0198-0211/90/1005-0267$02.00/0 FOOT& ANKLE Copyright 0 1990 by the American Orthopaedic Foot and Ankle Society, Inc.
Fasciotomy of the Foot: An Anatomical Study with Special Reference to Release of the Calcaneal Compartment Arthur Manoli, II,* M.D.and Timothy G. Weber,t M.D. Detroit, Michigan
ABSTRACT Three patients with calcaneal fractures developed clawing of the lesser toes as a late sequela. Believing that this complication may be the result of contractures from an occult compartment syndrome of the foot, an investigation of the anatomical compartments of the foot was performed. The various compartments of 17 unembalmed adult lower limb specimens were injected with dyed gelatin in a controlled fashion. After freezing, the feet were sectioned either transversely or sagittally. The distribution of the dyed gelatin was then studied. Nine compartments were identified. These were the (1) medial, (2) superficial, (3) lateral, (4) adductor, (5-8) four interossei, and (9) calcaneal. The contents of each compartment was then studied as was the compartment’s location in the foot and its position relative to other compartments. We identified a new, separate Compartment which lies deep to the superficial compartment in the hindfoot area only. This compartment contains the quadratus plantae muscle. We have named it the “calcaneal” compartment to emphasize its hindfoot location. In addition, a communication was demonstrated between the calcaneal compartment and the deep posterior compartment of the leg through the retinaculum behind the medial malleolus, following the neurovascular and tendinous structures. Claw toe deformity following calcaneus fracture appears to be due to late contracture of the quadratus plantae muscle in the calcaneal Compartment. A surgical technique for release of all of the foot compartments is described.
Extremity compartment syndromes are becoming increasingly acknowledged as an important source of severe, long-term disability. The major recognized sites of involvement are the forearm and the leg, with others seen sporadically (deltoid, arm, hand, gluteal, iliacus, thigh Recent works have focused on the foot as a possible site of involvement, but little information exists about the development of the hypothetical late contractures .2-4.7,15-17*20 We have seen three patients with fractures of the calcaneus who developed progressive clawing of the lesser toes after their injuries. This experience led us to a further study of the compartments of the foot and their decompression.
CASEREPORTS Case 1
A 28-year-old carpenter fell 20 feet from a roof and sustained a comminuted fracture of his right calcaneus. He was treated with elevation and a bulky compression dressing. Early motion was begun, followed by progressive partial weightbearing at 3 weeks after the injury. At 6 weeks, he was fully weight-bearing. The patient returned to work 6 months after his injury with only mild, intermittent pain over the lateral aspect of his heel, in the area of the peroneal tendons. Thirteen months after his injury he returned when he noticed the development of a moderate claw toe deformity of his second and third toes. The neurovascular status of the foot was normal. This deformity was treated with shoe and work boot modifications(a larger toe box).
* Assistant Professor, Department of Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, Michigan. To whom correspondence and requests for reprints should be addressed at: Department of Orthopaedic Surgery, Wayne State University School of Medicine, Hutzel Hospital, 4707 St. Antoine, 1-South, Detroit, Michigan 48201. t Resident, Department of Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, Michigan. No benefits in any form have been received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding sources were departmental research funds of the Fund for Medical Research and Education (Grant #2634), Wayne State University.
Case 2
A 23-year-old man was riding a three-wheeled motorcycle when he was struck by an automobile. He sustained a fracture of the right calcaneus with a skin avulsion over the medial portion of the arch. The patient underwent split-thickness skin graft to the ulcerated area. 267
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When seen 27 months after his injury, he complained of progressively rigid, fixed claw toe deformities of his second and third toes, which began 12 months after his initial injury. There was also decreased sensation over the plantar aspect of these toes. The patient had surgical repair of the deformities of his second and third toes by proximal interphalangeal joint resections and recovered uneventfully.
Case 3
A 37-year-old man fell off a ladder sustaining a comminuted fracture of the left calcaneus. He was treated with a long-leg cast for 8 weeks, followed by a shortleg walking cast for 3 weeks. Eight months after his fracture, it was noted that he was developing clawing of his lateral four toes. These progressed until he underwent surgical repair of these four toes, 1 year after his injury. This was done by excision of the proximal interphalangeal joints. Twenty-four years after the fracture, the patient had recurrence of the claw toe deformities of the second, third, and fourth toes. In addition, he had developed a painful bunionette over the lateral aspect of his fifth metatarsal head. There was very restricted subtalar joint motion, which was minimally symptomatic. The subtalar joint showed degenerative arthritis developing roentgenologically. The patient underwent uneventful surgical repair of his recurrent claw toe deformities and his symptomatic bunionette.
inject dyed gelatin through this wall to better evaluate the hindfoot portion of the "central" compartment. On the remaining three specimens, the medial compartment was again opened and the abductor hallucis longus muscle reflected upward, but the injection was performed at the mid-metatarsal level to better evaluate the forefoot portion of the "central" compartment. All of the foot specimens were then placed into a freezer ( -10" C). After at least 24 hours in the freezer, the specimens were then sectioned either transversely or sagittally with a band saw and the compartment anatomy studied by evaluating the distribution of the dye.l1 .18
RESULTS
Our injection studies demonstrated a total of nine compartments in the foot. Three run the entire length of the sole of the foot (medial, superficial, and lateral), whereas five are confined to the forefoot (adductor and four interossei). A previously undescribed compartment
MATERIAL AND METHODS
Our anatomical study consisted of 17 adult unembalmed lower limb specimens. Three different dissection and injection techniques were used to define the compartments of the foot. In nine specimens, we made a transverse skin incision across the plantar aspect of the foot, approximately 3 cm proximal to the fifth metatarsal tuberosity. The incision was carefully continued to the level of the plantar aponeurosis. The heel pad was then elevated, allowing clear visualization of the plantar compartment surfaces. Each compartment was then injected with a dyed gelatin solution (Baker's Analyzed cR>; J.P. Baker, Inc., Phillipsburg, NJ) just deep to the fascia. A different color was used for each compartment. On five feet, the medial compartment was opened posteriorly and the abductor hallucis longus muscle was reflected upwardly, exposing the medial wall of the previously described "central"' 16-18 or intermediate6l1l5Compartment. We then proceeded to
Fig. 1.
