Orthopaedic Surgery - Cubital Tunnel Syndrome

Basics

Cubital tunnel syndrome (CuTS) is an ulnar nerve entrapment neuropathy at the elbow caused by compression, traction, or both as the ulnar nerve passes through the cubital tunnel.

Patients typically experience pain, numbness, and paresthesias along the ulnar side of the forearm and hand. More advanced disease may produce weakness and wasting of muscles supplied by the ulnar nerve.

Synonym

Cubital tunnel syndrome is sometimes referred to as ulnar tunnel syndrome, although the term should be distinguished from compression of the ulnar nerve at Guyon canal in the wrist.

Epidemiology

Cubital tunnel syndrome is the second most common upper-extremity entrapment neuropathy, after carpal tunnel syndrome.

Men and women are affected at approximately similar rates, with reported incidences of about 25 per 100,000 person-years in men and 19 per 100,000 person-years in women.

Risk Factors

Important risk factors include diabetes mellitus and previous trauma around the elbow.

Degenerative changes, repetitive elbow flexion, local structural abnormalities, and prolonged external pressure may also contribute.

Etiology

Symptoms result from a combination of compression and traction on the ulnar nerve, particularly during elbow flexion.

Flexion decreases the volume of the cubital tunnel while simultaneously stretching the ulnar nerve around the medial epicondyle.

Potential Sites of Compression

The ulnar nerve may be compressed at several locations around the elbow.

These include the Arcade of Struthers, medial intermuscular septum, cubital tunnel proper, and the interval between the two heads of the flexor carpi ulnaris.

Cubital Tunnel Proper

The most common site of compression is the cubital tunnel itself, where the ulnar nerve passes behind the medial epicondyle and beneath Osborne’s ligament.

External and Structural Causes

Potential causes of compression include an enlarged medial head of the triceps, previous trauma, recurrent ulnar nerve subluxation, osteophytes from arthritis, ganglion cysts, and anomalous muscles such as an anconeus epitrochlearis.

Associated Conditions

Cubital tunnel syndrome may coexist with other compressive neuropathies, including carpal tunnel syndrome and thoracic outlet syndrome.

More than one site of nerve compression may therefore be present in the same patient.

Diagnosis

General Principles

The diagnosis is primarily clinical, based on the characteristic history and physical examination.

Nerve conduction studies can support the diagnosis, although false-negative electrodiagnostic studies may occur.

Signs and Symptoms

Patients commonly report a vague aching pain around the medial elbow that may extend into the ulnar aspect of the forearm, wrist, or hand.

Numbness and paresthesias commonly involve the ring and small fingers.

Sensory Symptoms

Altered sensation may occur in the ulnar distribution of the hand and sometimes the medial forearm.

Symptoms are often aggravated by prolonged elbow flexion, such as during sleep, driving, or telephone use.

Physical Examination

Sensory Examination

The examiner should identify sensory abnormalities in the ulnar nerve distribution but should also examine other dermatomes and peripheral nerves.

This is important for excluding cervical radiculopathy, additional peripheral nerve entrapment, or double-crush syndrome.

Dorsal Ulnar Hand Sensation

Numbness over the dorsal ulnar aspect of the hand suggests that ulnar nerve compression is proximal to Guyon canal because the dorsal sensory branch arises before the nerve enters the wrist canal.

Intrinsic Muscle Strength

Intrinsic hand strength should be assessed carefully.

Weakness may affect pinch, finger abduction and adduction, and other fine motor functions.

Froment Sign

The Froment test evaluates weakness of the adductor pollicis.

The patient grasps a piece of paper between the thumb and index finger while the examiner attempts to pull it away.

Positive Froment Sign

If the adductor pollicis is weak, the patient compensates by flexing the thumb interphalangeal joint using the flexor pollicis longus.

This compensatory thumb flexion constitutes a positive Froment sign.

Wartenberg Sign

A Wartenberg sign occurs when the small finger rests persistently in an abducted position.

This reflects weakness of the intrinsic muscles responsible for finger adduction.

Muscle Wasting

The hand should be inspected for intrinsic muscle atrophy.

Wasting is often especially visible in the first dorsal interosseous muscle and along the hypothenar region.

Tinel Sign

Tapping over the ulnar nerve at the cubital tunnel may reproduce tingling or electric sensations into the ring and small fingers.

This constitutes a positive Tinel sign at the elbow.

Elbow Flexion Test

The elbow is held in maximal flexion for approximately 1 minute, usually with the wrist maintained neutral or slightly extended.

Reproduction of ulnar-sided numbness or paresthesias supports the diagnosis.

Keeping the wrist neutral helps avoid provoking coexisting carpal tunnel syndrome.

Scratch Collapse Test

The scratch collapse test has been described as an additional provocative maneuver.

The patient resists shoulder internal rotation while the examiner lightly scratches the skin over the suspected compression site.

Transient loss of resistance has been described in association with compressive neuropathy, although this maneuver should be interpreted together with the rest of the examination.

Ulnar Nerve Subluxation

The ulnar nerve should be palpated while the elbow moves from extension into flexion.

Subluxation or dislocation of the nerve over the medial epicondyle may affect surgical planning and can favor anterior transposition in selected patients.

Imaging and Diagnostic Testing

Plain Radiographs

Elbow radiographs may be obtained when there is concern for a bony cause of compression, previous trauma, deformity, or osteoarthritis.

Radiographs are not required in every uncomplicated case.

Nerve Conduction Studies

Nerve conduction velocity studies may demonstrate slowing of ulnar nerve conduction across the elbow.

The above-elbow and below-elbow conduction velocities are compared.

Electrodiagnostic Criteria

Findings supporting cubital tunnel syndrome include a conduction velocity drop of more than approximately 10 m/s across the elbow or an absolute conduction velocity of less than approximately 50 m/s across the involved segment.

Electrodiagnostic findings should be correlated with clinical symptoms.

Pathological Findings

During surgical decompression, one or more specific areas of nerve constriction may be visible.

All potential sites of compression should be inspected to ensure complete release.

Differential Diagnosis

Cervical Radiculopathy

Compression of the C8 or T1 cervical nerve roots can produce hand numbness, weakness, and intrinsic muscle dysfunction similar to CuTS.

A cervical examination is therefore important when symptoms are atypical.

