Foot Compartment Syndrome 

 

Introduction  

Compartment syndrome of the foot is uncommon, accounting for < 5% of lower limb compartment syndromes. High index of suspicion is needed after a high energy injury to foot.  

It represents a surgical emergency caused by increased intracompartmental pressure. Left untreated, it results in ischemia and irreversible tissue necrosis, leading to clawing and long-term morbidity.


Anatomy

Traditional teaching divides the foot into 4 myofascial compartments – interosseous, medial, central and lateral.

Recently, studies have demonstrated 10 compartments:

  • medial
  • abductor hallucis
  • flexor hallucis brevis
  • lateral
  • abductor digiti minimi
  • flexor digiti minimi brevis
  • 4 interosseus
  • 3 central
  • superficial (flexor digitorum brevis)
  • calcaneal (quadratus plantae)
  • deep (adductor hallucis, posterior tibial NV bundle)
  • dorsal (recently added – extensor digitorum, extensor hallucis brevis)

 

  • Communication between the compartments can occur following traumatic disruption to fascial membranes
  • calcaneal compartment has the highest risk of developing compartment syndrome
  • interosseous compartment has the lowest risk 

 

Aetiology

  • High energy injuries e.g.:
    • crush injuries
    • midfoot and forefoot trauma
    • Lisfranc fracture dislocations
    • calcaneal fractures  
  • Tibial fracture with communication of posterior compartment of leg and calcaneal compartment of foot
  • Coagulopathy
  • Acute limb revascularisation (incl reperfusion syndrome)
  • Overexertion from sporting activity
  • Iatrogenic – tight casts and dressings

 

Pathophysiology 

  • Trauma, bleeding and oedema → interstitial pressure → vascular stasis from occlusion of blood vessles
  • Secondary ischaemia → nerve and intrinsic muscle damage →contracture and toe clawing
  • Unopposed extrinsic muscles +  fibrotic plantar component → cavus deformity
  • Irreversible peripheral nerve damage → neuropathic pain + ulcers  

 

Clinical presentation

Symptoms

  • Pain Pain Pain
    • out of proportion to severity of injury
    • most reliable clinical finding, but often late
  • Burning, deep and aching pain encompassing the entire foot
  • Progressive pain despite foot immobilisation and increased analgesia requirements
  • Tense feeling in foot

Examination findings

  • Pain with passive stretching and active dorsiflexion of toes
  • Loss of two point discriminatio, decreased light touch on plantar aspect of foot and toes
    • most sensitive finding for sensory changes
  • Swelling
  • Firmness of involved compartments
  • Intrinsic muscle weakness
  • NB: Warm and well perfused foot with palpable dorsalis pedis and posterior tibial pulses does not exclude the diagnosis

PAD sign:

  • P = pulses present
  • A = Arterial flow intact
  • D = Delayed capillary refill
  • PAD sign is critical in early recognition and management - do not rely on pulses alone

Specific examination

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

 

Investigations 

  • Compartment syndrome is a clinical diagnosis
  • Compartment pressure monitoring can be used to support the diagnosis especially when clinical examination is compromised (e.g. an unconscious patient)
    • needle manometry under the base of 1st metatarsal (medial and central compartments) or through dorsal intermetatarsal approach (interosseous and central)
      • normal compartment pressure is 8 to 15mmHg
      • >25mmHg, venous perfusion is obliterated within musculoskeletal compartments
      • pressures >30mmHg or within 30mmHg of diastolic pressure are pathological → fasciotomy indicated

 

Management

Immediate

  • Split any dressings or casts to skin
  • Elevate foot to level of the heart
  • Appropritate analgesia
  • Document neurovascular findings
  • Frequently reassess

Controversy exists whether decompression is always necessary and beneficial:

  • Without decompression:
    • contractures, toe deformities, paralysis, and sensory neuropathy can result
    • some of these can be corrected later if indicated
  • With decompression:
    • significant morbidity
    • multiple incisions and scarring / contractures

Surgical decompression 

Three incision technique:

  • incorporates all osseofascial compartments
  • medial incision
    • along medial arch
    • releases medial, lateral and central
      • retract NV bundle
      • release fascia overlying abductor hallucis and FDB
      • open medial intermuscular septum longitudinally
      • enter lateral compartment through blunt dissection
  • 2 dorsal incisions:
    • medial to 2nd ray
    • lateral to 4th ray
    • superficial fascia divided, elevate interossei off metatarsals to decompress

 

  • Other described teachniques inlude:
    • Single incision only:
      • Medial
      • Dorsal
    • Pie-crusting
      • multiple stab incisions to decompress fascia but avoid big wounds - limited evidence

Additional Treatment

  • Stabilisation of the skeletal injury (temporary or definitive)
    • will help with pain and swelling
  • Secondary closure of wounds +/- skin grafts if large defects persist

Post-operative management 

  • Ice and non-steroidal anti-inflammatories to reduce swelling
  • Massage to aid lymphatic drainage
  • Increase range of motion and mobility of joints through passive mobilisation of ankle joint

 

Complications

  • Cavus deformity
  • Neuropathic pain
  • Clawed toes
  • Scars and contractures

Can be managed with:

  • passive mobilisation and stretching for toe and cavus deformity
  • orthotics to control foot position
  • skin care and de-sensitisation for neuropathic pain
  • Surgical management may include:
    • tibial nerve neurolysis and branches (after confirmation from nerve conduction studies)
    • tenotomies / tendon lengthening
    • claw toe correction
    • arthrodesis or tarsectomy for cavus deformity

In all patients, it must be explained that normal function may not be restored although improvements in pain and function can be achieved.  