A . Transverse section through the base of the metatarsals The medial (M). lateral (L). superficial (S). and calcaneal (C) compartments are seen Artifactual staining of the intermetatarsal joints is seen. as the dark blue dye used to stain the lateral compartment tracked up the peroneal longus tendon sheath to enter them 8 Enlargement of 1 A Red dye injected into the superficial compartment (S) did not enter the calcaneal compartment (C)
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was identified and is confined to the hindfoot (calcaneal). The medial compartment is limited by the fascia overlying the abductor hallucis muscle medially, and the medial intermuscular septum arising from the medial edge of the plantar aponeurosis (Fig. 1A). The medial compartment contains the abductor hallucis muscle and the two heads of the flexor hallucis brevis muscle. The superficial compartment (Figs. 1-4) is limited superficially by the plantar aponeurosis and, medially and laterally, by the medial and lateral intermuscular septums. Posteriorly, the compartment begins at the anteromedial surface of the lateral intermuscular septum, as the lateral compartment sweeps medially to its origin from the undersurface of the calcaneus and its medial tuberosity. This compartment contains the flexor digitorum brevis muscle, the distal tendons of the flexor digitorum longus muscle, and the four lumbrical muscles. Previous terminology has referred to this area as the intermediate,6.’‘.15 or central compartment,2~’6-’B~20 but to avoid confusion with the other deep forefoot and hindfoot areas, we believe the term “superficial” compartment is more appropriate. The lateral compartment is limited laterally by the fascia overlying the abductor digiti minimi muscle and medially by the lateral intermuscular septum arising from the lateral edge of the plantar aponeurosis. The posterior extent Of the compartment continues to the inferior surface of the cakaneus where it continues transversely in a medial direction toward the medial
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calcaneal tuberosity (Figs. 2 and 4). At this point, the lateral compartment is actually proximal to the superficial compartment (Fig. 2). The lateral compartment contains the abductor digiti minimi and flexor digiti minimi brevis muscles. The adductor Compartment is confined to the forefoot. It is walled off by the two limbs of the Y-shaped horizontal septum and the lateral wall of the medial compartment (Fig. 5). This compartment contains the adductor hallucis muscle. There are four separate interosseous compartments (Fig. 5) in the forefoot. Each is limited inferiorly by the deep fascia1 membrane of the adductor compartment
Fig. 3. Transverse section through the proximal metatarsals. The distal extent of the quadratus plantae muscle (calcaneal compartment) is seen (arrow).
Fig. 2. Dark blue dye outlines the superficial compartment in this sagittal section The tissue deep to this area is the unstained calcaneal compartment in the hindfoot. and the adductor in the forefoot The superficial compartment arises from the anterior fascia of the lateral Compartment (arrow)
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Fig. 5. Transverse section through the mid-metatarsal level The adductor compartment (A) is stained dark blue The four interossei Compartments are stained alternately and numbered The flexor hallicus brevis muscle is unstained in the medial Compartment (arrows)
Fig. 4. Transverse section through the hindfoot The lateral compartment transverses under the calcaneus to the medial side of the foot In this injection. the most medial portion of the lateral compartment remains unstained (arrow)
or the superficial compartment. Medially and laterally, the compartment is limited by the respective metatarsals and a vertical fibrous septum which extends from the metatarsal to the fascial membrane limiting the adductor or superficial compartment. Superiorly, the overlying dorsal interosseous muscular fascia confines each Compartment. These four compartments each contain a dorsal and plantar interosseous muscle. The calcaneal compartment was discovered when injections of the superficial compartment did not fill a muscular zone in the area of the hindfoot (Figs. 1 and 2). Conversely, injections of this deep muscular area containing the quadratus plantae muscle did not communicate with the other foot compartments, although dye did follow the flexor digitorum longus tendon and posterior tibial neurovascular structures into the deep posterior compartment of the leg (Figs. 6 and 7). This compartment is limited medially and laterally by the
respective intermuscular septums. Superficially, the compartment is limited by a fascial plane which arises from the medial intermuscular septum and extends to the lateral intermuscular septum, thus separating this compartment from the superficial compartment. The deep aspect of the compartment is limited by the calcaneus and tarsal bones with their overlying ligaments. Distally, the compartment is limited by the flexor digitorum longus tendons into which the quadratus plantae muscle inserts (Fig. 3). Proximally, the compartment communicates with the deep posterior compartment of the leg as stated. The only muscle in the compartment is the quadratus plantae muscle. Proximally, the posterior tibial vessels and nerve, and more distally the lateral plantar vessels and nerve, are located within this compartment as they course past the ankle to supply the plantar surface of the foot.
DISCUSSION
The anatomy of the foot has been studied in many ways for a number of years. The various structures and their relationships to each other and to various spaces,8,’2 layer^,^,'^,'^ and compartments2~6~”~’5-’’~zo have been widely described. We found that these numerous descriptions have led to a good deal of confusion, as the various spaces, layers, and compartments vary in their position in the foot, with some being located along the entire length of the foot, whereas others are located in just the forefoot or the hindfoot. Henry’ emphasized that the layers of the foot alternate, and our injection studies have confirmed that the compart-
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I&Fig. 6. Sagittal section through the second metatarsal The calcaneal Compartment IS stained dark blue Note its hindfoot location The dye follows the structures behind the medial malleolus to communicate with the deep posterior compartment of the leg (arrow)
ments of the foot also alternate in a similar manner. We found that the medial, lateral, and superficial compartments run the entire length of the foot and that the adductor and interossei compartments are limited to the forefoot. The calcaneal compartment is situated in the hindfoot only. Grodinsky was one of the first persons to look at the anatomy of the foot in depth.8 His main interest was in the spread of infection through the fascia1 spaces. He performed injection studies of the spaces and diagrammed the foot in a transverse section (Fig. 8). One sees that he depicted the muscle bellies of the flexor digitorum brevis, adductor hallucis, and quadratus plantae to all be present in the same cross-section at midfifth metatarsal level. In our studies, the flexor digitorum brevis muscle was tendinous in nature at this level and the quadratus plantae muscle was absent (Fig. 6), having inserted more proximally into the tendons of the flexor digitorum longus muscle (Figs. 3 and 6). This error, illustrating the quadratus plantae muscle in the forefoot, has been repeated by others for 60 years (Figs. 8 and 9).' l1l2 15-18 The lumbrical muscles are the muscle tissues located in this area, as they attach to the distal portion of the flexor digitorum longus, and should be depicted as such. Also, our sagittal sections agreed with McMinn et al.'s study where the origin of the oblique head of the adductor was shown to be the proximal second through fourth metatarsal~,'~ in the forefoot. This area is distal to the obliquely coursing
