Timothy G. Weber

Fasciotomy of the Foot: An Anatomical Study with Special Reference to Release of the Calcaneal Compartment

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 compartments 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.

Normal tibiofibular relationships at the syndesmosis on axial CT imaging.

Objectives: Computed tomography (CT) is reported to be superior to plain radiography for imaging the syndesmosis, but CT criteria differentiating normal from abnormal tibiofibular relationships do not exist. The purpose of this study was to define normal tibiofibular relationships at the syndesmosis on axial CT imaging and to report the reliability of these measurements. Methods: Thirty healthy volunteers underwent CT evaluation of bilateral ankles. Axial CT measurements consisted of tibiofibular clear space, tibiofibular overlap, anterior tibiofibular interval, and fibular rotation (&thgr;fib). To assess reliability, 3 investigators independently made each CT measurement on 2 separate occasions. Results: Sixty ankles were included for analysis. CT measurements demonstrated excellent intrarater and interrater reliability. There was significant anatomic variability between individuals. Specifically, statistically significant gender differences were discovered in CT measurements of tibiofibular overlap and anterior tibiofibular interval. Variance between ankles of each subject was calculated. In an uninjured population, tibiofibular intervals do not vary by more than 2.3 mm, and the rotation of the fibula does not vary by more than 6.5° between ankles of the same person. Conclusions: Measurements of tibiofibular relationships made on axial CT images are reliable. Because of significant anatomic variation between individuals, using a patients contralateral ankle for comparison provides a precise definition of normal tibiofibular relationships. These criteria allow for the detection of subtle variations in the tibiofibular relationships indicating instability and provide a tool for postoperatively assessing the reduction of the injured syndesmosis.

Concurrent Compartment Syndromes of the Foot and Leg

We reviewed the case summaries of eight patients who developed concurrent compartment syndromes of the foot and leg after trauma. Patients with multiple fractures of the lower extremities, particularly the tibia, femur, and foot, may develop this disorder. The obvious causes of the concurrent syndromes, concurrent fractures and generalized limb ischemia, were seen only in two patients. The communication between the compartments of the foot and leg may be an additional causative factor. Delayed fasciotomy resulted in muscle necrosis and/or tibial nerve dysfunction. Suspected cases should have the diagnosis established by catheterization of the involved compartments. Prompt fasciotomies of the foot and leg should be performed if the pressures are significantly elevated.

Comparison of plate and screw fixation and screw fixation alone in a comminuted talar neck fracture model.

Background: Talar neck fracture fixation has been studied in noncomminuted fracture models, but no large clinical series of comminuted fracture patterns have been published and no biomechanical studies have compared plate fixation with screw fixation in comminuted talar neck fractures. Methods: Nine matched pairs of fresh frozen talar specimens were stripped of soft tissue and mounted in a cylindrical jig. The talar neck was fractured using a dorsally directed shear force at a rate of 200 mm/min, and dorsal comminution was simulated by removing a 2-mm section of bone from the distal fracture fragment. One specimen from each pair was fixed with either two solid 4.0-mm partially threaded cancellous screws posterior-to-anterior just lateral to the posterior process of the talus or with a four-hole 2.0-mm minifragment plate contoured to the lateral surface of the talar neck and secured with 2.7-mm screws. A 2.7-mm fully threaded cortical screw was placed medially using a lag technique. The specimens were then loaded to failure with a dorsally directed force at a rate of 200 mm/min. Failure was defined as the load producing 2 mm of displacement. A Students t-test analysis was used with significance set at p ≤ 0.05. Results: Posterior-to-anterior screw fixation had a statistically significant higher load to failure than plate fixation (p < 0.05). Mean load to failure for the screw group was 120.7 ± 68.5 N and 89.7 ± 46.6 N for the plating group. Conclusions: Plate fixation may offer substantial advantages in the ability to control the anatomic alignment of comminuted talar neck fractures, but it does not provide any biomechanical advantage compared with axial screw fixation. Further, the fixation strength of both methods was an order of magnitude lower than those found in previous studies of noncomminuted fractures.

