These authors detail the diagnosis and surgical treatment of foot compartment syndrome in a 31-year-old patient, who presented with multiple and comminuted metatarsal fractures after a motor vehicle accident.
A 31-year-old female with no significant past medical history reported to the Maricopa County Medical Center after incurring injuries as a restrained passenger in a motor vehicle accident with airbag deployment. She initially presented with loss of consciousness, upper cervical spine tenderness and right knee, ankle, and foot pain.
Subsequent CT imaging of the spine noted no acute cervical spine abnormality. Radiographs of the knee, ankle and foot revealed second, third, fourth and fifth metatarsal neck fractures with medial displacement of the distal fracture fragments. Additionally, the radiographs noted a mild diastasis between the 1st and 2nd metatarsals (see Figure 1). Citing the aforementioned lower extremity injuries, the trauma team consulted podiatry immediately after the primary workup and subsequent imaging for the patient were complete.
The podiatric exam revealed the patient was awake, alert, and oriented in moderate acute distress. The patient was in the emergency department in bed with a cervical collar in place and her right foot splinted. The dorsalis pedis pulse was absent and the posterior tibial pulse was diminished to the right foot. However, pulses were easily palpable in the left foot. Capillary fill time was 3 seconds to all digits of the bilateral lower extremities. The right foot appeared mildly erythematous with moderate edema. Hair growth was absent to the dorsal digits and foot bilaterally.
There was severe pain to palpation of the right dorsal foot but we noted no pain with palpation of the left foot. The patient was able to feel a 10-gram monofilament to the soles of both feet. The skin bilaterally was grossly intact without ulceration, erosion or blistering. Web spaces were clean and dry without maceration. There were no clinical signs of infection. We were unable to perform manual muscle testing due to the severe pain and swelling of the right foot.
Due to the severity of the injury, which included pulselessness to the right foot, severe pain and edema, compartment syndrome was of immediate concern. We immediately took the patient to the operating room for emergent intervention. After making a dorsomedial fasciotomy incision over the second metatarsal and a dorsolateral fasciotomy incision over the fourth metatarsal, we immediately evacuated 20 cc of hematoma and serosanguineous fluid with the incisions and blunt dissection into metatarsal compartments of the foot. Subsequently, we noted immediate resolution of foot edema and return of the dorsalis pedis artery. Accordingly, we did not make a plantar lateral fasciotomy incision.
It was easy to identify the metatarsal heads and proximal shafts through the fasciotomy sites and we used these sites to aid in open reduction and internal fixation of the metatarsal fractures. The metatarsal fractures were comminuted so screw and plate fixation was not practical. We decided that the combination of intramedullary rod fixation with 2.0 mm K-wires would adequately hold the fractures appropriately. We used four 2.0 mm single trocar K-wires and drove the sharp tip anterograde through the metatarsal head and out of the skin plantarly for the second through fourth metatarsals. Then we placed the wire retrograde into the reduced and aligned metatarsal shafts of the second through fourth metatarsals.
It was easy to reduce the fifth metatarsal after fixating the central metatarsals. To fixate the fifth metatarsal, we utilized intramedullary rod fixation in a retrograde manner, entering the skin at the fifth metatarsal head and driving the nail proximally into the reduced and aligned metatarsal shaft. We used intraoperative fluoroscopy to ensure proper fracture reduction, metatarsal alignment and hardware fixation (see Figure 2). Stress of the Lisfranc joint at this time revealed no instability. We placed a negative pressure wound therapy device with a white sponge over the fasciotomy sites and placed the leg in a posterior plaster splint.
We ordered a postoperative CT scan of the right foot to evaluate reduction of the metatarsal fractures, the suspected Lisfranc injury and to evaluate any other possible injuries not noted by plain film radiographs. The CT scan revealed internal fixation of the second through fifth metatarsals with acceptable alignment. While we also noted intra-articular fractures of the middle and medial cuneiform bones, and a small intra-articular fracture along the plantar lateral aspect of the base of the first metatarsal on the CT scan, these fractures were not significant enough to warrant further surgical interventions. The CT scan also ruled out any Lisfranc injury.
The patient was admitted to the surgical floor for neurovascular checks, pain control and additional surgery. There were no medical or surgical complications during her admission stay. Her pain control was adequate and there were no concerns with her neurovascular status of the right foot during her admission. Two days after the initial fasciotomy, we took the patient back to the operating room to address her fasciotomy sites. While we easily closed the dorsomedial fasciotomy site with no skin tension, the dorsolateral fasciotomy site had too much tension for primary closure. We decided to keep the patient in the hospital for an additional two days to attempt delayed primary closure of the dorsolateral fasciotomy site or consider split thickness skin grafting. At that time, a return to the operating room revealed the dorsolateral fasciotomy site was still under too much tension for delayed primary closure.
A split thickness skin graft (STSG), 0.012 inches in thickness, was then harvested from the ipsilateral thigh. We secured the skin graft in place with absorbable sutures, added a piece of non-adhesive gauze and utilized VAC therapy (75 mmHg, low continuous suction) with a silver sponge above the gauze.
The patient was subsequently discharged from the hospital with instructions to remain strictly non-weightbearing with the right foot. At the first week of follow-up in the clinic, we removed the VAC therapy device and inspected the STSG, which was firmly adherent and viable to the dorsolateral wound. The dorsomedial wound was coapted with sutures intact. The patient’s neurovascular status remained intact, there was no sign of infection and her pain was well controlled.
At her four-week follow-up visit, we removed the dorsomedial sutures. The dorsolateral fasciotomy site looked good with the skin graft completely adherent and intact with appropriate healing (see Figure 3). Radiographs revealed maintenance of proper alignment with fixation in place (see Figures 4 and 5). The patient continues to be adherent with nonweightbearing instruction and pin site care. She is supplementing bone healing with Vitamin D and calcium. We will remove her pins at six to eight weeks. At this time, the patient will start physical therapy to decrease any sequelae of joint stiffness and pain from the fixation through the plantar metatarsal heads.
This case illustrates an emergent case of compartment syndrome in which a delay in diagnosis and treatment could have had serious consequences in her functional outcome.
This case also demonstrates a relatively simple fixation technique for metatarsal neck fractures. These fractures are very unstable and plate fixation causes more vascular compromise to the bone due to periosteal stripping, and leads to a very technically challenging case. Furthermore, dorsal metatarsal plates may break and/or need to be removed since surgeons cannot place them on the tension side of the bone (plantar).
Lastly, one could scrutinize the plan and implementation of immediate fracture reduction at the time of the fasciotomy incisions. Due to the severe misalignment of the fractures and comminution of the fragments, we felt that delaying the fixation of the fractures would have been more difficult. In this case, if we had delayed the fracture fixation until the fasciotomy sites had closed and healed, there would have been a three to four week delay with the fixation. This would likely make fracture reduction and fixation very difficult. However, immediately reducing and fixing the fractures aids in the reduction of edema, pain management, wound closure and osseous healing.
Dr. Hooker is a second-year resident at the Maricopa County Medical Center in Phoenix.
Dr. Fishco is board-certified in foot surgery and reconstructive rearfoot and ankle surgery by the American Board of Podiatric Surgery. He is a Fellow of the American College of Foot and Ankle Surgeons, and is a faculty member of the Podiatry Institute. Dr. Fishco is in private practice in Phoenix.