flexor digitorum longus muscle and its proximally attached quadratus plantae muscle. Kamel and Sakla described the intermediate (central) compartment as being subdivided by a Y -shaped septum (Fig. 9).11 They felt that the adductor hallucis muscle and the two heads of the flexor hallucis brevis muscle were located in one compartment, whereas the flexor digitorum brevis muscle, the quadratus plantae and the lumbrical muscles were located in another, and finally, that the interossei were located in their own compartments. Our investigation does not completely concur with their findings in the forefoot, as we found the two heads of the flexor hallucis brevis muscle to be located in the medial Compartment. We confirmed however, that the adductor hallucis muscle is located in its own compartment (the adductor compartment) rather than in the intermediate or central compartment as thought by others.8,'6-'8 The interosseous muscles maintained their own compartments individually (Fig. 5). In the hindfoot, our results differ from Kamel and Sakla" as we found the quadratus plantae muscle to lie in a distinct compartment separate from the flexor digitorum brevis muscle of the superficial compartment. This was confirmed by complimentary injections into both of these compartments, and, in no case, did the To avoid confusion with dye enter the other (Fig. l).2,6,7 previous descriptions of the "intermediate"6,'',15 and ~~centra("2.16~18.21 compartment, and to emphasize its
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Fig. 9. Transverse section through the mid-portion of the fifth metatarsal bone The adductor compartment is shown (19.20) We found the flexor hallicus brevis muscle (20) to be located in the medial compartment, however Also, the quadratus plantae muscle does not exist at this level, as illustrated (10) (Reprinted with permission of publisher. from Kamel. R and Sakla. F B Anatomical compartments of the sole of the human foot Anatomical Record, 140 57-64, 1961)
Fig. 7. Transverse section through the hindfoot The dark blue stained calcaneal compartment is distinct from the other compartments
location in the hindfoot, we prefer to call this newlyfound, deep, centrally-located, hindfoot compartment the “calcaneal” compartment. The compartment containing the flexor digitorum brevis is best referred to as the superficial compartment to avoid confusion between it and the other centrally-located compartments (calcaneal, adductor, interossei). Injections into the calcaneal compartment tended to follow the flexor digitorum longus tendon and the posterior tibial neurovascular structures into the deep compartment of the leg (Fig. 6). A communication between the deep compartment of the leg and the central compartment of the foot has been described previ~ u s l y . ~ This ~ ~ communication ~”~’~ is clinically important, as it may lead to compartment syndromes in both the foot and leg when only one is significantly injured. A case is reported here to illustrate this point.
Case 4 d Sp.
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Fig. 8. Diagram of a transverse section through the forefoot The quadratus plantae muscle is incorrectly depicted in this forefoot location (Reprinted with permission of publisher. from Grodinsky. M A study of the fascia1 spaces of the foot and their bearing on infections Surgery, Gynecology. and Obstetrics 49 737-751, 1929)
A 44-year-old man fell off a car-carrier truck, landing on both feet. He sustained a very comminuted tibial pilon fracture with a fracture of the upper fibula on the right and fractures of his second and third metatarsal on the left. Soon after his injury, he developed massive swelling of his right leg with paresthesias and pain in his leg and foot, which became worse with passive stretching of the leg muscles. A clinical diagnosis of compartment syndrome of the leg was made. Slit catheter measurements of 68 mmHg of pressure in the anterior compartment and 38 mmHg of pressure in the deep posterior compartment confirmed the diagnosis.
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A four compartment leg fasciotomy was performed. Intraoperatively, it was noticed that his ipsilateral right foot had also become massively swollen, despite the absence of local bone injury, and slit catheter measurement showed 30 mmHg of pressure in the calcaneal compartment. A foot fasciotomy was performed through two dorsal incisions over the forefoot and a single medial incision over the hindfoot. After delayed wound closure and healing, the pilon fracture was internally fixed. The patient had an uneventful recovery and returned to work as a delivery man 18 months after his injury. He did not develop any claw toe or foot deformities as a result of his injuries. The calcaneal compartment is a distinct compartment separate from the remainder of the foot compartments. Late contracture of the quadratus plantae muscle due to ischemic changes of compartment syndrome could lead to the claw toe deformities seen in our patients (cases 1-3). Woodburne describes the quadratus plantae muscle as having a “tendinous lateral head that arises from the lateral border of the plantar surface of the calcaneus and from the long plantar ligament. The fleshy medial head takes origin from the medial surface of the calcaneus and from the medial border of the long plantar ligament.”” This muscular medial head may be more vulnerable to pressure ischemia resulting in the claw toe deformity occuring in the second and third toes of two of our patients (Cases 1 and 2). The more tendinous lateral head may be less susceptible to the consequences of ischemia and scarring, although it still may develop in this area (Case 3). One can also postulate that extensive contracture of other adjacent muscles (flexor digitorum brevis, abductor hallucis, interossei, etc.) may also increase the severity or rigidity of the deformities, as well as add an element of cavus to the foot. This was not seen in the patients in this series, however. In none of the patients was the clawing diminished by plantarflexing the ankle, indicating an intrinsic foot contracture. Without direct surgical exploration, it is difficult to prove conclusively that the three patients seen here with claw toe deformities after fractures of the calcaneus are suffering the sequela of a missed compartment syndrome of the foot. However, it is a highly likely explanation considering the deformity developed progressively over 8 to 13 months after the injury in our patients. This time sequence is similar to what is seen in established compartment syndromes of the leg and forearrn.l5Also, in the forearm, Tsuge states that “the most marked ischemia occurs in the deeply situated muscles,”’sa fact that if extrapolated to the foot, would support the theory of a contracted quadratus plantae muscle as the offender. Future direct compartmental exploration and release in similarly contracted patients will be necessary to prove this theory, however.
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This experimental evidence, coupled with the observations of others‘ as well as our own observations during foot fasciotomy, in which hemorrhage and swelling is consistent in the hindfoot compartments, have led us to recommend hindfoot fasciotomy as an integral part of foot compartment release. Myerson showed that with a dorsal, two-incision approach over the forefoot, increased pressure in the hindfoot may eventually be released, albeit ~ l o w l y . ’ We ~ ~ ’do ~ not know if the hindfoot pressure he was measuring during his experiment was from the calcaneal compartment or the superficial compartment. Since the calcaneal compartment does not extend into the forefoot, we do not feel that it can be adequately decompressed by the dorsaltwo-incision approach. We agree with Myerson that, in cases of hindfoot injury and suspected compartment syndrome, a hindfoot fasciotomy should accompany a dorsal-two-incisionfasciotomy.’6 This hindfoot fasciotomy should include release of the calcaneal compartment. The medial approach of Henry,g as used by Bonutti and Bell in their report,’ certainly will decompress all of the foot compartments. We have found, however, that this approach is very extensive and may be difficult to perform in a severely traumatized adult foot. Deep dissection along bloody and poorly differentiated planes may cause further damage to the important neurovascular structures. Combining a lateral approach to the Henry approach adds little to the procedure.” Therefore, we have developed the following technique for a complete nine compartment foot fasciotomy.
