Diagnosis and Treatment of Acute Compartment Syndrome

The onset of acute compartment syndrome is something of great concern to the emergency room physician, trauma surgeon, and podiatric foot and ankle surgeon.  It is something that is routinely screened for an any lower extremity trauma.

The muscles of the foot and leg are divided into compartments, each of which is separated by a layer of fascia.  This dividing fascia is tough and restricting, and does not allow for much expansion of the tissues within the compartment.  Normally this is a good thing, as it helps separate and organize the muscle compartments of the foot and leg.  However, when the volume of the compartment expands following injury, these bands of tissue help to restrict the fluid, creating an increase in the compartmental pressure.  This increase in pressure can cause damage to the muscles, nerves, and vessels within the compartment, and can lead to tissue death if not addressed properly. 

Signs and symptoms of acute compartment pressure include intense pain out of proportion for the given injury, numbness or tingling in the toes, loss of function of the toes or an inability to move them, and coolness to touch caused by decreased blood flow.  Later in the development of compartment syndrome, pulses may be absent and the toes may turn white in color. 

The diagnosis of compartment syndrome is largely based on the history and physical findings, but a device called a wick catheter may be used to confirm the diagnosis.  This is an instrument that is mainly composed of a needle attached to a pressure gauge, which acts to measure the compartmental pressure.  The normal pressure reading for a muscular compartment should be between 0 and 10 mmHg.  Pressures between 10-20mmHg are closely monitored, as they may continue to increase.  Pressures above 30mmHg are considered diagnostic of compartment syndrome in most cases. 

Once the diagnosis of compartment syndrome is made, the patient must be taken to surgery right away.  A delay in surgical treatment may result in irreversible muscle and tissue damage.  Surgery for compartment syndrome involves releasing the fascia between compartments to relieve the pressure.  This procedure is known as a fasciotomy. 

There are four muscle compartments in the leg to release; the superficial and deep posterior compartments, the lateral compartment, and the anterior compartment.  In the foot, there are also four main compartments; the medial, lateral, central, and interosseous.  Some references will divide the central compartment into a superficial, deep, and calcaneal compartment, and also consider each of the interosseous compartments their own separate compartment.  When acute compartment syndrome is diagnosed, both the leg and foot compartments will oftentimes be opened together. 

The incision sites are kept open, and local wound care is performed to keep the sites clean and prevent infection.  Compartment syndrome will generally keep a patient in the hospital for at least several days, while their condition can be monitored.  Any other injuries must also be addressed.  

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Paronychia

When an ingrown toenail becomes infected, it is referred to as a paronychia. This happens due to the nail literally digging into the skin, causing a breakdown in the soft tissue, which allows bacteria to penetrate the natural skin barrier. The organism that is usually responsible for the infection is a staphylococcus species.

Paronychia will appear as a small, localized area of redness that may spread up the toe. It is generally quite painful, and there is usually a fair amount of pus and drainage from the site. In patients that are immunocompromised, such as diabetics or patients on long-term steroid regimens, a paronychia can advance to a more complicated infection of the soft tissues. These should be dealt with rapidly and aggressively by a doctor.

Treatment for paronychia includes incision and drainage of the infection site, which will help to relieve pain as well as remove much of the infection. A bandage is applied, usually with a topical antibiotic, and oral antibiotics may be used as well. Augmentin is a commonly prescribed oral antibiotic for paronychia, though it may not always be necessary. The bandage may be changed once or twice a day for the first few days, and soaks in a dilute betadine solution may be beneficial as well.

If ingrown toenails and paronychia are a chronic problem, they can be addressed with one of several more permanent procedures. A podiatrist will typically be the type of doctor that deals with this problem. After the infection resolves, a chemical matricectomy may be performed. This procedure involves using a chemical, such as phenol or sodium hydroxide, to permanently remove a portion or the entire nail matrix. The nail and nail matrix may also be surgically removed. Both are relatively minor procedures, and allow for a quick recovery. The recurrence of ingrown toenails after these surgical procedures is extremely low.

Generally speaking, a paronychia is a minor infection, and is treated as such. It is only in the diabetic or otherwise immunocompromised patient that it becomes an area of greater concern. If not dealt with rapidly, a minor infection can become a more serious, even life-threatening infection.

If you are experiencing pain from an ingrown toenail, show it to your doctor. Even if it is not infected, it should be dealt with in an appropriate manner, to relieve pain, prevent regrowth of the ingrown portion of the nail, and prevent a pending infection. With time, many ingrown toenails will ultimately become infected.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com