, veins and nerves


Lateral compartment:
  • Abductor digiti minimi/quinti
  • Flexor digiti minimi
  • Opponens digiti minimi
  • Branches of the lateral plantar artery vein and nerve


 Central compartment (3 levels)
  • First level: Adductor hallucis
  • Second level: Quadratus plantae; lumbrical muscles; tendons of flexor digitorum longus
  • Third level: Flexor digitorum brevis
  • All levels of the central compartment contain (deep) branches of the plantar lateral artery, vein and nerve

Epidemiology /Etiology [edit | edit source]

Compartments of the foot-14E9C44BFB5786DE26D.jpg

Incidence of compartment syndrome of the foot is low. The calcaneal compartment seems to be at higher risk for developing compartment syndrome, whereas the interosseous compartments are usually at a lower risk.[1][5][6][7]

Chronic (exertional) compartment syndrome can develop through over exertion during sporting activity. The muscles become fatigued and irritated resulting in an inflammatory response and swelling. Sports like football, motorcross, running, tennis and gymnastics can be risk factors.[8] Training programmes may be inappropriate or incorrect footwear could be a cause.[3] Other causes can be biomechanical abnormailities, limb length differences, muscle weakness or muscular tightness.[8]

Crush injuries are the most common cause of compartment syndromes of the foot [3], as well as snake bites, burns, too tightly fitted bandages or casts, metatarsal fractures, talus or calcaneus fractures, Chopart and/or Lisfranc joint dislocations,[3] steroid or creatine use which can cause muscles to increase in volume.[9] 

Characteristics/Clinical Presentation[edit | edit source]

Pain is one of the key symptoms for compartment syndrome, being severe and spontaneous or occurring during active exercises, often increasing in intensity as the activity continues, only resolving on rest. Typically, the pain is described as an aching and/or burning sensation.[10]

Movement usually eliciting pain:[1][2][10][11]

  • Pain with passive stretching
  • Pain during active dorsiflexion of the ankle
  • Increased soreness caused by moving the toes
  • Pain on palpation or compressing the affected compartments

Other relevant signs:[1][2][10][11]

  • Swelling and tightness
  • Pale skin in the area of tissue damage
  • Sensory deficits caused by neurological injury[12]
  • Firmness of the involved compartments[10]
  • Muscle weakness of the intrinsic foot muscles[10]

The 5 P’s may be considered when diagnosing compartment syndrome: Pain, Pallor, Paresthesia, Paralysis, Pulselessness [13]

Differential Diagnosis[edit | edit source]

Compartment syndrome is characterised by an increase of the interstitial pressure with severe pain and pain associated with passive stretching of the muscles as a result. Other consequences consist of a reduced supply of blood and fluid supply to tissues.[1]

Diagnostic Procedures[edit | edit source]

Awareness of the signs and symptoms specific to this syndrome are key to an accurate diagnosis, alongside an appropriate clinical examination.[1] Where compartment syndrome is suspected, frequent examination is required in the acute phase, sometimes hourly, as muscle necrosis can occur within 3 hours.[12]

A quick and safe procedure to diagnose compartment syndrome is invasive measurement.[14] where a needle is placed into the area, the only valuable test to diagnose this syndrome, otherwise known as intracompartmental pressure monitoring. 

Outcome measures[edit | edit source]

Foot and Ankle visual analog scale from the American Orthopaedic Foot and Ankle Society measures the quality of life after fasciotomy.[15]

Physical Examination[edit | edit source]

Awareness of the complication, an appropriate clinical examination, comparison of the affected foot to the unaffected foot with attention to the syndrome's specific symptoms are most important. Pain levels are assessed through palpation and active and passive range of motion tests on the patient.

Physically relevant findings that may occur for compartment syndrome:[1][4]

  • Weak dorsiflexion (anterior compartment)
  • Weak eversion (lateral compartment)
  • Weak plantar flexion (posterior compartment)

Medical Management[edit | edit source]

It is necessary to immediately carry out a fasciotomy in order to remove the excess pressure. A cast or brace can be used, but they should be left open for patients with severe pain and/or excess pressure in the affected compartment. Affected limbs should not be raised in order to not affect the already impaired blood flow any further.[1]

Emergency decompressive fasciotomy is conducted with an acute compartment syndrome. 

  • Indication: when the intracompartmental pressure measurement has an absolute value of 30-45 mm Hg.
  • Techniques:
    • Dual dorsal incision is the gold standard technique. A dorsal medial and lateral incision is made to release the compartments.
    • A single medial incision is used to release all compartments, but it is technically more challenging.
    • Complications: chronic pain and hypersensitivity are possible complications and can be difficult to manage. Sometimes claw toes develops.[16]

Physiotherapy Management[edit | edit source]

Non-operative treatment is generally not successful.[17] Post-operatively, patients are advised to use ice and anti-inflammatory medication to reduce swelling and to rest. An exercise programme is given to improve muscle weakness and to stimulate proprioceptive sensors.