SURGICAL TECHNIQUE
Three incisions are used to decompress the compartments (Fig. 10). The hindfoot incision is over the medial portion of the heel, similar to that described for heel spur relea~e.’.~ It begins 4 cm anterior to the posterior portion of the heel, 3 cm from the plantar surface. The incision is 6 cm long, parallelingthe bottom of the heel pad. The incision is carried down to the fascial wall of the medial compartment. The subcutaneous tissue is then elevated both superiorly and inferiorly, exposing the plantar aponeurosis. The medial compartment is then opened longitudinally with an incision 1 cm from its inferior border. The 1-cm fascial strip that remains can be followed laterally and serves as a landmark for the deeper incisions. The abductor hallucis muscle is then reflected superiorly, and its attachment to the lateral fascial wall of the medial compartment is stripped. First, with forceps, lift the fascia lying superior to the fascial strip and place a small incision in it. This must be performed carefully as the lateral plantar nerve and
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CONCLUSIONS
Clawing of the lesser toes developed in three patients following a fracture of the calcaneus. It is felt that this may be due to progressive, late contracture of the quadratus plantae muscle lying in the deeply situated, previously undescribed compartment of the foot, the calcaneal Compartment. A communication exists between it and the deep compartment of the leg. Total foot fasciotomy can be accomplished safely and effectively through a three incision approach to the forefoot and hindfoot.
ACKNOWLEDGMENTS
The authors thank George Corondan, M.D., for his help with the preparation of the specimens, Cliff Roberts for his photographic assistance; James Dombrowski for his medical illustation, Katrina Turner and Olga Zoubareff for their technical assistance, and Bruce J. Sangeorzan, M.D., for his advice and encouragement.
REFERENCES Fig. 10. The surgical approach. Two dorsal forefoot incisions and one medial, hindfoot incision are used to decompress all of the foot compartments (see text).
artery lie just deep to this fascia. This incision is extended distally and decompresses the calcaneal compartment. The second deep incision is placed inferiorly to the fascial strip. It is carried the entire length of the skin incision and opens the superficial Compartment. At the most proximal portion, this fascial incision provides access to the lateral compartment where the abductor digiti quinti muscle takes origin from the undersurface of the calcaneus (Fig. 2). The lateral compartment is then released with an incision on the inferior-medial aspect of its overlying fascia, extending to the lateral side of the foot. To decompress the forefoot, incisions are made over the second and fourth metatarsal shafts. Taking care to protect the dorsal veins, the subcutaneous tissue is elevated medially and laterally to expose the respective interosseous muscle. The thin fascia over each is incised longitudinally. The first dorsal and plantar interossei are stripped from the shaft of the second metatarsal, retracted medially, and the fascia of the adductor compartment released longitudinally, deep within the interspace. All of the wounds are left open and a gentle pressure dressing is applied.
1. Baxter, D.E. and Thigpen, M.C.: Heel pain-operative results. Foot Ankle, 5:16-25, 1984. 2. Bonutti, P.M., and Bell, G.R.: Compartment syndrome of the foot. J. Bone Joint Surg., 68A:1449-1451, 1986. 3. Chuinard, E.G. and Baskin, M.: Claw foot deformity. J. Bone Joint Surg., 55A:351-362, 1973. 4. Cole, W.H.: The treatment of claw foot. J. Bone Joint Surg., 22~895-908,1940. 5. DuVries, H.L.: Heel spur (calcaneal spur). AMA Arch. Surg., 74~536-542,1957. 6. Feingold, M.L., Resnick, D., Niwayama, G., and Garetto, L.: The plantar compartments of the foot: a roentgen approach. I. Experimental observations. Investigative Radiology, 12:281288,1977. 7. Gissane, W.: A dangerous type of fracture of the foot. J. Bone Joint Surg., 338535438, 1951. 8. Grodinsky, M.: A study of the fascial spaces of the foot and their bearing on infections. Surgery, Gynecology and Obstetrics, 49:737-751,1929. 9. Henry, A.K.: Extensile Exposure. 2nd Ed. Baltimore, Williams & Wilkins, 1963, pp. 300-308. 10. Jones, R.: Volkmann's ischaemic contracture with special reference to treatment. Br. Med. J., 2:639-642. 1928. 11. Kamel, R. and Sakla, F.B.: Anatomical compartments of the sole of the human foot. Anat. Rec., 14057-64, 1961. 12. Loeffler, R.D. and Ballard, A.: Plantar fascial spaces of the foot and a proposed surgical approach. Foot Ankle, 1:ll-14, 1980. 13. McMinn, R.M.H., Hutchings, R.T., and Logan, B.M.: Color Atlas of Foot and Ankle Anatomy. England, Wolfe Medical Publications Ltd., 1982, pp. 29-76. 14. Mizeres, N.J.: Human Anatomy: A Synopic Approach. New York, Elsevier, 1981, p. 228. 15. Mubarak, S.J. and Hargens, A.R.: Compartment Syndrome and Volkmann's Contracture, Vol. 3. Philadelphia, W.B. Saunders,
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Foot & Ankle/Vol. 70,No. S/April, 7990 1981, pp. 44-45. 16. Myerson, M.S.: Acute Compartment syndromes of the foot. Bull. Hosp. Joint Dis. Orthop. Inst., 47:251-261, 1987. 17. Myerson, M.S.: Experimental decompression of the fascia1 compartments of the foot-the basis for fasciotomy in acute compartment syndromes. Foot Ankle, 8:308-314, 1988. 18. Richrnan, J.D. and Barre, P.S.: The plantar ecchymosis sign in fractures of the calcaneus. Clin. Orthop. Relat.. Res., 207:122125,1986. 19. Tsuge, K.: Treatment of established Volkmann’s contracture. J.
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Bone Joint Surg., 57A:925-929, 1975. 20. Whitesides, T.E.: Compartment Syndromes. In Disorders of the Foot. Jahss, M.H. Philadelphia,W.B. Saunders, 1982, pp. 12011204. 21. Woodburne, R.T.: Essentials of Human Anatomy. 6th Ed. New York: Oxford University Press, 1978, pp. 573-582. 22. Ziv, 1. Mosheitt, R., Zeligowski, A. Liebergal, M., Lowe, J., and Segal, D.: Crush injuries of the foot with compartment syndrome: immediate one-stage management. Foot Ankle, 9:285-289, 1989.
