ISOLATED MEDIAL COMPARTMENT SYNDROME OF THE FOOT: A CASE REPORT
December 5th, 1995
Mark S. Myerson, MD and Barry I. Berger, MD
Compartment syndrome, which results from increased pressure within a closed osseofascial compartment, compromises the viability of tissues and requires prompt fasciotomy for successful outcome. The vast majority of published series on compartment syndrome emphasizes the substantial amount of soft-tissue and/or bony trauma that accompanies the condition. This report describes an isolated medial compartment syndrome without evidence of specific injury.
In the recent past, compartment syndrome of the foot has gained increasing attention as a clinical entity that requires prompt diagnosis and treatment for optimal results. Its pathophysiology and treatment options have been clearly defined and the disabling outcomes associated with delayed diagnosis are well described. However, most reported cases of compartment syndrome of the foot are associated with substantial soft-tissue and/or bony trauma.1,4-7,9
We present a case report of an isolated medial compartment syndrome of the foot secondary to minor trauma.
A 25-year-old white male presented to an urgent care facility with unremitting medial right foot pain. His past medical history included treatment with Tegretol (200 mg orally four times daily) for a seizure disorder. He had suffered his first and only seizure at age 19; the basis for the disorder was unknown. On the day of presentation, he had been participating in a recreational football game. No traumatic event occurred during the game that the patient could recall. On the way home from the game, the patient experienced the onset of medial right foot pain. He sought no medical attention until he arrived home approximately 7 hours after the onset of pain.
At the urgent care facility, radiographs were taken and interpreted as negative for fracture or dislocation. The patient was treated with a soft compressive bandage, and antiinflammatory medications were prescribed. Upon returning home, the pain continued unabated, and he had the onset of tingling in his right great toe. Unable to sleep through the night, he sought orthopaedic consultation in the morning. Due to the concern that his symptoms were related to myoneural ischemia, the treating orthopaedist referred the patient to our facility.
Upon initial examination (18 hours after the pain began), the patient was writhing with pain. He was noted to have an extremely tense medial compartment with a shiny appearance and loss of skin turgor. No other swelling of the foot was present. Passive dorsiflexion of the great toe elicited exquisite pain in the medial foot. Light touch was diminished, and paresthesias were present in the distribution of the medial plantar nerve. Ankle dorsiflexion and plantarflexion were decreased due to pain in the medial foot. Passive extension of the lesser toes was well tolerated. The tibial and dorsalis pedis pulses were easily palpable and there was normal capillary refill time in all toes. Radiographs in the anteroposterior, oblique, and lateral projections were negative for fracture or dislocation.
Because the patient could not tolerate further manipulation of his foot, a regional block of the tibial nerve with 10 cc of 0.5% bupivacaine was administered, after which compartment pressures were measured using a portable hand-held device. The interosseous and calcaneal compartments measured 4 and 6 mmHg, respectively; the medial (abductor) pressure measured 78 mmHg. The patient was taken immediately to the operating room, where fasciotomy was performed under local anesthesia within 1 hour of examination.
The foot was prepped and draped in the usual sterile fashion. A medial incision was made approximately 1.5 cm below the plantar aspect of the first metatarsal, extending proximally in line with the medial malleolus (Fig. 1). The skin was incised from the origin of the abductor hallucis to the level of the metatarsal neck distally. The deep fascia was exposed and incised throughout the length of the skin incision. Upon incising the deep fascia, grayish muscle herniated into the wound (Fig. 2). The proximal and deep portions of the abductor hallucis were found to be poorly contractile and ischemic. The contents of the medial compartment were retracted inferiorly and the fascia of the medial septum forming the medial boundary of the deep central compartment was visualized. The compartment was soft to palpation and since there was no evidence of involvement in the calcaneal compartment, this compartment was not opened. After fasciotomy, the ischemic muscle appeared healthier, but it was difficult to determine whether or not it was viable. Therefore, no definitive debridement was undertaken at that time and the wounds were packed open.
Postoperatively, with cessation of the tibial nerve block, the patient had complete relief of the medial paresthesias and pain and dorsiflexion of the great toe was well tolerated. The wounds were managed with wet-to-dry dressing changes and, at 48 hours postsurgery, the patient was returned to the operating room for debridement. At that time, approximately 50% of the abductor hallucis muscle was found to be necrotic. This muscle was debrided, the wounds were packed open, and dressing changes were performed for an additional 48 hours. The patient was then returned to the operating room and the contents of the compartment were found to be well perfused with no further necrosis. Delayed primary closure was then performed in layers over a tubular drain. The drain was removed 24 hours later, at which time the patient had complete return of sensory and motor function and was discharged from the hospital. At the 6-month follow-up, the patient was engaged in full athletic activities and had no wound problems. He demonstrated no residual sensory loss or motor weakness and tolerated regular footwear without problems.
