Acute Compartment Syndrome of the Foot Due to Frostbite

Acute compartment syndrome of the foot and ankle is a relatively rare clinical finding. Lower extremity compartment syndrome is customarily due to vascular or orthopedic traumatic limb threatening pathology. Clinical correlation and measurement of intracompartmental pressure are paramount to efficient diagnosis and treatment. Delayed treatment can lead to local as well as systemically adverse consequences.

Frostbite, a comparatively more common pathology of the distal extremities, occurs when tissues are exposed to freezing temperatures. Both pathologies have detrimental outcomes if not treated in a timely and appropriate manner, with increasing amputation rates with time delay. Providers should have a high index of suspicion for compartment syndrome following frostbite injuries. Soft tissue swelling can occur in patients with a coagulopathy in the absence of trauma. As muscle tissue dies, ischemia causes intrafascicular and perifascicular edema in muscle fibers.

Revascularization can also result or add to compartment syndrome. In the reperfusion state, there is a complex mechanism that leads to vessel leakage and greater soft tissue edema. Awareness of traumatic or vascular pathology helps make a timely diagnosis of compartment syndrome. Once the diagnosis is made, prompt intervention is required. Decompression of the fascial compartments is the standard of treatment for patients with compartment syndrome. Maximum width between incisions is suggested to prevent dorsal flap necrosis. Care must be taken to avoid the neurovascular bundles while releasing the compartments.

If compartment syndrome is not addressed, there is a possibility of permanent myoneural tissue damage within the affected compartment due to elevated compartment pressure and decreased blood flow. The exact pressure at which this ischemia happens is debatable and conclusions are mostly from studies of the leg and forearm. What is agreed upon, however, is that acute compartment fasciotomies should be performed if there is any suspicion of compartment syndrome.

Wound healing complications following fasciotomies are reported especially in the setting of traumatic injury with concomitant soft tissue compromise. The assistance of negative pressure therapy has been advocated by some authors to reduce wound complications. Skin grafting and possible free flap reconstruction are often utilized for facilitating closure and defect. Closer routine post-operative follow-up is recommended for those with diabetes, peripheral vascular disease, and neuropathy.

In conclusion, acute thermal injury and frostbite leading to acute compartment syndrome of the foot and ankle is a rare occurrence but it does have long-term effects on function and quality of life if not diagnosed and treated promptly and effectively. Diagnosis can be made with a combination of clinical findings, laboratory values, and pressure monitors. Decompression of the compartments via fasciotomies is the standard treatment method with various approaches described. Incisional planning may be best done on a case-by-case basis while accounting for the unique fascial anatomy. 

From: JFAS VOLUME 57, ISSUE 2, P382-387, MARCH 2018. Acute Compartment Syndrome of the Foot Due to Frostbite: Literature Review and Case Report. Brandao, St. John, Langan, Schneekloth, Burns.