Soft tissue massage[8] may be used to provide lymphatic drainage. Passive mobilisation of the ankle joint, the metatarsals and phalanges[8] is useful for increased range of motion and mobility of joints along with lower limb stretches.

Orthotics[3][8] can be prescribed where there are biomechanical defaults.

Recommended strength exercises for the intrinsic foot muscles:

  • Toe curl: Place a towel beneath the feet of the patient and ask them to pull the towel towards them by curling the toes into the towel.
  • Picking up marbles or other small objects: The patient has to claw their toes to be able to pick up the object from the floor.
  • Walking: Early post-operative exercises include mobilising with crutches, gradually progressing to full weight bearing
  • Toe squeeze: Soft objects are squeezed between the toes and held for 5 seconds
  • Toe raises, toe curls
  • Dorsal and plantar flexion, inversion and eversion using a resistance band[18]

If pain or swelling occurs during or after exercise, elevate the foot and use ice to reduce the swelling.

Clinical Bottom Line[edit | edit source]

Compartment syndrome needs immediate surgical treatment to avoid ischemia, possible functional impairment and/or potential nerve damage of the foot.[1]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment syndrome of the lower leg and foot. Clinical Orthopaedics and Related Research 2010;468(4):940-50.
  2. ↑ 2.0 2.1 2.2 Medscape. Acute compartment syndrome. Available from: https://emedicine.medscape.com/article/307668-overview (accessed 06/04/2020).
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Ortho Info. Compartment syndrome. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/compartment-syndrome/ (accessed 04/06/2020).
  4. ↑ 4.0 4.1 Guyton GP, Shearman CM, Saltzman CL. The compartments of the foot revisited: rethinking the validity of cadaver infusion experiments. The Journal of bone and joint surgery, British volume 2001;83(2):245-9.
  5. ↑ 5.0 5.1 Manoli A, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle 1990;10:267–275.
  6. ↑ Myerson MS. Management of compartment syndromes of the foot. Clinical orthopaedics and related research 1991(271):239-48.
  7. ↑ Shereff MJ. Compartment syndromes of the foot. Instructional course lectures 1990;39:127-32.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Physio Adviser. Compartment Syndrome (Deep Posterior). Available from: http://www.physioadvisor.com.au/10513350/compartment-syndrome-chronic-compartment-syndrom.htm (accessed 06/04/2020).
  9. ↑ Tucker Alicia K. Chronic exertional compartment syndrome of the leg. Current Reviews in Musculoskeletal Medicine. 2 September 2010 http://ukpmc.ac.uk/articles/PMC2941579/ (accessed on november/december 2010) Level of evidence: A1
  10. ↑ 10.0 10.1 10.2 10.3 10.4 Tucker AK. Chronic exertional compartment syndrome of the leg. Current reviews in musculoskeletal medicine 2010;3(1-4):32-7.
  11. ↑ 11.0 11.1 Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? Journal of orthopaedic trauma 2002;16(8):572-7.
  12. ↑ 12.0 12.1 Vaillancourt C, Shrier I, Vandal A, Falk M, Rossignol M, Vernec A, Somogyi D. Acute compartment syndrome: how long before muscle necrosis occurs? Canadian Journal of Emergency Medicine 2004;6(3):147-54.
  13. ↑ Schünke M, Schulte E, Schumacher U, Voll M, Wesker K. Prometheus. Bohn Stafleu Van Loghum, Houten 2005. Pg 463
  14. ↑ Whitesides TE, Haney TC, Harada H, Holmes HE, Morimoto K. A simple method for tissue pressure determination. Archives of Surgery 1975;110(11):1311-3.
  15. ↑ Han F, Daruwalla ZJ, Shen L, Kumar VP. A prospective study of surgical outcomes and quality of life in severe foot trauma and associated compartment syndrome after fasciotomy. The Journal of Foot and Ankle Surgery 2015;54(3):417-23.
  16. ↑ Ortho Bullets. Foot Compartment Syndrome. Available from: https://www.orthobullets.com/trauma/1065/foot-compartment-syndrome (accessed 27/12/2016).
  17. ↑ Bong MR, Polatsch DB, Jazrawi LM, Rokito AS. Chronic Exertional Compartment Syndrome. Bulletin of the NYU Hospital for Joint Diseases 2005;62.
  18. ↑ Physio Adviser. Ankle stretches. Available from:http://www.physioadvisor.com.au/8047989/ankle-flexibility-exercises-ankle-sprains-ankle.htm (accessed 06/04/2020).
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