What is the immediate management approach for a patient with compartment syndrome secondary to a diabetic foot ulcer?

Immediate Management of Compartment Syndrome Secondary to Diabetic Foot Ulcer

Immediate surgical fasciotomy is the definitive treatment for compartment syndrome in diabetic foot ulcers, and must be performed urgently once diagnosed to prevent irreversible tissue necrosis, limb loss, and systemic complications. 1

Recognition and Diagnosis

The diagnosis of compartment syndrome in the diabetic foot setting differs critically from traumatic compartment syndrome:

• Compartment syndrome typically develops AFTER revascularization in diabetic foot ulcers with acute limb ischemia (ALI), not at initial presentation, due to reperfusion injury from oxygen-free radicals creating capillary leak and elevated compartment pressures 1
• Maintain high clinical suspicion based on duration of ischemia, elevated serum creatine kinase, and physical examination findings (pain out of proportion, pain with passive stretch, paresthesias) 1, 2
• Measure compartment pressures directly when clinical suspicion exists but diagnosis is uncertain—fasciotomy is indicated when compartment pressure exceeds 30 mmHg or is within 10-30 mmHg of diastolic blood pressure 3, 4
• The lower leg is the most common site, though the foot contains nine compartments that must all be assessed 1, 3, 4

Immediate Surgical Management

For established compartment syndrome:

• Perform immediate fasciotomy of ALL involved compartments without delay—this is the only adequate therapy and must interrupt progression to tissue necrosis 1, 5
• Use long incisions of both skin and fascia (therapeutic fasciotomy), split retinacula, excise any necrotic tissue, and evacuate hematoma 5
• Do NOT close the skin after fasciotomy due to postoperative swelling that can produce rebound compartment syndrome 5
• For lower leg: perform either single lateral incision or combined medial and lateral incisions to access all four compartments 3
• For foot: use dorsal incisions for forefoot compartments and medial plantar approach for calcaneal, medial, superficial, and lateral compartments 3, 4

For prolonged or severe ischemia (prophylactic approach):

• Consider prophylactic fasciotomy at time of revascularization or early in presentation (before clinical compartment syndrome develops) in patients with threatened but salvageable limbs (category IIa or IIb) to avoid devastating complications from delayed diagnosis 1
• Observational data show early fasciotomy associates with lower amputation rates and shorter hospitalization 1
• Balance benefits against risks: dysesthesia from nerve injury, incisional complications, and infection 1

Post-Fasciotomy Wound Management

• Delayed primary closure at 4-8 days if minimal tissue bulge is noted or resolves with systemic diuresis and leg elevation 1, 5
• If delayed primary closure not possible, use negative pressure wound therapy (NPWT) to reduce discomfort, facilitate closure, or prepare wound bed for skin grafting 1
• Perform second-look operation at time of closure for tissue re-debridement 5

Critical Concurrent Management

Vascular assessment and revascularization:

• If not already done, immediately measure ankle-brachial index (ABI) and ankle pressure—if ankle pressure <50 mmHg or ABI <0.5, pursue urgent vascular imaging and revascularization 6, 7, 8
• The goal is restoring direct flow to at least one foot artery (preferably supplying the wound region) to achieve skin perfusion pressure ≥40 mmHg, toe pressure ≥30 mmHg, or TcPO2 ≥25 mmHg 1

Infection control:

• Start empiric antibiotics immediately targeting S. aureus and streptococci (cephalexin, flucloxacillin, or clindamycin for mild infection; broad-spectrum parenteral for severe) 6, 7, 8
• Patients with PAD and foot infection are at particularly high risk for major amputation and require emergency treatment 1

Amputation consideration:

• In patients with prolonged ischemia and dense regional symptoms (limited functional motor activity), concurrent amputation with revascularization may be clinically appropriate to avoid morbidity of reperfusion 1

Common Pitfalls to Avoid

• Do not delay fasciotomy waiting for compartment pressure measurements if clinical diagnosis is clear—time to decompression directly impacts outcomes 1, 2, 4
• Do not assume intact pulses exclude compartment syndrome—pulses are often present in compartment syndrome 2
• Do not perform limited or subcutaneous fasciotomy for manifest compartment syndrome—only full therapeutic fasciotomy with long skin and fascial incisions is adequate 5
• Do not close skin primarily after fasciotomy—this creates rebound compartment syndrome 5
• Diabetic neuropathy may mask pain symptoms, making diagnosis more challenging—rely heavily on objective measures and mechanism of injury 1, 9