Thoracic Outlet Syndrome

Thoracic outlet syndrome may produce ulnar-sided paresthesias and upper-extremity discomfort.

The distribution and associated vascular or proximal neurologic findings can help distinguish it from isolated cubital tunnel syndrome.

Guyon Canal Syndrome

Ulnar nerve compression at Guyon canal in the wrist can produce sensory and motor abnormalities in the ulnar hand.

Preserved dorsal ulnar hand sensation favors compression at the wrist rather than the elbow.

Carpal Tunnel Syndrome

Carpal tunnel syndrome affects the median nerve rather than the ulnar nerve but may coexist with CuTS.

The sensory distribution and provocative examination findings help distinguish the two.

Neurologic Disorders

Systemic neurologic conditions such as Guillain–Barré syndrome and amyotrophic lateral sclerosis can produce weakness or sensory changes that mimic peripheral entrapment neuropathy.

Medial Epicondylitis

Medial epicondylitis causes pain over the medial elbow but does not usually produce ulnar nerve sensory loss or intrinsic muscle weakness unless associated CuTS is also present.

Ulnohumeral Osteoarthritis

Degenerative arthritis of the elbow can cause medial elbow pain and osteophyte formation.

Large osteophytes may also contribute directly to ulnar nerve compression.

Treatment

General Measures

Initial treatment is usually nonoperative in patients with mild or moderate symptoms and no progressive motor deficit.

The primary goals are to reduce nerve compression and minimize prolonged elbow flexion.

Night Splinting

A nighttime elbow splint, brace, or soft wrap can be used to prevent excessive flexion during sleep.

Keeping the elbow from flexing beyond approximately 50° may reduce nocturnal symptoms.

Activity Modification

Patients should avoid prolonged elbow flexion and repetitive activities that provoke symptoms.

Direct pressure over the cubital tunnel, such as leaning the medial elbow on a desk or armrest, should also be minimized.

Duration of Conservative Treatment

A trial of nonoperative treatment for approximately 1–3 months is reasonable in patients without severe weakness or progressive neurologic impairment.

Surgery

Indications

Surgery should be considered when symptoms persist despite appropriate conservative care, when numbness is worsening, or when weakness of ulnar-innervated muscles is present.

Progressive muscle wasting is a particularly important indication for surgical evaluation.

Surgical Options

Operative techniques include in situ decompression, anterior ulnar nerve transposition, and medial epicondylectomy.

The optimal procedure depends on nerve stability, anatomy, previous surgery, and the specific site of compression.

In Situ Decompression

Simple decompression releases constricting structures while leaving the ulnar nerve in its native position.

The procedure can be performed through an open or endoscopic approach.

Anterior Transposition

Anterior transposition relocates the ulnar nerve from behind the medial epicondyle to a position anterior to it.

The nerve may be placed subcutaneously, intramuscularly, or submuscularly.

Indications for Transposition

After decompression, the nerve is examined dynamically.

If it is unstable, subluxates, or dislocates over the medial epicondyle, anterior transposition may be performed.

Medial Epicondylectomy

Medial epicondylectomy removes part of the medial epicondyle to reduce tension and compression on the ulnar nerve.

Care must be taken to protect the medial collateral ligament of the elbow.

Medial Antebrachial Cutaneous Nerve

Branches of the medial antebrachial cutaneous nerve cross the operative field during medial elbow surgery.

These branches should be carefully identified and protected because injury can produce painful neuroma or numbness.

Follow-Up

Nonoperative Prognosis

In patients with mild cubital tunnel syndrome, nonoperative management has historically produced excellent results in approximately 58% of cases, excluding many post-traumatic neuropathies.

Surgical Prognosis

Surgical treatment produces good to excellent outcomes in approximately 70–90% of patients.

The degree of recovery depends partly on the severity and duration of preoperative nerve dysfunction.

Decompression Versus Transposition

In the absence of ulnar nerve instability or hypermobility, outcomes after simple decompression are generally comparable with those following anterior transposition.

This allows a less extensive procedure in appropriately selected patients.

Recovery of Weakness

Sensory symptoms may improve earlier than motor weakness.

When severe intrinsic muscle atrophy has been present for a prolonged period, complete strength recovery may not occur even after adequate decompression.

Complications

Postoperative Nerve Irritation

Persistent or new nerve irritation may occur after surgery.

Scar formation, incomplete decompression, nerve instability, or iatrogenic injury may contribute.

Complex Regional Pain Syndrome

Complex regional pain syndrome, historically termed reflex sympathetic dystrophy, may rarely occur after surgery and can produce disproportionate pain, stiffness, and autonomic changes.

Untreated Severe Neuropathy

Progressive untreated ulnar neuropathy can lead to intrinsic muscle atrophy, persistent sensory loss, and clawing of the ring and small fingers.

Ulnar Clawing

Loss of intrinsic muscle function allows imbalance between the extrinsic flexors and extensors.

This can produce hyperextension at the metacarpophalangeal joints and flexion at the interphalangeal joints of the ring and small fingers.

Joint Contractures

Longstanding muscle imbalance and clawing can eventually produce fixed joint contractures.

Early treatment of progressive motor dysfunction may reduce this risk.

Patient Monitoring

Follow-up examinations should document motor strength, sensory function, intrinsic muscle bulk, provocative findings, and progression or improvement of symptoms.

Patients treated surgically should also be monitored for wound problems, recurrent nerve instability, persistent compression, and recovery of hand function.

Orthopaedic Surgery - Computed Tomography

Basics

Computed tomography (CT) is a noninvasive imaging technique that uses a rotating X-ray source and detectors to generate cross-sectional images of the body.

It is particularly useful in musculoskeletal imaging because the acquired data can be reconstructed into multiple planes and displayed as three-dimensional or volume-rendered images.

CT is especially valuable for evaluating complex osseous anatomy, fractures, joint surfaces, cortical bone, mineralization, and postoperative hardware.

Historical Development

CT was introduced in 1972, with the first clinical scanners installed between approximately 1974 and 1976.

By 1980, CT had become widely available.

During the mid-1980s, newer applications were introduced, including dynamic scanning, multiplanar reformations, and three-dimensional CT reconstruction with volume rendering and shaded-surface display.

