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C OPYRIGHT Ó 2012 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Injury Patterns Causing Isolated Foot

Compartment Syndrome
Nikhil A. Thakur, MD, Matthew McDonnell, MD, Christopher J. Got, MD, Nicole Arcand, MD,
Kevin F. Spratt, PhD, and Christopher W. DiGiovanni, MD

Investigation performed at the Department of Orthopaedics, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island

Background: The true incidence and primary predictors of foot compartment syndrome remain controversial. Our aim
was to better define the overall incidence of foot compartment syndrome in relation to the frequency and location of
various foot injuries. We hypothesized that (1) the incidence would increase in proportion to the number of anatomic
locations of injury, (2) the incidence would be higher in association with hindfoot and crush injuries compared with any
other injury categories, and (3) not only would the incidence associated with calcaneal fractures be lower than the often
quoted 10% but foot compartment syndrome would also be fairly uncommon after such fractures.
Methods: The National Trauma Data Bank was used to identify patients who had undergone a fasciotomy for the
treatment of isolated foot compartment syndrome. Strict inclusion and exclusion criteria were used to identify only
patients with foot injuries who had undergone fasciotomy for foot compartment syndrome.
Results: Three hundred and sixty-four patients with an isolated foot compartment syndrome were identified. The highest
incidence of foot compartment syndrome was seen in association with a crush mechanism combined with a forefoot injury
(18%, nineteen of 106), followed by an isolated crush injury (14%, twenty-three of 162). Only 1% (thirty-two) of 2481
patients with an isolated calcaneal fracture underwent fasciotomy. An increase in the number of anatomic locations of
injury did not appear to correspond to an increased incidence of foot compartment syndrome.
Conclusion: Our results demonstrate that injuries involving a crush mechanism, either in isolation or in combination with
a forefoot injury, should raise suspicion about the possibility that a foot compartment syndrome will develop.
Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

T
rauma to the foot has long been recognized as a cause
of foot compartment syndrome, a serious complication
first described by Bonutti and Bell1 in a 1986 case report
and later by Myerson in 1987 and 19882,3. Untreated or delayed
management of foot compartment syndrome can lead to sub-
stantial long-term disability, so a prompt diagnosis is required.
A high index of suspicion is often necessary for patients at risk
for developing foot compartment syndrome on the basis of the
history and physical examination findings. To our knowledge, a
stratification of injury patterns in the foot corresponding to the
relative risk of foot compartment syndrome has not been de-
fined. The inability to clearly predict patients at risk necessitates
more reliance on serial physical examinations and has promoted
a more reactive, rather than a proactive, clinical approach.
Foot compartment syndrome should be suspected after any
substantial foot injury. As pointed out by Myerson and Manoli,
the diagnosis should be based foremost on the development of
disproportionate or uncontrollable pain in the presence of typical
physical findings such as severe swelling, ecchymosis, pain with
passive motion of the toes, decreased sensation, or obvious struc-
tural deformity2-4. If time permits, intracompartmental pressure
measurements are recommended to confirm the diagnosis4,5.
Abnormal clinical examination findings and elevated compart-
mental pressure measurements are useful and relatively reliable
diagnostic tools when used together. Elevated pressure mea-
surements alone, however, may not accurately reflect the pres-
ence of compartment syndrome, particularly when the physical
examination findings do not correlate with these measurements6.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any
aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this
work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has
had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this
work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2012;94:1030-5 d http://dx.doi.org/10.2106/JBJS.J.02000