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Fasciotomy of the Foot: An Anatomical Study with Special Reference to Release of the Calcaneal Compartment Arthur Manoli, II,* M.D.and Timothy G. Weber,t M.D. Detroit, Michigan
ABSTRACT Three patients with calcaneal fractures developed clawing of the lesser toes as a late sequela. Believing that this complication may be the result of contractures from an occult compartment syndrome of the foot, an investigation of the anatomical compartments of the foot was performed. The various compartments of 17 unembalmed adult lower limb specimens were injected with dyed gelatin in a controlled fashion. After freezing, the feet were sectioned either transversely or sagittally. The distribution of the dyed gelatin was then studied. Nine compartments were identified. These were the (1) medial, (2) superficial, (3) lateral, (4) adductor, (5-8) four interossei, and (9) calcaneal. The contents of each compartment was then studied as was the compartment’s location in the foot and its position relative to other compartments. We identified a new, separate Compartment which lies deep to the superficial compartment in the hindfoot area only. This compartment contains the quadratus plantae muscle. We have named it the “calcaneal” compartment to emphasize its hindfoot location. In addition, a communication was demonstrated between the calcaneal compartment and the deep posterior compartment of the leg through the retinaculum behind the medial malleolus, following the neurovascular and tendinous structures. Claw toe deformity following calcaneus fracture appears to be due to late contracture of the quadratus plantae muscle in the calcaneal Compartment. A surgical technique for release of all of the foot compartments is described.
Extremity compartment syndromes are becoming increasingly acknowledged as an important source of severe, long-term disability. The major recognized sites of involvement are the forearm and the leg, with others seen sporadically (deltoid, arm, hand, gluteal, iliacus, thigh Recent works have focused on the foot as a possible site of involvement, but little information exists about the development of the hypothetical late contractures .2-4.7,15-17*20 We have seen three patients with fractures of the calcaneus who developed progressive clawing of the lesser toes after their injuries. This experience led us to a further study of the compartments of the foot and their decompression.
CASEREPORTS Case 1
A 28-year-old carpenter fell 20 feet from a roof and sustained a comminuted fracture of his right calcaneus. He was treated with elevation and a bulky compression dressing. Early motion was begun, followed by progressive partial weightbearing at 3 weeks after the injury. At 6 weeks, he was fully weight-bearing. The patient returned to work 6 months after his injury with only mild, intermittent pain over the lateral aspect of his heel, in the area of the peroneal tendons. Thirteen months after his injury he returned when he noticed the development of a moderate claw toe deformity of his second and third toes. The neurovascular status of the foot was normal. This deformity was treated with shoe and work boot modifications(a larger toe box).
* Assistant Professor, Department of Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, Michigan. To whom correspondence and requests for reprints should be addressed at: Department of Orthopaedic Surgery, Wayne State University School of Medicine, Hutzel Hospital, 4707 St. Antoine, 1-South, Detroit, Michigan 48201. t Resident, Department of Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, Michigan. No benefits in any form have been received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding sources were departmental research funds of the Fund for Medical Research and Education (Grant #2634), Wayne State University.
Case 2
A 23-year-old man was riding a three-wheeled motorcycle when he was struck by an automobile. He sustained a fracture of the right calcaneus with a skin avulsion over the medial portion of the arch. The patient underwent split-thickness skin graft to the ulcerated area. 267
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When seen 27 months after his injury, he complained of progressively rigid, fixed claw toe deformities of his second and third toes, which began 12 months after his initial injury. There was also decreased sensation over the plantar aspect of these toes. The patient had surgical repair of the deformities of his second and third toes by proximal interphalangeal joint resections and recovered uneventfully.
Case 3
A 37-year-old man fell off a ladder sustaining a comminuted fracture of the left calcaneus. He was treated with a long-leg cast for 8 weeks, followed by a shortleg walking cast for 3 weeks. Eight months after his fracture, it was noted that he was developing clawing of his lateral four toes. These progressed until he underwent surgical repair of these four toes, 1 year after his injury. This was done by excision of the proximal interphalangeal joints. Twenty-four years after the fracture, the patient had recurrence of the claw toe deformities of the second, third, and fourth toes. In addition, he had developed a painful bunionette over the lateral aspect of his fifth metatarsal head. There was very restricted subtalar joint motion, which was minimally symptomatic. The subtalar joint showed degenerative arthritis developing roentgenologically. The patient underwent uneventful surgical repair of his recurrent claw toe deformities and his symptomatic bunionette.
inject dyed gelatin through this wall to better evaluate the hindfoot portion of the "central" compartment. On the remaining three specimens, the medial compartment was again opened and the abductor hallucis longus muscle reflected upward, but the injection was performed at the mid-metatarsal level to better evaluate the forefoot portion of the "central" compartment. All of the foot specimens were then placed into a freezer ( -10" C). After at least 24 hours in the freezer, the specimens were then sectioned either transversely or sagittally with a band saw and the compartment anatomy studied by evaluating the distribution of the dye.l1 .18
RESULTS
Our injection studies demonstrated a total of nine compartments in the foot. Three run the entire length of the sole of the foot (medial, superficial, and lateral), whereas five are confined to the forefoot (adductor and four interossei). A previously undescribed compartment
MATERIAL AND METHODS
Our anatomical study consisted of 17 adult unembalmed lower limb specimens. Three different dissection and injection techniques were used to define the compartments of the foot. In nine specimens, we made a transverse skin incision across the plantar aspect of the foot, approximately 3 cm proximal to the fifth metatarsal tuberosity. The incision was carefully continued to the level of the plantar aponeurosis. The heel pad was then elevated, allowing clear visualization of the plantar compartment surfaces. Each compartment was then injected with a dyed gelatin solution (Baker's Analyzed cR>; J.P. Baker, Inc., Phillipsburg, NJ) just deep to the fascia. A different color was used for each compartment. On five feet, the medial compartment was opened posteriorly and the abductor hallucis longus muscle was reflected upwardly, exposing the medial wall of the previously described "central"' 16-18 or intermediate6l1l5Compartment. We then proceeded to
Fig. 1.
