Treating Acute Bilateral Foot Compartment Syndrome From Rhabdomyolysis And Frostbite

Allison Rottman, DPM, Steven Geary, DPM, and Raymond Yong, DPM

These authors discuss the diagnosis and treatment of a 57-year-old male who had rhabdomyolysis, an acute kidney injury and alcoholic neuropathy that masked compartment syndrome.

Acute compartment syndrome of the foot is an emergent condition, requiring surgical fasciotomies as soon as possible after one has diagnosed the condition. The most common cause is trauma such as crush injury or fracture. A study from a Level 1 trauma center over seven years showed 164 cases of acute compartment syndrome. The incidences were 7.3 per 100,000 for men and 0.7 per 100,000 for women.1 Sixty-nine percent of these cases were the result of fracture with 23 percent resulting from non-traumatic soft tissue injuries.1 These non-traumatic injuries can include vascular injuries, thermal injuries and prolonged limb compression.

   In this particular case study, the patient developed bilateral frostbite in both feet, which caused rhabdomyolysis and ultimately bilateral compartment syndrome in the feet.

   Rhabdomyolysis is a condition in which damaged skeletal muscle cells break down and leach toxins into systemic circulation.2,3 Acute kidney injury is a common side effect of rhabdomyolysis due to the release of myoglobin, which is nephrotoxic. Some causes include thermal injuries, compromise of blood supply to muscle, crush injuries, severe inflammation or infection.4,5 If the damaged muscle is contained within a fascial compartment, there is the risk of compartment syndrome.

   An acute compartment syndrome involves cellular anoxia to a fascial compartment containing muscle. The fascial compartment prevents expansion of swollen and damaged tissues.6 This condition is best explained by the arteriovenous pressure gradient theory.7 This describes a decrease in local blood flow due to extreme swelling, causing ischemia and an inability to meet local tissue metabolic demands. As more fluid enters the compartment and cannot leave due to venous compression, the compartment pressure rises, reducing venous outflow even more. This causes a decrease in the arteriovenous pressure gradient. Finally, arteriolar pressure cannot overcome the compartment pressure so blood is shunted away from the affected tissue.

   In 1990, a study by Manoli and Weber showed there are nine foot fascial compartments: lateral, medial, superficial, adductor, calcaneus compartments and four interosseous compartments.8 The calcaneal compartment communicates with the deep posterior compartment of the leg, which can potentially cause compartment syndrome of both the foot and leg.

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