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To date, calcaneal fracture is the only specific type of foot
injury that has a clearly established relationship with an evolving
foot compartment syndrome (a 10% incidence4), although high-
energy crush injuries have also been associated with compart-
ment syndrome1,7-9. Foot compartment syndrome has been
documented after other injury types such as Lisfranc fracture-
dislocations and multiple metatarsal and phalangeal fractures,
but, as is the case for crush injuries, the actual incidence asso-
ciated with these other injury patterns remains poorly under-
stood8. Patients can also develop concurrent compartment
syndrome of the foot and leg in the presence of multiple lower-
extremity fractures as a result of communication between the
calcaneal compartment and the deep posterior compartment of
the leg10,11. Open fractures do not preclude the possibility of
foot compartment syndrome12.
The most common sequelae of a missed foot compartment
syndrome are intrinsic minus claw toe deformities, due to either
intrinsic muscle weakness or contracture of the quadratus plantae
within the calcaneal compartment1,9,11,13-15. Following a com-
partment syndrome, cavus deformity may also result from fi-
brosis of the plantar foot structures or a concurrent compartment
syndrome in the leg16. Currently, the specific patterns of foot
injury that pose the highest risk of foot compartment syndrome
remain unknown. Our purpose in performing this study was
to better define the overall incidence of foot compartment syn-
drome in relation to the frequency and location of various foot
injuries.
We hypothesized that (1) the incidence of foot compart-
ment syndrome would increase in proportion to the number of
anatomic locations of injury involved, (2) the incidence of foot
compartment syndrome would be higher in association with
hindfoot and crush injuries compared with other injury cate-
gories, and (3) not only would the incidence associated with
calcaneal fractures be lower than the often quoted 10% but foot
compartment syndrome would also be fairly uncommon after
such fractures.
Materials and Methods
T he primary data source for this study was the National Trauma Data Bank
(NTDB), which is published by the American College of Surgeons and
serves as a public resource to enhance trauma care through research. We used
version 7.0, which contains data from 2002 through 2008, to identify a target
population of patients with isolated foot injuries or fractures who had under-
gone fasciotomy for the treatment of a compartment syndrome of the foot.
Several ICD-9 (International Classification of Diseases, Ninth Revision)
diagnostic codes were used to search the data bank to identify the at-risk target
population. The Appendix lists these codes, which include all patterns of foot
injury that may result in compartment syndrome. The codes were then sepa-
rated into four categories on the basis of either the anatomic location of injury
or whether the injury was caused by a crush mechanism. While ICD-9 codes
958.90 and 958.92 identify patients with compartment syndrome and trau-
matic compartment syndrome of the lower extremity, respectively, these codes
were not populated in the NTDB. As an alternative, the procedure code 83.14
(defined in the NTDB as ‘‘fasciotomy’’) was used to determine which patients in
the cohort underwent fasciotomy of any extremity, presumably for the diag-
nosis of compartment syndrome.
Since the 83.14 code does not discriminate between anatomic sites of
fasciotomy, the procedure codes involving injuries to the femur, tibia, or fibula
that may have been associated with compartment syndrome were considered