Routine spiral or helical CT scanning became established around 1989 and subsequently developed into modern multidetector CT technology.

Advantages

Rapid Image Acquisition

One of the major advantages of CT is its speed.

Rapid image acquisition is particularly valuable for trauma patients, seriously ill patients, and children, because scanning can often be completed before significant movement occurs and may reduce the need for sedation.

Complex Anatomic Regions

CT provides excellent visualization of areas that may be difficult to evaluate completely with plain radiographs.

Examples include the spine, pelvis, scapula, wrist, ankle, and other small or anatomically complex joints.

Multiplanar Reconstruction

Modern multidetector CT scanners acquire a volumetric data set that can subsequently be reconstructed in multiple planes.

Images can therefore be generated in the axial, sagittal, coronal, or oblique planes without repeating the scan.

Three-Dimensional Reconstruction

Three-dimensional and volume-rendered reconstructions can clarify complex relationships between fracture fragments, joints, implants, and reconstructed bone.

These techniques are particularly useful for preoperative planning and evaluation of complicated skeletal anatomy.

Imaging Around Hardware

CT may provide useful assessment around metallic implants.

Modern reconstruction and artifact-reduction techniques can substantially decrease metal-related streak artifact, allowing better visualization of bone, implants, graft-host junctions, and surrounding structures.

MRI may be limited by artifact in some patients with extensive metallic hardware.

Patients Unable to Undergo MRI

CT can be performed in patients who cannot safely undergo MRI because of certain implanted devices or metallic foreign bodies.

Examples may include selected non-MRI-compatible cardiac devices, particular aneurysm clips, or metallic orbital foreign bodies.

The actual MRI compatibility of modern implants should always be verified because many contemporary devices are MRI conditional.

Availability and Cost

CT is widely available, rapid, and relatively cost-effective for many clinical problems.

It can often answer important skeletal questions more efficiently than other advanced imaging modalities.

Disadvantages

Soft-Tissue Limitations

CT is generally inferior to MRI for evaluation of bone marrow, spinal cord, peripheral nerves, ligaments, tendons, and many other soft tissues.

MRI is therefore preferred when detailed soft-tissue characterization is the primary goal.

Ionizing Radiation

CT exposes the patient to ionizing radiation.

Radiation dose is greater than with most conventional radiographic examinations, making appropriate patient selection and dose optimization important.

Cost Compared With Radiographs

CT is more expensive than plain radiography and should be used when the additional cross-sectional information is likely to influence diagnosis or treatment.

Intravenous Contrast Risks

When iodinated intravenous contrast is required, potential complications include hypersensitivity reactions and renal adverse effects in susceptible patients.

The indication for contrast should therefore be considered carefully.

CT Technique

Skeletal Imaging

Bone pathology is generally evaluated using thin-section acquisition.

Modern multidetector scanners can obtain very thin slices, allowing high-resolution multiplanar and three-dimensional reconstructions.

Postprocessing

The acquired data can be processed at a workstation to create coronal, sagittal, oblique, three-dimensional, and volume-rendered images.

These reconstructions are especially valuable when evaluating fractures and complex skeletal deformity.

Soft-Tissue Imaging

Extremely thin sections are less critical when the principal target is soft tissue rather than bone.

Reconstructed slice thicknesses of approximately 2–3 mm may be adequate for many soft-tissue applications.

Intravenous Contrast

Evaluation of a soft-tissue mass, abscess, inflammatory process, or vascular injury commonly requires intravenous iodinated contrast.

Contrast improves visualization of vascular structures and patterns of tissue enhancement.

Contrast Administration

Contrast administration protocols vary according to the examination.

High-flow injection may be required for vascular or contrast-enhanced studies, with the exact rate determined by the clinical indication and scanner protocol.

Renal Impairment

Iodinated contrast should be used carefully in patients with significant renal impairment.

Renal function, hydration status, indication for contrast, and alternative imaging methods should be considered before administration.

Previous Contrast Reaction

Patients should be questioned about prior reactions to iodinated contrast.

Those with previous significant reactions may require alternative imaging, a modified contrast strategy, or premedication according to institutional protocol.

Postoperative Applications

Hardware Complications

CT is useful for identifying complications related to orthopedic hardware.

These may include fracture, implant loosening, malposition, surrounding bone destruction, and selected manifestations of infection.

Osteomyelitis

CT may demonstrate cortical destruction, sequestra, gas, or other changes associated with osteomyelitis, particularly in postoperative patients.

MRI is often more sensitive for early marrow infection, but CT can provide valuable structural detail.

Tumor Recurrence

CT may help evaluate possible tumor recurrence in patients with metallic hardware, particularly when MRI is significantly degraded by artifact.

Foreign Bodies

CT is effective for detecting and localizing many retained foreign bodies.

Its cross-sectional nature allows accurate determination of the object’s relationship to bone, joints, vessels, and other structures.

Orthopaedic Oncology Applications

Tumor Mineralization

CT is highly sensitive for detecting calcification and ossification within a lesion.

The pattern of mineralization can help characterize a tumor and narrow the differential diagnosis.

Myositis Ossificans

CT may help distinguish myositis ossificans from neoplasm by demonstrating the characteristic distribution and maturation pattern of peripheral ossification.

Cortical and Periosteal Changes

CT provides excellent visualization of the cortex and periosteal surface.

Patterns of cortical thinning, erosion, destruction, expansion, sclerosis, or periosteal reaction may help distinguish benign from aggressive lesions.

Bone Destruction

The degree of osseous destruction can be assessed accurately with CT.

This information can help estimate structural integrity and risk of pathologic fracture.

Osteoid Osteoma

CT is particularly useful for identifying the small nidus of an osteoid osteoma.

It can also provide image guidance for definitive minimally invasive treatment, such as CT-guided radiofrequency ablation.

Neurovascular and Compartment Involvement

CT can demonstrate tumor extension into adjacent compartments and may identify involvement of major neurovascular structures.

MRI is generally superior for detailed evaluation of these soft-tissue relationships.

Trauma Applications

Occult or Equivocal Fractures

CT is extremely useful when a fracture is suspected clinically but plain radiographs are equivocal or nondiagnostic.

It can reveal subtle fracture lines that are difficult to appreciate on conventional imaging.