A . Transverse section through the base of the metatarsals The medial (M). lateral (L). superficial (S). and calcaneal (C) compartments are seen Artifactual staining of the intermetatarsal joints is seen. as the dark blue dye used to stain the lateral compartment tracked up the peroneal longus tendon sheath to enter them 8 Enlargement of 1 A Red dye injected into the superficial compartment (S) did not enter the calcaneal compartment (C)
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was identified and is confined to the hindfoot (calcaneal). The medial compartment is limited by the fascia overlying the abductor hallucis muscle medially, and the medial intermuscular septum arising from the medial edge of the plantar aponeurosis (Fig. 1A). The medial compartment contains the abductor hallucis muscle and the two heads of the flexor hallucis brevis muscle. The superficial compartment (Figs. 1-4) is limited superficially by the plantar aponeurosis and, medially and laterally, by the medial and lateral intermuscular septums. Posteriorly, the compartment begins at the anteromedial surface of the lateral intermuscular septum, as the lateral compartment sweeps medially to its origin from the undersurface of the calcaneus and its medial tuberosity. This compartment contains the flexor digitorum brevis muscle, the distal tendons of the flexor digitorum longus muscle, and the four lumbrical muscles. Previous terminology has referred to this area as the intermediate,6.’‘.15 or central compartment,2~’6-’B~20 but to avoid confusion with the other deep forefoot and hindfoot areas, we believe the term “superficial” compartment is more appropriate. The lateral compartment is limited laterally by the fascia overlying the abductor digiti minimi muscle and medially by the lateral intermuscular septum arising from the lateral edge of the plantar aponeurosis. The posterior extent Of the compartment continues to the inferior surface of the cakaneus where it continues transversely in a medial direction toward the medial
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calcaneal tuberosity (Figs. 2 and 4). At this point, the lateral compartment is actually proximal to the superficial compartment (Fig. 2). The lateral compartment contains the abductor digiti minimi and flexor digiti minimi brevis muscles. The adductor Compartment is confined to the forefoot. It is walled off by the two limbs of the Y-shaped horizontal septum and the lateral wall of the medial compartment (Fig. 5). This compartment contains the adductor hallucis muscle. There are four separate interosseous compartments (Fig. 5) in the forefoot. Each is limited inferiorly by the deep fascia1 membrane of the adductor compartment
Fig. 3. Transverse section through the proximal metatarsals. The distal extent of the quadratus plantae muscle (calcaneal compartment) is seen (arrow).
Fig. 2. Dark blue dye outlines the superficial compartment in this sagittal section The tissue deep to this area is the unstained calcaneal compartment in the hindfoot. and the adductor in the forefoot The superficial compartment arises from the anterior fascia of the lateral Compartment (arrow)
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Fig. 5. Transverse section through the mid-metatarsal level The adductor compartment (A) is stained dark blue The four interossei Compartments are stained alternately and numbered The flexor hallicus brevis muscle is unstained in the medial Compartment (arrows)
Fig. 4. Transverse section through the hindfoot The lateral compartment transverses under the calcaneus to the medial side of the foot In this injection. the most medial portion of the lateral compartment remains unstained (arrow)
or the superficial compartment. Medially and laterally, the compartment is limited by the respective metatarsals and a vertical fibrous septum which extends from the metatarsal to the fascial membrane limiting the adductor or superficial compartment. Superiorly, the overlying dorsal interosseous muscular fascia confines each Compartment. These four compartments each contain a dorsal and plantar interosseous muscle. The calcaneal compartment was discovered when injections of the superficial compartment did not fill a muscular zone in the area of the hindfoot (Figs. 1 and 2). Conversely, injections of this deep muscular area containing the quadratus plantae muscle did not communicate with the other foot compartments, although dye did follow the flexor digitorum longus tendon and posterior tibial neurovascular structures into the deep posterior compartment of the leg (Figs. 6 and 7). This compartment is limited medially and laterally by the
respective intermuscular septums. Superficially, the compartment is limited by a fascial plane which arises from the medial intermuscular septum and extends to the lateral intermuscular septum, thus separating this compartment from the superficial compartment. The deep aspect of the compartment is limited by the calcaneus and tarsal bones with their overlying ligaments. Distally, the compartment is limited by the flexor digitorum longus tendons into which the quadratus plantae muscle inserts (Fig. 3). Proximally, the compartment communicates with the deep posterior compartment of the leg as stated. The only muscle in the compartment is the quadratus plantae muscle. Proximally, the posterior tibial vessels and nerve, and more distally the lateral plantar vessels and nerve, are located within this compartment as they course past the ankle to supply the plantar surface of the foot.
DISCUSSION
The anatomy of the foot has been studied in many ways for a number of years. The various structures and their relationships to each other and to various spaces,8,’2 layer^,^,'^,'^ and compartments2~6~”~’5-’’~zo have been widely described. We found that these numerous descriptions have led to a good deal of confusion, as the various spaces, layers, and compartments vary in their position in the foot, with some being located along the entire length of the foot, whereas others are located in just the forefoot or the hindfoot. Henry’ emphasized that the layers of the foot alternate, and our injection studies have confirmed that the compart-
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I&Fig. 6. Sagittal section through the second metatarsal The calcaneal Compartment IS stained dark blue Note its hindfoot location The dye follows the structures behind the medial malleolus to communicate with the deep posterior compartment of the leg (arrow)
ments of the foot also alternate in a similar manner. We found that the medial, lateral, and superficial compartments run the entire length of the foot and that the adductor and interossei compartments are limited to the forefoot. The calcaneal compartment is situated in the hindfoot only. Grodinsky was one of the first persons to look at the anatomy of the foot in depth.8 His main interest was in the spread of infection through the fascia1 spaces. He performed injection studies of the spaces and diagrammed the foot in a transverse section (Fig. 8). One sees that he depicted the muscle bellies of the flexor digitorum brevis, adductor hallucis, and quadratus plantae to all be present in the same cross-section at midfifth metatarsal level. In our studies, the flexor digitorum brevis muscle was tendinous in nature at this level and the quadratus plantae muscle was absent (Fig. 6), having inserted more proximally into the tendons of the flexor digitorum longus muscle (Figs. 3 and 6). This error, illustrating the quadratus plantae muscle in the forefoot, has been repeated by others for 60 years (Figs. 8 and 9).' l1l2 15-18 The lumbrical muscles are the muscle tissues located in this area, as they attach to the distal portion of the flexor digitorum longus, and should be depicted as such. Also, our sagittal sections agreed with McMinn et al.'s study where the origin of the oblique head of the adductor was shown to be the proximal second through fourth metatarsal~,'~ in the forefoot. This area is distal to the obliquely coursing