I N J U R Y P AT T E R N S C AU S I N G I S O L AT E D F O O T
C O M PA R T M E N T S Y N D R O M E
exclusion criteria in our cohort in order to isolate foot fasciotomies. This step
eliminated patients who had thigh or leg compartment syndrome or who might
have developed foot compartment syndrome as a result of injury to the tibia or
fibula. Procedures in the upper extremities that might have been associated
with upper-extremity compartment syndrome requiring fasciotomy were also
eliminated. The Appendix summarizes the exclusion procedure codes that were
used to isolate patients who had had fasciotomy only of the foot for a presumed
foot compartment syndrome.
Patient demographics such as age, sex, race, mechanism of injury, Injury
Severity Score (ISS), length of hospital stay, and time of arrival in the emergency
room were recorded. The regional location of the hospitals in the United States
(Northeast, South, Midwest, and West) and the types of hospitals (teaching
versus nonteaching and trauma-level designation) were also recorded.
Two cohorts were generated for comparison: (1) patients with foot
injuries who had undergone a fasciotomy for a presumed foot compartment
syndrome and (2) patients with similar injury patterns who had not undergone
a fasciotomy. Additionally, an attempt was made to determine any effect of
patient demographics and hospital factors on the fasciotomy rate.
Statistical Analysis
Basic descriptive statistics means, standard deviations, and rates associated with
the independent and foot compartment syndrome outcome variables were used
to describe the sample and to summarize the univariate relationships between
foot compartment syndrome and the selected predictors and covariates.
Differences in foot compartment syndrome rates were evaluated with
use of Poisson regression with log link modeling using the GENMOD and
GLIMMIX procedures available in SAS 9.2 software. These models produce
unadjusted foot compartment syndrome rates and the relative risk of foot
compartment syndrome when demographic factors are evaluated one at a time
and produce adjusted foot compartment syndrome rates and relative risks of
foot compartment syndrome when all demographic factors are considered in
the model simultaneously.
Source of Funding
There was no external funding source for this study.
Results
M ore than 1.1 million entries in the National Trauma Data
Bank, version 7.0, were screened. The total number of
patients with isolated foot injuries in the NTDB was 18,676 as
determined by our inclusion and exclusion criteria. Of these
patients, 364 (overall incidence, 2%) had a fasciotomy of the
foot for a presumed foot compartment syndrome, based on
procedure code 83.14 and with use of our exclusion criteria.
The average age of patients undergoing fasciotomy for
foot compartment syndrome was thirty-eight years. Most pa-
tients sustaining foot injuries were male (68%, 12,701 patients)
and white (71%, 13,272 patients). The average ISS for the co-
hort was 10.7 ± 4. The mean length of hospital stay was 7.3
days, and the mean time in the intensive care unit was two days.
In the cohort of patients undergoing fasciotomy, 83% were
male and 71% were white.
Fifty-nine percent of the patients had the fasciotomy in
hospitals in the Northeast and South (34% and 25%, respectively),
23% had it in the Midwest, and the remainder had it in the West.
Fasciotomy Rates Based on Categories of Injury
Of the 18,676 patients with isolated foot injuries, 8749 (47%)
had involvement of the forefoot. The number of patients with
an isolated forefoot injury was 6714 (36%), which was the
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TABLE I Incidence of Fasciotomy Based on Categories of Injury (P < 0.001)