Axially Oriented Fractures

Multiplanar and three-dimensional reconstructions are particularly useful for fractures that are oriented in a plane poorly visualized on plain radiographs.

Fracture Extent

CT can accurately determine the extent, displacement, comminution, articular involvement, and physeal involvement of a fracture.

This information is frequently essential for operative planning.

Intra-Articular Fragments

CT can identify small fracture fragments within a joint and define areas of articular depression or step-off.

Nonunion

CT is useful for evaluating suspected fracture nonunion, particularly when overlapping anatomy or implanted hardware makes plain radiographs difficult to interpret.

It can demonstrate persistent fracture gaps and the amount of osseous bridging.

Cervical Spine Trauma

CT is a principal imaging modality for evaluating the cervical spine in moderate- and high-risk trauma patients.

It provides rapid assessment of fractures, alignment, facet injuries, and other bony abnormalities.

Complex Skeletal Regions

CT is particularly useful in trauma involving the pelvis, scapula, wrist, ankle, and spine, where overlapping structures can limit the accuracy of radiographs.

Infection Applications

Postoperative Infection

In postoperative patients, CT may help evaluate new symptoms and identify structural complications after treatment.

It can demonstrate collections, gas, cortical destruction, or other changes suggesting infection.

Extent of Infection

CT can help determine whether infection involves bone, muscle, fascia, or subcutaneous tissue.

Defining the compartments involved may assist in deciding whether medical management alone is adequate or surgical intervention is required.

Response to Treatment

Serial imaging may occasionally be useful for monitoring structural changes during treatment of musculoskeletal infection, although clinical findings and laboratory markers remain important.

Pediatric Applications

Skeletal Dysplasias

CT can be useful in skeletal dysplasias when a large and anatomically complex region must be defined accurately.

It may also be valuable after reconstructive surgery.

Developmental Dysplasia of the Hip

Developmental dysplasia of the hip is usually diagnosed using physical examination, ultrasound, and plain radiographs.

CT may be used in difficult cases or with carefully optimized low-dose protocols.

Evaluation After Hip Reduction

CT has historically been useful for confirming successful hip reduction after placement of a spica cast.

Low-dose imaging protocols are important in these young patients.

Slipped Capital Femoral Epiphysis

CT can demonstrate the orientation of the proximal femoral physis and may help identify contralateral abnormalities with coronal and sagittal reconstructions.

However, routine diagnosis of slipped capital femoral epiphysis is usually based on radiographs, with MRI used in selected early or occult cases.

Alternative Causes of Pediatric Hip Pain

Cross-sectional imaging can also help identify alternative diagnoses such as osteoid osteoma when the source of hip pain is uncertain.

Legg–Calvé–Perthes Disease

CT may occasionally be used for preoperative definition of femoral head deformity and disease severity.

Because of radiation exposure, its use is selective.

Pectus Deformity

CT can define thoracic anatomy in patients with pectus excavatum or other chest-wall deformities.

It may be particularly useful for surgical planning or after unsuccessful previous repair.

Tarsal Coalition

CT is highly effective for characterizing osseous tarsal coalitions.

Multiplanar reconstructions accurately demonstrate the location, orientation, and extent of the coalition and may assist in operative planning.

Pediatric Considerations

Radiation Sensitivity

Children are more sensitive to ionizing radiation than adults.

Because they also have a longer remaining lifespan, the potential lifetime risk of radiation-induced malignancy is greater.

Dose Optimization

CT parameters should therefore be adjusted according to the child’s size, age, and clinical indication.

Only examinations that are likely to provide meaningful clinical information should be performed.

Avoid Multiphase Studies

Unnecessary multiphase CT examinations should be avoided in children.

Obtaining both noncontrast and postcontrast scans without a specific indication can substantially increase radiation dose.

Multidetector CT

Modern multidetector technology allows a single volumetric acquisition to be reconstructed in multiple planes, reducing the need for repeated scanning.

Pregnancy Considerations

Limiting Scan Volume

When CT is necessary during pregnancy, the scan should be restricted to the smallest anatomical region required to answer the clinical question.

Unnecessary multiphase imaging should be avoided.

Radiation Optimization

Protocols should use the lowest radiation exposure that still produces diagnostically adequate images.

Departments should maintain quality-assurance programs and appropriate dose protocols.

Alternative Imaging

When clinically appropriate, ultrasound or MRI should be considered because these techniques do not use ionizing radiation.

However, a necessary CT examination should not be withheld when the expected diagnostic benefit outweighs the potential radiation risk.

Iodinated Contrast in Pregnancy

Iodinated contrast crosses the placenta and should therefore be administered only when it is expected to provide important additional diagnostic information.

No consistent teratogenic effect has been established from routine diagnostic exposure, but use should remain clinically justified.

Abdominal and Pelvic Protection

Radiation exposure outside the imaged region should be minimized through appropriate collimation and modern dose-reduction techniques.

Routine external lead shielding is no longer universally recommended because contemporary CT systems rely primarily on optimized scan parameters and shielding may occasionally interfere with automatic exposure control.

Breastfeeding After Contrast

Modern recommendations generally do not require interruption of breastfeeding after routine iodinated intravenous contrast administration, because only very small amounts reach breast milk and an even smaller amount is absorbed by the infant.

Follow-Up and Complications

Contrast Reactions

Iodinated contrast can produce hypersensitivity reactions ranging from mild symptoms to rare severe reactions.

Patients with a previous contrast reaction have the greatest risk of another reaction.

Asthma may also increase susceptibility.

Premedication

Selected high-risk patients may undergo premedication using corticosteroids and antihistamines according to institutional protocols.

Premedication reduces but does not completely eliminate the possibility of a reaction.

Renal Adverse Effects

Patients with significant pre-existing renal disease are at greatest risk for renal complications related to iodinated contrast.

Other relevant factors may include dehydration, diabetes, severe systemic illness, and concurrent nephrotoxic medications.

Renal Protection

When contrast is necessary in a patient at increased renal risk, appropriate hydration, avoidance of unnecessary nephrotoxic exposures, and use of the minimum effective contrast dose may reduce risk.

Modern low- or iso-osmolar contrast agents are typically used.

Overall Role in Orthopaedics

CT is an especially valuable orthopaedic imaging modality when detailed evaluation of cortical bone, fracture anatomy, joint surfaces, complex skeletal regions, calcification, reconstruction, or implanted hardware is required.

