Compartment Syndrome of the Foot

Compartment Syndrome of the Foot N. Craig Stone M.D. F.R.C.S.(C) Discipline of Orthopaedic Surgery U of T Foot and Ankle Symposium 2002 Introduction Definition  Pathophysiology  Etiology  Clinical Presentation  Treatment  Long term sequelae  U of T Foot and Ankle Symposium 2002 Definition Increased pressure within a closed fascial compartment  Sufficient magnitude to impede vascular inflow  U of T Foot and Ankle Symposium 2002 Pathophysiology Insult to muscle within a closed compartment  Intracellular swelling/Hematoma  Pressure rises and capillary perfusion drops  Vicious circle  U of T Foot and Ankle Symposium 2002 Pathophysiology  Tissues vary in susceptibility to damage Nerve < 4 hours  Muscle < 8 hours   After 8 hours irreversible damage U of T Foot and Ankle Symposium 2002 Pathophysiology ? Critical pressure  Proportional to systemic blood pressure  Not a fixed number  Experimentally  Within 10mmHg of diastolic pressure  Injured tissue 20 mmHg  U of T Foot and Ankle Symposium 2002 Fascial Anatomy of the Foot At least 9 separate compartments  4 are clinically relevant  Medial, central, lateral, interosseous  U of T Foot and Ankle Symposium 2002 Etiology  Crush injuries / trauma  +/- fracture U of T Foot and Ankle Symposium 2002 Etiology  Temporary vascular occlusion Trauma, thrombus  Altered consciousness  • CNS • Drugs, alcohol U of T Foot and Ankle Symposium 2002 Clinical Presentation History of injury / energy absorbed  Swelling  Pain  Passive stretch  Pallor, paresthesia, pulselessness, paralysis  U of T Foot and Ankle Symposium 2002 Investigations  Compartmental pressure measurements Whiteside technique  Arterial line setup  Commercially available monitors  U of T Foot and Ankle Symposium 2002 Investigations 1 sample vs continuous monitoring  Measure all four compartments  Don’t delay getting measurements if diagnosis is obvious  U of T Foot and Ankle Symposium 2002 What number to we use? Fixed number (30 mmHg) VS. Variable (20 mmHG less than diastolic) U of T Foot and Ankle Symposium 2002 Treatment Remove dressings  Do not excessively elevate the foot   Level of the heart Analgesia  Have low threshold to proceed surgically  U of T Foot and Ankle Symposium 2002 Treatment Emergency fascial release  3 incisions   1 medial 2 Dorsal Blunt and finger dissection  Divide fascia  Delayed closure   +/- skin grafting U of T Foot and Ankle Symposium 2002  Prophylactic releases Missed Compartment Syndromes  Early Myonecrosis  Renal concerns   Late Deformities from contracture of necrotic muscle  Nerve Injury  • Ulcerations U of T Foot and Ankle Symposium 2002 Summary High index of suspicion  Careful with altered consciousness  Be aggressive to prevent long term sequelae  U of T Foot and Ankle Symposium 2002 U of T Foot and Ankle Symposium 2002 U of T Foot and Ankle Symposium 2002 U of T Foot and Ankle Symposium 2002 U of T Foot and Ankle Symposium 2002 U of T Foot and Ankle Symposium 2002 U of T Foot and Ankle Symposium 2002