No. of Patients Total No. of Patients with Incidence of Fasciotomy

Requiring Fasciotomy Injury in Each Category within Each Category
Category of Injury* (N = 364) (N = 18,676) of Injury (%)

Forefoot only 109 6714 1.6

Midfoot only 14 804 1.7
Hindfoot only 67 7008 1.0
Crush only 23 162 14.2
Forefoot and midfoot 42 722 5.8
Forefoot and hindfoot 17 584 2.9
Midfoot and hindfoot 4 503 0.8
Forefoot, midfoot, and hindfoot 11 279 3.9
Forefoot and crush 19 106 17.9
Midfoot and crush 4 19 21.1
Forefoot, midfoot, and crush 1 11 9.1

*Several categories (hindfoot and crush; midfoot, hindfoot, and crush; forefoot, hindfoot, and crush; and forefoot, midfoot, hindfoot, and crush) are not shown
because of a small sample size or because it was not populated.

largest group in the forefoot category (6714 of 8749). Isolated patients treated with a fasciotomy. Combined injuries in-
forefoot injuries resulted in a fasciotomy rate of 1.6%. volving both the forefoot and the midfoot were present in
Hypothesis 1: Individual fasciotomy rates following in- 12% of the fasciotomy group. Sixty-two percent of the injuries
juries of the forefoot, the midfoot, and the hindfoot were in the forefoot associated with a foot compartment syndrome
comparable. Combining the anatomic locations of injury (levels were metatarsal fractures (Table III). An isolated midfoot
of involvement) did not appear to increase the rates of fasci- injury was present in 4% (fourteen) of the 364 patients who
otomy (Table I). For example, only 4% (eleven) of the 279 underwent fasciotomy, and an isolated hindfoot injury was
patients with combined forefoot, midfoot, and hindfoot in- present in 18% (sixty-seven) of these 364 patients. Further-
juries underwent a fasciotomy for a presumed foot compart- more, 48% (thirty-two) of the sixty-seven isolated hindfoot
ment syndrome, whereas 6% (forty-two) of the 722 patients injuries in patients who developed a foot compartment syn-
with combined forefoot and midfoot injuries underwent such drome were calcaneal fractures (Table III).
a fasciotomy.
Hypothesis 2: A crush mechanism of injury was one of the
most important factors in the development of a foot com- TABLE II Patterns of Injury in Patients with and without
partment syndrome. Of the 162 patients with an isolated crush Fasciotomy (P < 0.001)
mechanism, 14% (twenty-three) underwent a fasciotomy for
a presumed foot compartment syndrome. Furthermore, 18% Fasciotomy Non-Fasciotomy
Group† Group†
(nineteen) of the 106 patients who had a forefoot injury Category of Injury* (N = 364) (N = 18,312)
combined with a crush mechanism of injury underwent a
fasciotomy for a presumed foot compartment syndrome (Table Forefoot only 29.9% (109) 36.1% (6605)
I). However, less than 1% (sixty-seven) of the 7008 patients Midfoot only 3.8% (14) 4.4% (804)
with an isolated hindfoot injury underwent such a fasciotomy. Hindfoot only 18.4% (67) 37.9% (6941)
Hypothesis 3: Of the 2481 patients with an isolated cal- Forefoot and midfoot 11.5% (42) 3.7% (680)
caneal fracture in the entire cohort, only 1% (thirty-two) un- Crush only 6.3% (23) <1% (139)
derwent a fasciotomy for foot compartment syndrome.
Forefoot and crush 5.2% (19) <0.5% (87)
Forefoot and hindfoot 4.7% (17) 3.1% (567)
Injury Patterns in the Fasciotomy Group
The most common injury pattern in patients undergoing fasci- Midfoot and hindfoot 1.1% (4) 2.7% (499)
otomy involved the forefoot (Table II). Almost one-third (109; Forefoot, midfoot, 3% (11) 1.5% (268)
30%) of the patients who underwent a foot fasciotomy in this and hindfoot
study had a noncrush injury isolated to the forefoot. If the injury
category (location of fracture or injury as defined in the Ap- *Categories that were not populated or with a small sample size were
excluded. †The values are the percentage (number) with involvement of the
pendix) included at least the forefoot, along with other areas in particular injury category.
the foot, this rate increased to almost two-thirds (213; 59%) of all
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dergo fasciotomy. The relative risk of a patient undergoing

TABLE III Frequency of Most Common Injury Patterns fasciotomy when he or she had a forefoot injury, compared
in Fasciotomy Group Based on Anatomic
Location of Injury with one who did not have a forefoot injury, was 1.5, when
adjusted for significant patient and hospital variables as indi-
Anatomic Most Common No. and Percentage of cated below. The adjusted relative risk of a crush mechanism
Location Injury Pattern in Patients with Fasciotomy
of Injury Fasciotomy Group in Injury Category
leading to fasciotomy was 1.7. The relative risk of a patient with
a hindfoot injury undergoing fasciotomy was 1.9, when simi-
Forefoot Metatarsal fractures 67 (61.5%) larly adjusted, but an isolated calcaneal fracture did not sig-
Midfoot Tarsal fractures 14 (100%) nificantly increase the risk of a fasciotomy (relative risk = 0.55).
(navicular, cuboid/
cuneiform) Patient and Hospital Variables
Hindfoot Calcaneal fracture 32 (47.8%) Age, sex, and the region of the country, when unadjusted and
adjusted for each other, all individually affected fasciotomy rates.
The length of stay in the hospital differed between patients who
General crush injuries represented another significant underwent a fasciotomy and those who did not when stratified
predictor of foot compartment syndrome requiring fasciot- for similar injury patterns. These differences were all significant
omy. Fifty patients (14%) in the fasciotomy group had a crush (p < 0.05), as demonstrated in Table IV. Certain patient and
mechanism as part of their injury pattern. Of these patients, hospital factors such as race, time of arrival into the emergency
twenty-three (6%) had an isolated crush injury with no frac- department, ISS, and type of hospital did not significantly affect
tures in the foot. fasciotomy rates (p > 0.1), with the number of patients studied.
Patients with injury patterns resulting in fasciotomy were
compared with those with similar patterns who did not un- Discussion