Its major limitations are ionizing radiation and relatively inferior soft-tissue contrast compared with MRI, so the imaging modality should be selected according to the specific clinical question.

Orthopaedic Surgery - Compartment Syndrome of the Foot

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Basics

Foot compartment syndrome (FCS) occurs when hemorrhage and interstitial edema increase pressure within the closed muscle compartments of the foot, resulting in impaired capillary perfusion.

If pressure remains elevated, progressive ischemia of muscles and nerves may lead to myoneural necrosis and permanent functional impairment.

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General Prevention

The most important factor in preventing the long-term consequences of foot compartment syndrome is maintaining a high index of clinical suspicion.

The diagnosis can be difficult because severe foot trauma itself commonly causes pain and swelling.

Early recognition and treatment are essential.

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Epidemiology

Foot compartment syndrome is uncommon and represents less than 5% of limb compartment syndromes.

Its incidence varies according to the mechanism and severity of injury.

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Calcaneus Fractures

FCS has been reported in up to approximately 10% of patients with calcaneal fractures.

The risk is greater with high-energy, displaced, and markedly swollen injuries.

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Crush Injuries

When a crush mechanism is combined with a forefoot injury, compartment syndrome may occur in as many as approximately 18% of cases.

Crush injuries produce extensive soft-tissue damage, hemorrhage, and edema, making them particularly high risk.

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Isolated Foot Injuries

Among isolated foot injuries overall, compartment syndrome is considerably less common, occurring in approximately 2% of cases.

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Pathophysiology

As intracompartmental pressure rises, the pressure gradient required for capillary perfusion decreases.

When local tissue pressure becomes sufficiently high relative to arterial pressure, blood flow becomes inadequate and tissue ischemia develops.

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Myoneural Ischemia

Continued ischemia damages both muscle and peripheral nerves.

If untreated, this progresses to myonecrosis, nerve injury, fibrosis, contracture, and permanent deformity.

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Long-Term Consequences

Late consequences can include chronic pain, paresthesias, stiffness, claw-toe deformity, cavus or cavovarus alignment, and other structural foot deformities.

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Etiology

Foot compartment syndrome most often follows high-energy trauma.

Common causes include calcaneus fractures, midfoot and forefoot injuries, severe crush injuries, and Lisfranc fracture-dislocations.

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Open Injuries

An open wound does not exclude compartment syndrome.

Open foot injuries may still have intact deeper fascial compartments in which dangerously elevated pressures develop.

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Association With Tibial Fractures

FCS can occasionally occur after a tibial fracture.

This may be related to communication between the deep posterior compartment of the leg and the calcaneal compartment of the foot, allowing swelling or hemorrhage to extend distally.

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Diagnosis

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General Principles

Because FCS is relatively uncommon and the injured foot is often painful and swollen even without compartment syndrome, diagnosis requires careful correlation of the mechanism of injury, serial examination, and compartment pressure measurements when necessary.

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Signs and Symptoms

Typical findings include severe pain, tense swelling, and pain with passive stretching of the toes.

The clinical pattern should be assessed repeatedly because symptoms may evolve over time.

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Severe Pain

Pain is often intense and may appear excessive for the apparent injury.

Persistent or progressively worsening pain despite appropriate immobilization and analgesia should raise concern.

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Tense Swelling

The foot may become markedly swollen and tense.

Because substantial swelling commonly accompanies calcaneal and crush injuries, this finding alone is not diagnostic.

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Pain With Passive Toe Stretch

Pain produced by passive movement of the toes is a common feature.

However, it is not specific for compartment syndrome because fractures and severe soft-tissue injuries can also produce pain with passive motion.

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Sensory Changes

Paresthesias or diminished sensation may develop as nerve ischemia progresses.

Sensory findings can be inconsistent and are less reliable than the overall clinical picture.

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Pulses

Diminished or absent pulses are unreliable for early diagnosis.

Foot pulses may remain present despite critically elevated compartment pressures because larger arteries can remain patent while microvascular perfusion is compromised.

Pulselessness is therefore a late and concerning finding.

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Imaging

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Plain Radiographs

Plain radiographs of the foot and ankle should be obtained to identify fractures or dislocations responsible for the swelling and trauma.

Imaging helps define the underlying skeletal injury but does not diagnose compartment syndrome itself.

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Compartment Pressure Measurement

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Diagnostic Role

Invasive measurement of intracompartmental pressures is useful when the diagnosis is uncertain and has traditionally been considered the objective diagnostic standard for FCS.

Pressure findings should always be interpreted together with the clinical examination.

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Medial Compartment

The medial, or abductor hallucis, compartment may be accessed by placing the pressure needle directly inferior to the first metatarsal.

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Deep Compartment

The deep compartment may be reached by advancing the needle approximately 1 cm deeper from the medial compartment beneath the arch of the foot.

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Interosseous Compartments

Interosseous pressures can be measured from the dorsal foot, commonly by inserting the needle between the third and fourth metatarsals.

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Lateral Compartment

The lateral compartment can be assessed by inserting the needle plantar to the fifth metatarsal.

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Pressure Threshold

Historically, an absolute compartment pressure greater than approximately 30 mm Hg has been considered concerning.

In modern practice, pressure is often interpreted in relation to the patient’s diastolic blood pressure, and the complete clinical picture remains essential.

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Limitations of Pressure Measurement

An elevated isolated pressure value does not necessarily establish compartment syndrome.

Pressure measurements may vary according to technique, location, blood pressure, and injury pattern.

When measured pressures do not correlate with the physical findings, repeated examination and reassessment are important.

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Treatment

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Initial Stabilization

Circumferential or constrictive dressings should be avoided when compartment syndrome is suspected.

Any tight bandage, splint, or dressing should be loosened or removed because external compression may further increase tissue pressure.

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Limb Position

The injured foot should generally be maintained at approximately the level of the heart while the patient is being observed.

Excessive elevation may reduce arterial perfusion, whereas allowing the foot to hang dependently can worsen swelling.

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Serial Examination

Repeated clinical examinations are essential.

Changes in pain intensity, analgesic requirement, swelling, sensory findings, and pain with passive toe motion should be documented.