 

MCQs 

The following clinical findings are consistent with compartment syndrome in the foot:

  1. Pain, swelling, weakness of eversion and dorsiflexion, sensory loss, palpable pulses 
  2. Pain, swelling, loss of active foot movement, pain on passive stretch, loss of Doralis pedis pulse 
  3. Swelling, plantar ecchymosis, weakness of the intrinsic muscles, sensory disturbance, pain on passive stretch, palpable pulses 
  4. Pain, rasied compartment pressure to 35mmHg, absent DP pulse, pale skin 
  5. All of the above 

(Answer 5) 

 

The following muscles are found in the medial compartment of the foot:

  1. Flexor Hallucis Brevis, Abductor Hallucis, Adductor Hallucis 
  2. Abductor Hallucis, Flexor Hallucis brevis, Plantar inteossei 
  3. Abductor Hallucis, Plantar interossei, Flexor digitorum brevis 
  4. Flexor digitorum brevis, Abductor digit minimi, Adductor Hallucis 
  5. Flexor digiti minimi, Opponens digiti minimi, Adductor Hallucis 

(Answer 2) 

 

If compartment pressures are measured the following readings would suggest decompression is necessary:

  1. A reading of 30mmHG and 25mmHg above the systolic blood pressure 
  2. A reading of 20mmHG or within 50mmHg of the systolic blood pressure 
  3. A reading of 20mmHg or within 50mmHg of the diastolic blood pressure 
  4. A reading of 30mmHG or within 30mmHg of the diastolic blood pressure 
  5.  A reading of 30mmHG or within 30mmHg of the systolic blood pressure 

(answer 4) 

 

A 32-year-old man presents to the resuscitation bay following a high-speed road traffic collision.

He was extricated from the vehicle. Primary and secondary ATLS surveys were completed.
He has sustained a subdural hemorrhage and rib fractures managed non-operatively.
His left foot is swollen and bruised dorsally, but there are no open wounds.

Vital signs: BP 140/90 mmHg, HR 102 bpm, SpO₂ 97% on air.
He received 10 mg of IV morphine 2 hours ago. He reports persistent, severe foot pain unresponsive to analgesia.
On examination, the dorsum of the foot is tense and tender with reduced capillary refill and pain on passive toe movement.

Which of the following is the most appropriate next step in management?

  1. Clinical examination with delayed capillary refill and passive stretch pain confirms the need for urgent fasciotomy
  2. Administer additional morphine and perform foot X-ray in the resuscitation bay
  3. Transfer to ICU for pulse oximetry and nursing Doppler checks of dorsalis pedis and posterior tibial arteries
  4. Complete clinical examination, obtain foot X-ray, elevate the limb, provide adequate analgesia, and reassess urgently
  5. Delaying the next step of management risks permanent foot deformity
  6. None of the above

Best answer: 4
Rationale: Early diagnosis requires a structured approach. Clinical assessment (PAD sign, passive stretch), analgesia, elevation, and imaging form the initial workup. Although option 1 may eventually be correct, fasciotomy requires confirmation and broader planning. Option 4 reflects safe, staged care.

 

You are performing a fasciotomy for suspected foot compartment syndrome.

Which of the following statements is/are true?

  1. A dual dorsal incision approach is an accepted surgical technique for decompression
  2. Decompression of the deep central compartment involves exposure of quadratus plantae
  3. Medial compartment release may risk injury to the Baxter nerve
  4. The extensor hallucis brevis can be used as a landmark for dorsalis pedis artery and branches
  5. All of the above

Best answer: 5 
Rationale: All listed statements are surgically accurate. Quadratus plantae lies in the deep central compartment. Baxter’s nerve passes near the medial plantar fascia and can be at risk. The dorsalis pedis artery runs with the EHB. Dual dorsal incisions are the standard fasciotomy technique.

 

 

References   

  • Kamel R, Sakla FB. Anatomical compartments of the sole of the human foot. Anat Rec 1961;140:57–60. doi:10.1002/ar.1091400109. 
  • Manoli A, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle 1990;10:267–75. 
  • Ling ZX, Kumar VP. The myofascial compartments of the foot: A CADAVER STUDY. J Bone Jt Surg - Br Vol 2008;90-B:1114–8. doi:10.1302/0301-620X.90B8.20836. 
  • Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment Syndrome of the Lower Leg and Foot. Clin Orthop Relat Res 2010;468:940–50. doi:10.1007/s11999-009-0891-x. 
  • Myerson MS. Management of compartment syndromes of the foot. Clin Orthop Relat Res 1991:239–48. 
  • 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;83:245–9. 
  • Fakhouri AJ, Manoli A. Acute foot compartment syndromes. J Orthop Trauma 1992;6:223–8. 
  • Perry MD, Manoli A. Foot compartment syndrome. Orthop Clin North Am 2001;32:103–11. 
  • Myerson M, Manoli A. Compartment syndromes of the foot after calcaneal fractures. Clin Orthop Relat Res 1993:142–50. 
  • Botte MJ, Santi MD, Prestianni CA, Abrams RA. Ischemic contracture of the foot and ankle: principles of management and prevention. Orthopedics 1996;19:235–44. 
  • Santi MD, Botte MJ. Volkmann’s Ischemic Contracture of the Foot and Ankle: Evaluation and Treatment of Established Deformity. Foot Ankle Int 1995;16:368–77. doi:10.1177/107110079501600610.