T he true incidence and primary predictors of foot com-

partment syndrome remain unknown. Foot compartment
syndrome has been reported to develop in approximately 10%
TABLE IV Adjusted Relationships Between Fasciotomy
Rates and Patient Demographics* of patients who have sustained a calcaneal fracture4. Other injury
patterns such as Lisfranc fracture-dislocations and metatarsal
Fasciotomy* No Fasciotomy* Adjusted
Patient Factor (%) (%) P Value fractures have also been reported to cause foot compartment
syndrome8. Ojike et al., in a recent review of the literature in-
Age <0.03 volving thirty-nine patients, reported that crush injury to the
<18 yr 10.7 8.8 foot was the most common cause of foot compartment syn-
18-64 yr 84.3 79
drome7. We conducted the present study to better define the
‡65 yr 1.4 8.6
overall incidence of foot compartment syndrome in relation to
Not documented 3.6 3.6
the frequency and location of various foot injuries to increase
Sex <0.001
surgeons’ awareness of and improve their ability to anticipate,
Male 83 67.7
Female 17 32.3
diagnose, and appropriately manage patients at risk for foot
compartment syndrome. To our knowledge, this study repre-
Region of country <0.002
sents the largest reported series of patients treated with fasciot-
Northeast 34.1 26.2
Midwest 22.5 26.3
omy for presumed foot compartment syndrome.
South 25.3 32 Our first hypothesis stated that an increase in the number
West 18.1 15.5 of anatomic locations of injury would result in higher rates of
ISS <0.07
compartment syndrome. This was not supported by the results
Minor: 0-9 71.7 62.3 as indicated in Table I. For example, the incidence of fasciot-
Moderate: 10-15 11.5 15 omy associated with combined forefoot and midfoot injuries
Severe: 16-24 9.1 12.8 was higher than that associated with a combined forefoot,
Very severe: 25-75 7.1 8.9 midfoot, and hindfoot injury pattern.
Not documented 0.6 1 Our second hypothesis stated that the incidence of foot
Length of stay in <0.001 compartment syndrome following crush injuries would be
the hospital higher than that in any other category of injury. Our data sup-
0-2 days 7.1 28 ported this hypothesis. Patients with an isolated crush injury, or a
3-9 days 50.8 48.5
crush injury in combination with a forefoot injury, had the
‡10 days 39.3 20.9
highest rate of fasciotomy. Hence, foot crush injuries should be
Not documented 2.8 2.6
considered an important predisposing factor in the development
*The values are the percentages of patients with or without a fasciotomy
of foot compartment syndrome; the presence of a crush mech-
who had each demographic factor. anism almost doubles the relative risk of developing a foot com-
partment syndrome. These injuries should raise the vigilance of
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the treating physician regarding the development of foot com-
partment syndrome in a trauma patient. These results echo those
of Ojike et al.7, who reported that a crush mechanism was the
major factor predicting the development of compartment syn-
drome. However, the number of patients with combined midfoot
and crush injuries and the number with combined forefoot,
midfoot, and crush injuries were not large enough for us to draw
any applicable conclusions despite the high rates of fasciotomies
(Table I).
Our second hypothesis also stated that the incidence of foot
compartment syndrome after hindfoot injuries would be higher
than that after an injury in any other zones. The data did not
support this hypothesis. Isolated hindfoot injuries comprised a
significant percentage of the injury patterns in the fasciotomy
group (18%), but only 1% of all hindfoot injuries were followed
by the development of a foot compartment syndrome. This rate
was lower than those in other injury groups. Also, isolated injury
to the forefoot accounted for almost one-third of the foot com-
partment syndromes identified in this study. We theorize that this
finding may be related to disruption of the intermetatarsal ar-
terial branches, which exit from dorsal to plantar through the
interosseous space, leading to extensive bleeding, swelling, and
increased intracompartmental pressures. Additional study will
be required to investigate this hypothesis. Another explanation
could be that, from an anatomic perspective, the fascial com-
partments in the forefoot are more prone to the development
of compartment syndrome by virtue of structure or location.