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Pressure Monitoring

If the diagnosis remains uncertain, invasive pressure measurements should be obtained promptly.

Repeated measurements may be required if symptoms are evolving.

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Swelling Control

Measures to reduce swelling may be used while the diagnosis is being clarified, provided they do not delay definitive treatment.

Pneumatic foot pumps have historically been described for early post-traumatic swelling in selected situations.

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Diuretics

Diuretic therapy has historically been described as a means of reducing generalized edema, but it does not substitute for decompression when true compartment syndrome is present.

Once FCS is diagnosed, treatment is surgical.

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Early Fasciotomy

The most reliable method of preventing irreversible consequences is early surgical fasciotomy.

Once the diagnosis is established, decompression should not be delayed.

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Surgical Planning

The fasciotomy approach should be selected with future fracture fixation and reconstruction in mind.

Incisions that interfere with later definitive fixation should be avoided whenever possible.

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Activity

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Bed Rest

Patients with massive swelling or suspected FCS should generally remain at bed rest during acute evaluation.

The foot should be kept at heart level and protected from weight-bearing.

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Nursing Care

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Frequent Monitoring

Patients with severe foot trauma require close nursing observation.

Increasing, persistent, or inadequately controlled pain should prompt immediate reassessment by the treating clinician.

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Passive Stretch Testing

Pain with passive toe movement should be reassessed frequently.

A worsening response may indicate increasing compartment pressure.

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Change in Clinical Status

Any deterioration in swelling, pain, sensation, or motor function should prompt urgent physician evaluation and consideration of compartment pressure measurement or operative decompression.

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Physical Therapy

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Late Rehabilitation

Physical therapy may be useful for patients who develop residual problems following FCS.

Treatment can include stretching, range-of-motion exercises, strengthening, gait rehabilitation, and desensitization.

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Desensitization

Desensitization techniques may be useful for patients with persistent hypersensitivity or neuropathic symptoms after severe crush injury or compartment syndrome.

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Surgery

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Fasciotomy

Once foot compartment syndrome has been diagnosed, urgent surgical fasciotomy is required.

The goal is complete decompression of the involved compartments before irreversible myoneural injury occurs.

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Three-Incision Technique

A commonly described approach uses three incisions.

Two dorsal incisions are made over the second and fourth metatarsals, while a separate medial incision is made along the arch.

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Dorsal Incisions

The dorsal incisions provide access to the interosseous compartments and can assist with decompression of adjacent spaces.

One incision is positioned over the second metatarsal region and the other over the fourth.

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Medial Arch Incision

The medial incision allows decompression of the abductor hallucis and deeper central muscle compartments.

This approach provides access to important plantar structures not adequately reached from the dorsum.

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Alternative Single Medial Approach

An alternative technique uses a single medial incision.

The abductor hallucis and deep compartments are released, after which the muscles can be reflected plantarly to gain access to additional compartments.

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Interosseous Release Through Medial Approach

Using the single medial technique, the interosseous compartments may be approached internally after mobilization of the plantar musculature.

This avoids multiple dorsal incisions but is technically demanding.

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Plantar-Based Single-Incision Technique

Another described approach uses a plantar-medial incision beginning approximately 5 cm distal to the posterior heel on the non-weight-bearing instep and extending distally.

The intent is to decompress the intermediate and lateral compartments through a single incision.

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Pie-Crusting Technique

A minimally invasive “pie-crusting” technique has also been described.

Multiple small stab incisions are made over the intermetatarsal spaces, followed by blunt fascial release with a hemostat.

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Purpose of Pie-Crusting

The theoretical advantage of this approach is reduction in the size of open wounds and therefore a lower need for skin grafting.

However, complete compartment release remains the overriding surgical priority.

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Wound Management

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Delayed Closure

Fasciotomy wounds are usually left open initially because severe swelling makes immediate closure unsafe.

Closure is commonly attempted approximately 5–7 days later, after edema has substantially decreased.

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Skin Grafting

If the wound edges cannot be approximated without excessive tension, a split-thickness skin graft may be required.

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Follow-Up

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Referral

Severe foot trauma, substantial swelling, or suspected compartment syndrome requires urgent orthopaedic consultation.

Delay in specialist assessment can result in permanent disability.

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Prognosis

The prognosis of a missed or untreated foot compartment syndrome is poor.

Patients frequently develop chronic pain, stiffness, deformity, and impaired walking ability.

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Chronic Pain

Persistent pain may result from muscle necrosis, nerve injury, scar formation, joint stiffness, or abnormal loading of the foot.

It can be significantly disabling.

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Cavus and Cavovarus Deformity

Necrosis and subsequent fibrosis of the intrinsic foot muscles can alter muscle balance.

This may lead to cavus or cavovarus foot deformity.

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Claw Toes

Intrinsic muscle fibrosis and imbalance can produce claw-toe deformities.

Severe fixed claw toes may eventually require operative release or reconstruction.

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Complex Regional Pain Syndrome

Complex regional pain syndrome may develop after severe crush injury or compartment syndrome.

It can cause persistent pain, hypersensitivity, autonomic changes, stiffness, and substantial functional impairment.

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Complications

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Pain

Chronic pain is one of the most frequent consequences of delayed or severe FCS.

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Paresthesias

Nerve ischemia can produce persistent paresthesias, numbness, or sensory disturbance.

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Stiffness

Fibrosis, prolonged immobilization, and joint injury may lead to significant foot and toe stiffness.

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Claw-Toe Deformity

Loss of normal intrinsic muscle function may result in progressive clawing of the toes.

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Foot Deformity

Permanent structural abnormalities may include cavus, cavovarus, toe contractures, abnormal gait, and altered weight-bearing.

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Patient Monitoring

Patients at risk for FCS require repeated assessment of pain, swelling, sensation, motor function, passive stretch discomfort, and compartment pressures when indicated.

Following fasciotomy, monitoring should include wound condition, neurovascular function, edema, fracture healing, toe alignment, range of motion, and the development of chronic deformity or pain.

Orthopaedic Surgery - Compartment Syndrome

Basics

Compartment syndrome occurs when pressure rises within a closed fascial space, reducing tissue perfusion and compromising the function and viability of the muscles, nerves, and vessels contained within that compartment.