flexor digitorum longus muscle and its proximally attached quadratus plantae muscle. Kamel and Sakla described the intermediate (central) compartment as being subdivided by a Y -shaped septum (Fig. 9).11 They felt that the adductor hallucis muscle and the two heads of the flexor hallucis brevis muscle were located in one compartment, whereas the flexor digitorum brevis muscle, the quadratus plantae and the lumbrical muscles were located in another, and finally, that the interossei were located in their own compartments. Our investigation does not completely concur with their findings in the forefoot, as we found the two heads of the flexor hallucis brevis muscle to be located in the medial Compartment. We confirmed however, that the adductor hallucis muscle is located in its own compartment (the adductor compartment) rather than in the intermediate or central compartment as thought by others.8,'6-'8 The interosseous muscles maintained their own compartments individually (Fig. 5). In the hindfoot, our results differ from Kamel and Sakla" as we found the quadratus plantae muscle to lie in a distinct compartment separate from the flexor digitorum brevis muscle of the superficial compartment. This was confirmed by complimentary injections into both of these compartments, and, in no case, did the To avoid confusion with dye enter the other (Fig. l).2,6,7 previous descriptions of the "intermediate"6,'',15 and ~~centra("2.16~18.21 compartment, and to emphasize its
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Fig. 9. Transverse section through the mid-portion of the fifth metatarsal bone The adductor compartment is shown (19.20) We found the flexor hallicus brevis muscle (20) to be located in the medial compartment, however Also, the quadratus plantae muscle does not exist at this level, as illustrated (10) (Reprinted with permission of publisher. from Kamel. R and Sakla. F B Anatomical compartments of the sole of the human foot Anatomical Record, 140 57-64, 1961)
Fig. 7. Transverse section through the hindfoot The dark blue stained calcaneal compartment is distinct from the other compartments
location in the hindfoot, we prefer to call this newlyfound, deep, centrally-located, hindfoot compartment the “calcaneal” compartment. The compartment containing the flexor digitorum brevis is best referred to as the superficial compartment to avoid confusion between it and the other centrally-located compartments (calcaneal, adductor, interossei). Injections into the calcaneal compartment tended to follow the flexor digitorum longus tendon and the posterior tibial neurovascular structures into the deep compartment of the leg (Fig. 6). A communication between the deep compartment of the leg and the central compartment of the foot has been described previ~ u s l y . ~ This ~ ~ communication ~”~’~ is clinically important, as it may lead to compartment syndromes in both the foot and leg when only one is significantly injured. A case is reported here to illustrate this point.
Case 4 d Sp.
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Fig. 8. Diagram of a transverse section through the forefoot The quadratus plantae muscle is incorrectly depicted in this forefoot location (Reprinted with permission of publisher. from Grodinsky. M A study of the fascia1 spaces of the foot and their bearing on infections Surgery, Gynecology. and Obstetrics 49 737-751, 1929)
A 44-year-old man fell off a car-carrier truck, landing on both feet. He sustained a very comminuted tibial pilon fracture with a fracture of the upper fibula on the right and fractures of his second and third metatarsal on the left. Soon after his injury, he developed massive swelling of his right leg with paresthesias and pain in his leg and foot, which became worse with passive stretching of the leg muscles. A clinical diagnosis of compartment syndrome of the leg was made. Slit catheter measurements of 68 mmHg of pressure in the anterior compartment and 38 mmHg of pressure in the deep posterior compartment confirmed the diagnosis.
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A four compartment leg fasciotomy was performed. Intraoperatively, it was noticed that his ipsilateral right foot had also become massively swollen, despite the absence of local bone injury, and slit catheter measurement showed 30 mmHg of pressure in the calcaneal compartment. A foot fasciotomy was performed through two dorsal incisions over the forefoot and a single medial incision over the hindfoot. After delayed wound closure and healing, the pilon fracture was internally fixed. The patient had an uneventful recovery and returned to work as a delivery man 18 months after his injury. He did not develop any claw toe or foot deformities as a result of his injuries. The calcaneal compartment is a distinct compartment separate from the remainder of the foot compartments. Late contracture of the quadratus plantae muscle due to ischemic changes of compartment syndrome could lead to the claw toe deformities seen in our patients (cases 1-3). Woodburne describes the quadratus plantae muscle as having a “tendinous lateral head that arises from the lateral border of the plantar surface of the calcaneus and from the long plantar ligament. The fleshy medial head takes origin from the medial surface of the calcaneus and from the medial border of the long plantar ligament.”” This muscular medial head may be more vulnerable to pressure ischemia resulting in the claw toe deformity occuring in the second and third toes of two of our patients (Cases 1 and 2). The more tendinous lateral head may be less susceptible to the consequences of ischemia and scarring, although it still may develop in this area (Case 3). One can also postulate that extensive contracture of other adjacent muscles (flexor digitorum brevis, abductor hallucis, interossei, etc.) may also increase the severity or rigidity of the deformities, as well as add an element of cavus to the foot. This was not seen in the patients in this series, however. In none of the patients was the clawing diminished by plantarflexing the ankle, indicating an intrinsic foot contracture. Without direct surgical exploration, it is difficult to prove conclusively that the three patients seen here with claw toe deformities after fractures of the calcaneus are suffering the sequela of a missed compartment syndrome of the foot. However, it is a highly likely explanation considering the deformity developed progressively over 8 to 13 months after the injury in our patients. This time sequence is similar to what is seen in established compartment syndromes of the leg and forearrn.l5Also, in the forearm, Tsuge states that “the most marked ischemia occurs in the deeply situated muscles,”’sa fact that if extrapolated to the foot, would support the theory of a contracted quadratus plantae muscle as the offender. Future direct compartmental exploration and release in similarly contracted patients will be necessary to prove this theory, however.
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This experimental evidence, coupled with the observations of others‘ as well as our own observations during foot fasciotomy, in which hemorrhage and swelling is consistent in the hindfoot compartments, have led us to recommend hindfoot fasciotomy as an integral part of foot compartment release. Myerson showed that with a dorsal, two-incision approach over the forefoot, increased pressure in the hindfoot may eventually be released, albeit ~ l o w l y . ’ We ~ ~ ’do ~ not know if the hindfoot pressure he was measuring during his experiment was from the calcaneal compartment or the superficial compartment. Since the calcaneal compartment does not extend into the forefoot, we do not feel that it can be adequately decompressed by the dorsaltwo-incision approach. We agree with Myerson that, in cases of hindfoot injury and suspected compartment syndrome, a hindfoot fasciotomy should accompany a dorsal-two-incisionfasciotomy.’6 This hindfoot fasciotomy should include release of the calcaneal compartment. The medial approach of Henry,g as used by Bonutti and Bell in their report,’ certainly will decompress all of the foot compartments. We have found, however, that this approach is very extensive and may be difficult to perform in a severely traumatized adult foot. Deep dissection along bloody and poorly differentiated planes may cause further damage to the important neurovascular structures. Combining a lateral approach to the Henry approach adds little to the procedure.” Therefore, we have developed the following technique for a complete nine compartment foot fasciotomy.
