Compartment Syndrome of the Foot

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Original Editors - Jessie Tourwe

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Search Strategy 

Databases searched: Pubmed, PEDro, eMedicine, Medscape
Keywords searched: compartment syndrome foot, lower leg, loge syndrome, crush injuries, treatment compartment syndrome,…

Definition/Description

This syndrome is a condition that can appear in many parts of the body: foot, leg, thigh, forearm, hand, buttocks etc. A compartment syndrome occurs when the muscles along with nerves and blood vessels are compressed in a compartment.
The developing of swelling and/or a hematoma causes the pressure to increase and because the fascia – made of inelastic connective tissue – can’t extend, the blood flow is disrupted. Tissue death can take place if the concentration of oxygen drops too low for too long.

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.

-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 longus Medial plantar arteries, veins and nerves
- Lateral compartment: Abductor digiti minimi 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 

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.
It is possible that athletes don’t have the appropriate training program so that they overstrain their muscles. Use of inappropriate footwear.
Other causes can be biomechanical faults in a person’s anatomy. 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, next to this fact one notices snake bites, burns, metatarsal fractures, talus or calcaneus fractures, dislocation of the Chopart and/or Lisfranc joints etc.
Steroids: Using steroids or creatine makes the muscles increase in volume.

Bandages: If a tape, bandage or cast is too tight fitted, it may lead to a compartment syndrome.

The connective tissue of a compartment is not able to stretch, so when there appears a bleeding or a swelling of the muscles within the compartment, the pressure rises likely.
Normally a non-contracting muscle contains a pressure near zero, nevertheless if the pressure rises up to 30 mmHg, the vessels will be compressed resulting into pain and a reduction of blood flow. Also the lymphatic drainage will activate to prevent the increasing interstitial fluid pressure, when this reached to its maximum; the pressure between the compartments will cause physiological defects such as a nerve dysfunction and deformation. A hemorrhage of an edema causes the interstitial pressures within the soft tissues to increase, creating possible ischemia by loss of capillary refill.
Ischemia starts when the local blood flow can’t fulfill the metabolic demands of the tissues. When a body part is not provided with blood for more than eight hours, the damage is irreversible and may lead to the death of the concerning tissues.

Characteristics/Clinical Presentation

The most specific signs are:
- The skin appears pale and tensely swollen on the spot of tissue damage.
- Pain occurs when squeezing and/or touching the affected compartments.
- Pain when applying passive stretching to ankle, metatarsal joints and toes.
- Increased pain on dorsal flexion of the metatarsophalangeal joints.
- Muscle weakness of the intrinsic foot muscles when moving the foot in any way.
- Enlarged soreness radiating to the toes when moving them actively up and down.
Late findings are:
- It is possible the pulses are not palpable because the foot is very swollen.
- Neurological deficits: when a nerve is damaged the patient can report a decreased sensation.
Considering the 5 P’s: Pain, Pallor, Paresthesia, Paralysis, Pulselessness

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.
The only valuable test to diagnose this syndrome is an invasive measurement of the absolute compartment pressures. 

- Intracompartmental pressure monitoring (ICP):
When measuring the ICP using a needle, a plastic tube filled with a saline solution and air, connected to a mercury manometer.
This objective method can provide a continuous recording of pressure measurement for up to 16 to 24 hours.
The normal ICP ranges from zero to 10 mmHg. When the pressure is near a 30 mmHg below the diabolic pressure a fasciotomy is required.  Time is also a very significant parameter but very difficult to measure. Decompression within 6 hours will be resulted in a full recovery. If more than 12 hours pass by without any acting an inevitable disability will be identified.

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