Acute compartment syndrome is a limb-threatening surgical emergency. In contrast, chronic or exertional compartment syndrome is usually an exercise-related condition that is symptomatic but not immediately limb threatening.

Tissue Ischemia

As intracompartmental pressure increases, local blood flow falls below the metabolic requirements of the tissues.

Continued ischemia can lead to muscle necrosis, nerve injury, ischemic contracture, weakness, numbness, or irreversible loss of limb function.

Systemic Consequences

Extensive muscle necrosis can produce rhabdomyolysis.

Release of intracellular contents may lead to myoglobinuria, hyperkalemia, acute tubular necrosis, and acute kidney failure.

For this reason, severe compartment syndrome can become a systemic as well as a local emergency.

General Prevention

A high index of suspicion is essential.

Diagnosis is particularly difficult in obtunded trauma patients, sedated or anesthetized patients, patients with drug intoxication, and young children, because pain and other clinical findings may be unreliable.

Anatomic Locations

The leg and forearm are the most commonly involved regions.

However, compartment syndrome can also occur in the thigh, hand, foot, arm, fingers, and gluteal region.

Epidemiology

Acute compartment syndrome is associated most frequently with fractures and high-energy extremity trauma.

Reported incidence includes approximately 1–5% of tibial fractures, 0.25% of distal radius fractures, 3% of forearm fractures, and up to 10% of displaced calcaneal fractures.

Risk Factors

Important risk factors include high-energy trauma, crush injury, prolonged pressure on a dependent limb, anesthesia, drug overdose, altered mental status, fractures, osteotomies, vascular injury, reperfusion, burns, tight casts, constrictive dressings, and tight surgical closure.

High-Risk Patients

Young adult males with tibial or forearm fractures are particularly vulnerable.

Children with displaced supracondylar humerus fractures also require careful surveillance.

Prolonged Procedures and Positioning

Long surgical procedures can produce compartment syndrome because of prolonged external pressure or positioning.

An unconscious or anesthetized patient cannot report progressive pain, making recognition more difficult.

Vascular and Reperfusion Injury

Ischemic injury followed by restoration of blood flow can produce marked tissue edema.

This reperfusion injury may rapidly increase intracompartmental pressure after vascular repair.

Soft-Tissue Causes

Soft-tissue injury alone can produce compartment syndrome.

Examples include severe contusions, crush injury, snake bites, and extensive muscle damage with hemorrhage and edema.

Iatrogenic Causes

Iatrogenic causes include tight casts, restrictive dressings, infiltration of intravenous fluid, intraosseous infusion, antishock garments, and overly tight surgical closure.

Intracompartmental Hemorrhage

Bleeding into a closed compartment can elevate pressure significantly.

Patients with coagulopathy or anticoagulation may therefore be at increased risk.

Pathophysiology

The central mechanism is failure of local tissue perfusion to satisfy metabolic demand.

As tissue pressure rises, the arteriovenous perfusion gradient decreases, resulting in progressive ischemia.

Ischemic Cascade

Muscle ischemia causes cellular swelling, which further increases compartment pressure.

This produces a vicious cycle of increasing pressure, worsening perfusion, greater edema, and progressive tissue necrosis.

Etiology

Any condition that either increases the volume within a compartment or decreases the size of the compartment can produce compartment syndrome.

External Compression

External compression may result from casts, splints, dressings, body positioning, or other constrictive devices.

Removing the external source of compression is an immediate priority when compartment syndrome is suspected.

Fracture-Related Hemorrhage

Fractures may produce substantial bleeding and swelling within a compartment.

Pressure can rise after the initial injury or following fracture manipulation.

Both open and closed fractures can be associated with compartment syndrome.

Vascular Injury

Arterial or venous injury can cause bleeding into a closed space.

Reperfusion following vascular repair can further increase swelling.

Crush Injury

Severe crush injury causes direct muscle damage, hemorrhage, and cell death.

Leakage of intracellular and extracellular fluid then contributes to rapid compartment expansion and pressure elevation.

Associated Conditions

Conditions associated with compartment syndrome include coagulopathy and altered mental status.

Both can increase risk or make diagnosis more difficult.

Diagnosis

Signs and Symptoms

The traditional findings are described as the five P’s: pain, pallor, paresthesia, paralysis, and pulselessness.

However, not all of these findings are present early.

Pain and pain with passive stretch are generally more useful early findings, whereas paralysis and pulselessness are late and ominous signs.

High Index of Suspicion

Clinical findings alone may be unreliable.

This is especially true in children, unconscious patients, heavily sedated patients, and those with distracting injuries.

Serial examinations are therefore essential.

Pain Out of Proportion

The classic early symptom is pain that appears excessive compared with the apparent severity of the injury.

The patient may report escalating discomfort despite appropriate immobilization and analgesia.

Increasing Analgesic Requirement

An increasing requirement for pain medication can be an important warning sign.

This may be particularly useful in children, who may show increasing agitation or analgesic requirements before other findings appear.

Loss of Pain

The disappearance of pain does not necessarily indicate improvement.

If nerves become ischemic and lose function, pain may diminish despite worsening tissue necrosis.

Thus, absence of pain in advanced compartment syndrome is a late and poor prognostic sign.

Paresthesias

Numbness or tingling may develop as sensory nerves become ischemic.

Paresthesias can precede frank sensory loss.

Physical Examination

Mental Status

The patient’s level of consciousness should be documented.

A reliable examination requires the patient to be awake and able to describe symptoms accurately.

Vital Signs

Vital signs should be assessed, with particular attention to the diastolic blood pressure, because the relationship between diastolic pressure and compartment pressure is used in determining tissue perfusion.

Motor Examination

Motor function of muscles within and distal to the involved compartment should be tested and documented serially.

New weakness may indicate progressive nerve or muscle ischemia.

Sensory Examination

Sensation should be examined carefully in the distribution of nerves passing through the affected compartment.

New sensory changes are concerning for nerve compromise.

Hand Compartment Syndrome

Hand compartment syndrome may not cause obvious sensory loss because the major digital sensory nerves are relatively superficial and may lie outside the affected muscle compartments.

Therefore, a normal sensory examination does not exclude compartment syndrome of the hand.

Compartment Tenseness

The involved compartment may feel firm, swollen, or tense to palpation.

This finding can support the diagnosis but is subjective.