The anatomy of the foot has been well described with respect to the clinically important osseofascial compartments.2,8 The medial compartment is bound superiorly by the plantar surface of the shaft of the first metatarsal and medially by the deep fascia, which is an extension of the plantar aponeurosis. The lateral and inferior borders are the medial intermuscular septum and the plantar aponeurosis, respectively. The other clinically significant compartments of the foot are the calcaneal, central, lateral, and interosseus. The calcaneal compartment is located deep in the hindfoot and has previously been treated as part of the central compartment. Recently, the role of the quadratus plantae muscle in traumatic clawtoe deformity4 and the difficulty in experimentally decompressing this compartment from a two-incision, dorsal approach8 have resulted in consideration of this compartment as a separate entity.
A review of the literature shows that compartment syndrome is most commonly, although not always, associated with high-energy mechanisms of injury, a substantial crush component, and multiple fractures and/or dislocations. There are no reports of isolated medial compartment syndrome. The case report presented here is notable for three factors: the medial compartment syndrome presented as an isolated condition, it occurred without fracture or dislocation, and the patient could not recall the initiating event. These factors illustrate the importance of maintaining an index of suspicion when clinical symptoms greatly exceed those expected based on the mechanism of injury and a negative radiograph.
Although the injury occurred in cold weather, it would appear that the cold itself was not responsible for the development of compartment syndrome. The patient's symptoms continued for a long period of time after rewarming occurred and there was no cutaneous manifestations of superficial cold injury at the time of presentation. Frostbite would not be expected to lessen the pain of myoneural ischemia.
The fact that the patient was taking Tegretol is unlikely to be related to the etiology of the compartment syndrome. Tegretol is known to cause rare cases of thrombocytopenia and agranulocytosis, but these findings were not in evidence in our patient. Qualitative platelet and coagulation dysfunction are not known side effects of this medication. Therefore, it is unlikely that intramuscular bleeding would have occurred to a greater extent than that normally attributed to the medication.
Exercise-induced compartment syndrome, well described in the leg and thigh, could have played a causative role, but was not a plausible etiology in this patient.
Therefore, we theorized that the compartment syndrome may have been caused by a kick to the foot (spiking), which was not recalled by the patient, possibly due to the cold playing conditions. In this particular case, the medial approach to decompression was used. Since it was clear that the medial compartment only was involved, it alone was released despite its anatomic proximity to the calcaneal compartment.3,9
1. Fakhouri, A.J., and Manoli, A., II: Acute foot compartment syndromes. J. Orthop. Trauma, 6:223-228, 1992.
2. Kamel, R., and Sakla, F.B. Anatomical compartments of the sole of the foot. Anat. Rec. 140:57-64, 1961.
3. Manoli, A., and Weber, T.G. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment [see comments]. Foot Ankle, 10:267-275, 1990.
4. Manoli, A., II: Compartment syndromes of the foot: current concepts. Foot Ankle, 10:340-344, 1990.
5. Myerson, M. Crush injuries and compartment syndromes of the foot. Int. J. Orthop. Trauma, 3:109-113, 1993.
6. Myerson, M., and Manoli, A. Compartment syndromes of the foot after calcaneal fractures. Clin. Orthop. 290:142-150, 1993.
7. Myerson, M., and McGarvey, W.C. Crush injuries and compartment syndromes. In Current Therapy in Foot and Ankle Surgery, Myerson, M. (ed.). St. Louis, Mosby-Year Book Inc, 1993, pp. 264-273.
8. Myerson, M.S. Experimental decompression of the fascial compartments of the foot -- the basis for fasciotomy in acute compartment syndromes. Foot Ankle, 8:308-314, 1988.
9. Myerson, M.S. Management of compartment syndromes of the foot. Clin. Orthop. 271:239-248, 1991.
Fig. 1. Clinical photograph of foot before decompression. Note the shiny appearance of the skin and the absence of its normal wrinkling pattern. The medial fasciotomy incision is outlined.
Fig. 2. Herniation of necrotic appearing abductor hallucis after fasciotomy. Approximately half of the medial compartment was eventually debrided.