SLR - December 2018 - Dhagash P. Patel

Predictors of Compartment Syndrome of the Foot After Fracture of the Calcaneus

Reference: Park YH, Lee JW, Hong JY, Choi GW, Kim HJ. Predictors of Compartment Syndrome of the Foot After Fracture of the Calcaneus. Bone Joint J. 2018 Mar 1; 100-B(3):303–308.

Scientific Literature Review

Reviewed By: Dhagash P. Patel, DPM
Residency Program: Hoboken University Medical Center, Hoboken, NJ

Podiatric Relevance: The diagnosis of compartment syndrome can be quite challenging and devastating if not performed in a timely manner. It becomes a challenge in decision making for trauma cases to follow proper protocol and provide treatment for these patients. Early diagnosis and emergent fasciotomy are recommended to relieve the compartment pressure and prevent further tissue injury. To prevent delay in diagnosis, clinicians must identify these patients at greater risks at the time of initial encounter. The purpose of this retrospective study was to identify predictors of compartment syndrome after calcaneal fractures.

Methods: Over the years of 2008 to 2016, 333 cases of calcaneal fractures were studied using electronic medical records. Of the 333 cases, 20 patients were excluded due to open fracture and missing data about the compartment syndrome, limiting the total studied subject population to 313 patients. Compartment syndrome was diagnosed using clinical signs and symptoms as well as pressure monitoring. Clinical symptoms included assessing patient for sensory and motor impairment, tense compartments and pain on passive stretching. Compartment pressure monitoring included pressure > 30mmHg compared to opposite side, with no improvement for at least two hours. For the patients who did not undergo fasciotomy, the absence of compartment syndrome was confirmed by absence of sequelae of missed compartment syndrome. CT scans were reviewed between two authors to classify intra-articular fractures using Sanders classification. Clinical outcome at one-year follow-up was measured using AOFAS hind foot score. Other factors included age, gender, smoking status, occupation, anticoagulant therapy and mechanism of injury.

Results: Of the 313 calcaneal fractures, 12 were associated with compartment syndrome. The mean age of the patient was 49.2 years; 236 men and 67 women. Eight fractures were treated with emergent fasciotomy due to high suspicion. Four fractures were not treated by fasciotomy, but it was confirmed as having developed a missed compartment syndrome with definite sequelae. The mean interval between injury and fasciotomy was 4.7 hours. Sanders type 4 was significantly associated with development of compartment syndrome. Other variables, such as anticoagulant therapy, did not show significance. The AOFAS score of patients with missed compartment syndrome were significantly worse than those for patients who underwent fasciotomy and those without compartment syndrome. The AOFAS score of patients who underwent fasciotomy for compartment syndrome were similar to those without compartment syndrome.

Conclusions: It was concluded that compartment syndrome was most likely to occur in association with Sanders type 4 calcaneal fractures. The mechanism of injury was not as significant, which indicates that the amount of energy leading to injury and comminution of the fracture are more important factors. Diagnosing compartment syndrome in these cases is a challenging task and often overlooked due to pain arising from the fracture itself, leading to its neglect. Consequences of misdiagnosing are very severe when dealing with traumatic cases. Therefore, understanding that a Sanders type 4 fracture is a predictor of compartment syndrome may help surgeons diagnose and treat compartment syndrome earlier, which may lead to fewer morbidities and better patient outcomes.

Educational Opportunities