Complications Associated with Open Calcaneus Fractures

Background: Literature on open calcaneus fractures is limited and inconsistent. This studys purpose was to report complications such as osteomyelitis, amputations, and soft tissue infections in open calcaneus fractures that were treated at a Level I Trauma Center. Methods: From January 1995 through December 2007, 1,157 calcaneus fractures were identified with 127 fractures being open (11.0%). Average followup time was 9.1 (range, 2 to 53) months. All open fractures were treated by a similar protocol of intravenous (IV) antibiotics, emergent irrigation and debridement (I&D), initial fracture stabilization if possible, subsequent I&Ds as needed, and delayed definitive fixation. One hundred fifteen open calcaneus fractures in 112 patients had sufficient followup for study inclusion. For this study complications were classified into four categories: superficial infections, deep infections, osteomyelitis, and amputations. Results: Medial based wounds occurred in 63 (54.8%) fractures. The overall complication rate was 23.5% with 16 fractures (13.9%) requiring a reoperation. Eleven (9.6%) fractures experienced superficial wound infection and 14 (12.2%) had deep wound infection. Six (5.2%) amputations were required with three being for either soft tissue infection or wound necrosis. Culture-positive osteomyelitis occurred in six (5.2%) patients. Conclusion: Utilizing a standardized protocol, open calcaneus fractures were found to have a lower complication rate than has been previously reported. Level of Evidence: III, Retrospective Comparative Study

Inpatient soft tissue protocol and wound complications in calcaneus fractures.

Background: Operative treatment of calcaneus fractures is associated with the risk of early wound complications. Though accepted practice dictates surgery should be delayed until soft tissues recover from the initial traumatic insult, optimal timing of surgery has not been delineated. Methods: A retrospective chart and radiographic review at a level I trauma center was performed to determine if an aggressive inpatient soft tissue management protocol designed to decrease the time delay from injury to surgery is effective at reducing complications. Ninety-seven patients (17 female, 80 male; mean age, 39.7 ± 14.0 years) with 102 calcaneus fractures treated between October 1995 and January 2005 were identified. Differences in complication rates and quality of reduction between the inpatient and outpatient treatment groups were analyzed. Quality of reduction was determined by measuring postoperative Bohlers angle and posterior facet articular step-off. Results: Mean time from injury to surgery was 6.2 days for the inpatient group and 10.8 days for the outpatient group (p < 0.0001). The overall complication rate was over twice as high in the outpatient group (27 versus 12%, p = 0.04) and the serious complication rate was 6.5 times higher when patients were managed as outpatients (9% versus 1%, p = 0.09). With the numbers available, there were no significant differences in the quality of reduction obtained at surgery. Conclusion: This study suggests that this inpatient soft tissue management protocol of calcaneal fractures is a feasible treatment option when a patient is kept in the hospital that offers a reduction in postoperative wound complications while enabling surgery 4 days earlier on average. Level of Evidence: III, Retrospective Comparative Study

Compartmental catheterization and fasciotomy of the foot

Foot compartment syndromes are becoming increasingly recognized in a number of foot injuries. Tense swelling of the involved foot is the best clinical sign, but severe pain, pain on passive stretch of the foot muscles, and sensory disturbances are sometimes observed. Once suspected, the diagnosis is best confirmed by multiple stick catheterization of the foot. It is essential to measure the pressure in the calcaneal and lateral compartments in the hindfoot as they frequently have the highest pressures. A three-incision fasciotomy with a single medial hindfoot incision and two dorsal forefoot incisions is recommended to release the foot compartments.

Patient Mortality in Geriatric Distal Femur Fractures

Objectives: To estimate 1-year mortality rates in elderly patients who undergo operative treatment for distal femur fractures and identify potential risk factors for mortality. Design: Retrospective chart review. Setting: Level 1 and Level 2 trauma centers. Patients/Participants: Two hundred eighty-three elderly patients (average age 76.0 years ± 9.8) who sustained distal femur fractures between 2002 and 2012. Intervention: Fracture fixation of the distal femur. Main Outcome Measure: Survival up to 1 year after surgery. Results: The 1-year mortality rate for distal femur fractures in elderly patients was 13.4%. There were no statistically significant differences in overall mortality between native bone and periprosthetic fractures, intramedullary nail or open reduction internal fixation, or across Orthopaedic Trauma Association fracture classifications. Overall patient mortality was significantly higher at 30 days (P = 0.036), 6 months (P = 0.019), and 1 year (P = 0.018), when surgery occurred more than 2 days from the injury. Mean Charlson Comorbidity Index scores were significantly lower in survivors versus nonsurvivors at all time intervals (30 days, P = 0.023; 6 months, P = 0.001 and 1 year P ⩽ 0.001). A time to surgery of more than 2 days, regardless of baseline illness, did not result in improved survivability at 1 year. Conclusions: Overall mortality for distal femur fractures was 13.4% in the elderly population. A surgical treatment more than 2 days after injury was associated with increased patient mortality. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.