Can compartment syndrome occur in the foot?

Compartment Syndrome in the Foot

Yes, compartment syndrome can definitely occur in the foot, which contains nine distinct compartments that can be affected by increased intracompartmental pressure, potentially leading to tissue necrosis and permanent functional impairment if not promptly diagnosed and treated. 1, 2

Anatomy and Pathophysiology

The foot contains nine compartments, each enclosed by relatively inelastic fascial boundaries:

• Medial compartment
• Lateral compartment
• Central compartment
• Calcaneal compartment
• Superficial compartment
• Four interosseous compartments

When pressure increases within these closed spaces, it can compromise blood flow, leading to:

• Decreased capillary and venous blood flow
• Tissue ischemia
• Further edema and release of vasoactive mediators
• Progressive increase in compartment pressure 3

Causes of Foot Compartment Syndrome

Common causes include:

• Crush injuries 4
• Fractures (particularly calcaneal fractures) 5
• Surgery
• Vascular injury
• Circumferential burns
• Prolonged ischemia
• Reperfusion after ischemia 2, 6

Clinical Presentation and Diagnosis

Key Clinical Signs

• Pain out of proportion to the injury
• Pain on passive stretch of the affected compartment
• Paresthesia (numbness and tingling)
• Tense edema
• Paralysis (late sign)
• Pulselessness (very late sign indicating advanced disease) 3, 1, 4

The presence of both severe pain and pain on passive stretch gives a positive predictive value of 68%, while adding paralysis increases this to 93% 3.

Diagnostic Approach

1. Clinical assessment for the classic signs
2. Direct measurement of compartment pressures when diagnosis is uncertain
   • Compartment syndrome is diagnosed when:
     • Absolute pressure exceeds 30 mmHg, OR
     • Differential pressure (diastolic BP minus compartment pressure) is less than 30 mmHg 3, 1

Due to the multiple compartments in the foot, multi-stick needle catheterization is often necessary to accurately measure pressures in all affected compartments 2.

Management

Immediate Treatment

Compartment syndrome of the foot is a surgical emergency requiring prompt fasciotomy to prevent devastating complications:

1. Urgent fasciotomy when:

   • Clear clinical signs of compartment syndrome are present
   • Compartment pressure exceeds 30 mmHg
   • Differential pressure is less than 30 mmHg 1, 2

2. Surgical approaches:

   • Two dorsal incisions for forefoot compartments
   • One medial incision for calcaneal, medial, superficial, and lateral compartments 2

Post-Operative Care

• Negative pressure wound therapy (NPWT) for fasciotomy wounds
• Early physical therapy to maintain range of motion
• Progressive strengthening exercises
• Edema management
• Scar management 1

Complications if Untreated

Untreated foot compartment syndrome can lead to:

• Tissue necrosis
• Permanent functional impairment
• Contractures
• Deformity (including clawing of toes)
• Weakness
• Paralysis
• Sensory neuropathy
• Chronic pain
• Need for multiple rehabilitation procedures 2, 5

Special Considerations

Chronic Compartment Syndrome

• Can occur in the foot, particularly in the medial compartment
• Presents with pain during exercise that resolves with rest
• Diagnosis requires dynamic pressure measurements before and after exercise
• Treated with fasciotomy 7

High-Risk Patients

Be particularly vigilant for compartment syndrome in:

• Patients with crush injuries
• Calcaneal fractures (approximately 10% develop compartment syndrome) 5
• Motorcyclists with lower extremity injuries
• Patients with vascular injuries or prolonged ischemia 6

Early recognition, diagnosis with compartment pressure measurements when indicated, and prompt surgical decompression are essential to prevent the devastating long-term consequences of foot compartment syndrome.