Our third hypothesis was that the incidence of foot com-
partment syndrome associated with calcaneal fractures would be
lower than the often-quoted 10% and that foot compartment
syndrome would be fairly uncommon following these fractures.
We found that only 1% of the patients with an isolated calcaneal
fracture underwent fasciotomy for a presumed foot compartment
syndrome, which supported our hypothesis. This rate is much
lower than the 10% rate reported by Myerson and Manoli4. Fur-
thermore, calcaneal fractures represented <50% of the hindfoot
injuries in the fasciotomy group. This suggests that other injuries in
the hindfoot, as listed in the Appendix, should also raise suspicion
about foot compartment syndrome in a symptomatic patient.
There are several limitations of this study. Before we began
the study, the NTDB was queried with use of ICD-9 codes 958.90
and 958.92 (compartment syndrome and traumatic compart-
ment syndrome of the lower extremity, respectively) to determine
the incidence of patients who had a diagnostic code for com-
partment syndrome documented in the data bank. One limitation
of the study was that we could not find any patients with codes for
these diagnoses, which we believe was a reporting error and a
limitation of the data bank. Hence, the procedure code 83.14
(defined by the NTDB as fasciotomy) was used as a surrogate to
isolate patients of interest. Patients with possible fasciotomy
procedures in other parts of the body were eliminated with our
exclusion criteria as documented in the Materials and Methods
section. We then made the assumption that the remaining
patients with diagnoses of isolated foot injury who had un-
dergone a fasciotomy procedure did so for a foot compartment
syndrome.
I N J U R Y P AT T E R N S C AU S I N G I S O L AT E D F O O T
C O M PA R T M E N T S Y N D R O M E
A second limitation of the study is that the results that we
document are based on data obtained from the NTDB and thus
depend on the quality of data entered into that database. Users
cannot independently verify the accuracy of the data or confirm
compliance with reporting. While we identified a large cohort of
patients with foot injuries, we were able to isolate only 364 who
had had a foot fasciotomy performed for a foot compartment
syndrome on the basis of our stringent exclusion criteria. We
believe that this may represent under-reporting and/or non-
reporting of data of patients from the various participating in-
stitutions who developed foot compartment syndrome following
foot injuries. Koval et al.17 documented this issue previously in a
study in which they utilized the same data bank.
A final limitation of this study is that some multiply
injured patients with concomitant foot injuries resulting in foot
compartment syndrome might have been eliminated on the
basis of our exclusion criteria. This is reflected by the majority
of our patients having a low ISS score. We believe, nonetheless,
that we managed to effectively isolate patients with foot com-
partment syndrome resulting from foot injuries only.
In conclusion, our study shows that a crush mechanism
of injury, either in isolation or in combination with injury to
other areas of the foot such as the forefoot, results in the highest
incidence of foot compartment syndrome requiring fasciot-
omy. Combined injuries to the forefoot and midfoot are also
risk factors for the development of foot compartment syn-
drome. A better understanding of these relationships should
help the treating physician predict and diagnose foot com-
partment syndrome in patients with these injury patterns.
Appendix
Tables showing the diagnostic codes that defined the cohort
of interest and the NTDB procedure codes that served to
exclude patients from the foot fasciotomy cohort are available
with the online version of this article as a data supplement at
jbjs.org. n
Nikhil A. Thakur, MD
Matthew McDonnell, MD
Christopher J. Got, MD
Christopher W. DiGiovanni, MD
Department of Orthopaedics,
Rhode Island Hospital/Brown University,
2 Dudley Street, Providence, RI 02903.
E-mail address for N.A. Thakur: nthakur79@gmail.com
Nicole Arcand, MD
Norwich Orthopaedic Group,
82 New Park Avenue,
North Franklin, CT 06254
Kevin F. Spratt, PhD
Department of Orthopaedics, Dartmouth Medical School,
Dartmouth Hitchcock Medical Center,
One Medical Center Drive, Lebanon, NH 03756
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