SURGICAL TECHNIQUE
Three incisions are used to decompress the compartments (Fig. 10). The hindfoot incision is over the medial portion of the heel, similar to that described for heel spur relea~e.’.~ It begins 4 cm anterior to the posterior portion of the heel, 3 cm from the plantar surface. The incision is 6 cm long, parallelingthe bottom of the heel pad. The incision is carried down to the fascial wall of the medial compartment. The subcutaneous tissue is then elevated both superiorly and inferiorly, exposing the plantar aponeurosis. The medial compartment is then opened longitudinally with an incision 1 cm from its inferior border. The 1-cm fascial strip that remains can be followed laterally and serves as a landmark for the deeper incisions. The abductor hallucis muscle is then reflected superiorly, and its attachment to the lateral fascial wall of the medial compartment is stripped. First, with forceps, lift the fascia lying superior to the fascial strip and place a small incision in it. This must be performed carefully as the lateral plantar nerve and
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CONCLUSIONS
Clawing of the lesser toes developed in three patients following a fracture of the calcaneus. It is felt that this may be due to progressive, late contracture of the quadratus plantae muscle lying in the deeply situated, previously undescribed compartment of the foot, the calcaneal Compartment. A communication exists between it and the deep compartment of the leg. Total foot fasciotomy can be accomplished safely and effectively through a three incision approach to the forefoot and hindfoot.
ACKNOWLEDGMENTS
The authors thank George Corondan, M.D., for his help with the preparation of the specimens, Cliff Roberts for his photographic assistance; James Dombrowski for his medical illustation, Katrina Turner and Olga Zoubareff for their technical assistance, and Bruce J. Sangeorzan, M.D., for his advice and encouragement.
REFERENCES Fig. 10. The surgical approach. Two dorsal forefoot incisions and one medial, hindfoot incision are used to decompress all of the foot compartments (see text).
artery lie just deep to this fascia. This incision is extended distally and decompresses the calcaneal compartment. The second deep incision is placed inferiorly to the fascial strip. It is carried the entire length of the skin incision and opens the superficial Compartment. At the most proximal portion, this fascial incision provides access to the lateral compartment where the abductor digiti quinti muscle takes origin from the undersurface of the calcaneus (Fig. 2). The lateral compartment is then released with an incision on the inferior-medial aspect of its overlying fascia, extending to the lateral side of the foot. To decompress the forefoot, incisions are made over the second and fourth metatarsal shafts. Taking care to protect the dorsal veins, the subcutaneous tissue is elevated medially and laterally to expose the respective interosseous muscle. The thin fascia over each is incised longitudinally. The first dorsal and plantar interossei are stripped from the shaft of the second metatarsal, retracted medially, and the fascia of the adductor compartment released longitudinally, deep within the interspace. All of the wounds are left open and a gentle pressure dressing is applied.
1. Baxter, D.E. and Thigpen, M.C.: Heel pain-operative results. Foot Ankle, 5:16-25, 1984. 2. Bonutti, P.M., and Bell, G.R.: Compartment syndrome of the foot. J. Bone Joint Surg., 68A:1449-1451, 1986. 3. Chuinard, E.G. and Baskin, M.: Claw foot deformity. J. Bone Joint Surg., 55A:351-362, 1973. 4. Cole, W.H.: The treatment of claw foot. J. Bone Joint Surg., 22~895-908,1940. 5. DuVries, H.L.: Heel spur (calcaneal spur). AMA Arch. Surg., 74~536-542,1957. 6. Feingold, M.L., Resnick, D., Niwayama, G., and Garetto, L.: The plantar compartments of the foot: a roentgen approach. I. Experimental observations. Investigative Radiology, 12:281288,1977. 7. Gissane, W.: A dangerous type of fracture of the foot. J. Bone Joint Surg., 338535438, 1951. 8. Grodinsky, M.: A study of the fascial spaces of the foot and their bearing on infections. Surgery, Gynecology and Obstetrics, 49:737-751,1929. 9. Henry, A.K.: Extensile Exposure. 2nd Ed. Baltimore, Williams & Wilkins, 1963, pp. 300-308. 10. Jones, R.: Volkmann's ischaemic contracture with special reference to treatment. Br. Med. J., 2:639-642. 1928. 11. Kamel, R. and Sakla, F.B.: Anatomical compartments of the sole of the human foot. Anat. Rec., 14057-64, 1961. 12. Loeffler, R.D. and Ballard, A.: Plantar fascial spaces of the foot and a proposed surgical approach. Foot Ankle, 1:ll-14, 1980. 13. McMinn, R.M.H., Hutchings, R.T., and Logan, B.M.: Color Atlas of Foot and Ankle Anatomy. England, Wolfe Medical Publications Ltd., 1982, pp. 29-76. 14. Mizeres, N.J.: Human Anatomy: A Synopic Approach. New York, Elsevier, 1981, p. 228. 15. Mubarak, S.J. and Hargens, A.R.: Compartment Syndrome and Volkmann's Contracture, Vol. 3. Philadelphia, W.B. Saunders,
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Foot & Ankle/Vol. 70,No. S/April, 7990 1981, pp. 44-45. 16. Myerson, M.S.: Acute Compartment syndromes of the foot. Bull. Hosp. Joint Dis. Orthop. Inst., 47:251-261, 1987. 17. Myerson, M.S.: Experimental decompression of the fascia1 compartments of the foot-the basis for fasciotomy in acute compartment syndromes. Foot Ankle, 8:308-314, 1988. 18. Richrnan, J.D. and Barre, P.S.: The plantar ecchymosis sign in fractures of the calcaneus. Clin. Orthop. Relat.. Res., 207:122125,1986. 19. Tsuge, K.: Treatment of established Volkmann’s contracture. J.
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Bone Joint Surg., 57A:925-929, 1975. 20. Whitesides, T.E.: Compartment Syndromes. In Disorders of the Foot. Jahss, M.H. Philadelphia,W.B. Saunders, 1982, pp. 12011204. 21. Woodburne, R.T.: Essentials of Human Anatomy. 6th Ed. New York: Oxford University Press, 1978, pp. 573-582. 22. Ziv, 1. Mosheitt, R., Zeligowski, A. Liebergal, M., Lowe, J., and Segal, D.: Crush injuries of the foot with compartment syndrome: immediate one-stage management. Foot Ankle, 9:285-289, 1989.
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