Deep Posterior Compartment

The deep posterior compartment of the leg is difficult to assess by palpation because of its location.

A clinically soft superficial compartment does not exclude elevated pressure in the deep posterior compartment.

Pain With Passive Stretch

Pain produced by passively stretching muscles that cross the involved compartment is an important early sign.

For example, passive toe movement may stretch ischemic muscles in the leg and reproduce severe pain.

Pulses

Distal pulses should be assessed and compared with the opposite extremity.

However, preserved pulses do not exclude compartment syndrome because arterial pressure can remain sufficient to maintain flow even when microvascular perfusion is critically impaired.

Pulselessness is generally a late finding.

Compartment Pressure Measurement

General Principles

Direct measurement of intracompartmental pressure is useful when the diagnosis is uncertain or the patient cannot provide a reliable examination.

Pressure measurement should not delay surgery when the clinical diagnosis is clear.

Leg Compartments

The leg contains four major compartments that may require assessment:

Anterior compartment

Lateral compartment

Superficial posterior compartment

Deep posterior compartment

Thigh Compartments

The thigh contains anterior, posterior, and medial compartments.

Hand Compartments

Relevant hand compartments include the thenar, hypothenar, interosseous, adductor pollicis, and carpal tunnel compartments.

Foot Compartments

The foot contains several compartments, including medial, lateral, central, and intrinsic muscle compartments.

Forearm Compartments

The forearm includes volar, dorsal, and mobile-wad compartments.

Arm Compartments

The upper arm contains anterior and posterior compartments, with the deltoid region also considered when clinically appropriate.

Gluteal Compartment

Gluteal compartment syndrome typically involves the gluteus maximus region and may occur after prolonged unconsciousness or high-energy trauma.

Fingers

Compartment syndrome of the fingers is primarily a clinical diagnosis.

Pressure measurements are less commonly used.

Pressure Thresholds

Historically, an absolute compartment pressure of approximately 40 mm Hg has been considered concerning.

More commonly, the delta pressure, calculated as diastolic blood pressure minus compartment pressure, is used.

A delta pressure of 30 mm Hg or less is generally considered an indication for urgent decompression when consistent with the clinical setting.

Serial Pressure Monitoring

When the diagnosis remains uncertain, pressure measurements may be repeated every few hours.

The measurement should be obtained close to the suspected site of injury because pressures may vary within the compartment.

Chronic Compartment Syndrome

Chronic exertional compartment syndrome is characterized by elevated pressure during exercise or delayed normalization after activity.

Its diagnosis and treatment differ from those of acute compartment syndrome.

Laboratory Studies

Basic Metabolic Panel

Electrolytes should be checked when extensive muscle injury is suspected.

Particular attention should be paid to serum potassium, because muscle necrosis may cause life-threatening hyperkalemia.

Creatine Kinase

Serial creatine kinase measurements may help quantify the extent of muscle breakdown when significant rhabdomyolysis is suspected.

Marked elevations support substantial muscle injury but do not diagnose compartment syndrome by themselves.

Urine Myoglobin

Urinalysis can identify myoglobinuria caused by muscle necrosis.

Dark urine may occur when myoglobin levels are high.

Hematocrit

Hematocrit may be useful when substantial hemorrhage into a large compartment, such as the thigh, is suspected.

Preoperative Tests

Standard preoperative laboratory studies are obtained according to the clinical condition and urgency of surgery.

They should not delay decompression in a limb-threatening emergency.

Imaging

Plain Radiographs

Radiographs are used mainly to identify associated fractures or other skeletal injuries.

Imaging is supportive and should never delay treatment when acute compartment syndrome is clinically evident.

Pathological Findings

At fasciotomy, affected muscle may bulge outward once the fascia is opened because of the high intracompartmental pressure.

If diagnosis has been delayed, areas of ischemic or necrotic muscle may be present.

Differential Diagnosis

Arterial Occlusion

Acute arterial occlusion can also produce pain, pallor, paresthesia, weakness, and pulselessness.

However, arterial occlusion does not necessarily produce a tense compartment or elevated intracompartmental pressure.

Neurapraxia

Peripheral neurapraxia can produce weakness or numbness after trauma.

Unlike compartment syndrome, it is not associated with increased compartment pressure or marked compartment tenseness.

Treatment

General Measures

Acute compartment syndrome is a surgical emergency.

Once the diagnosis is established, treatment requires prompt decompression to prevent irreversible muscle and nerve injury.

Remove External Compression

Any cast, splint, dressing, or circumferential bandage should be split, loosened, or removed immediately if compartment syndrome is suspected.

Padding beneath a cast may also need to be completely divided.

Limb Position

When a developing compartment syndrome is being observed, the extremity should generally be maintained at approximately the level of the heart.

Excessive elevation may further reduce arterial perfusion, while dependent positioning can worsen venous congestion and swelling.

Bed Rest

Patients with suspected acute compartment syndrome should remain at rest while urgent assessment proceeds.

Activity that increases tissue demand or swelling should be avoided.

Nursing Care

Frequent neurovascular examinations are essential.

Changes in pain, motor function, sensation, compartment firmness, and analgesic requirements should be reported promptly.

Medical Management

Rhabdomyolysis

When myoglobinuria or major muscle necrosis is present, intravenous fluids may be administered to maintain renal perfusion.

Urine alkalinization may be considered in selected cases, depending on the clinical context.

Hyperkalemia

Hyperkalemia should be treated urgently because of the risk of cardiac arrhythmia.

Electrolytes should be monitored serially in patients with extensive muscle injury.

Treatment of Underlying Conditions

Associated problems may require separate treatment.

Examples include antibiotics for an open fracture or contaminated wound and anticoagulation for a confirmed deep vein thrombosis when appropriate.

Such treatment does not replace surgical decompression of an acute compartment syndrome.

Surgery

Fasciotomy

Definitive treatment consists of longitudinal opening of the fascia surrounding the involved compartment or compartments.

This allows swollen tissues to expand and restores the pressure gradient necessary for adequate perfusion.

Wound Management

Fasciotomy wounds are usually left open initially because immediate closure may recreate elevated compartment pressure.

Delayed primary closure or skin grafting is performed after swelling has subsided.

Negative-Pressure Wound Therapy

Postoperative wounds may be managed with moist dressings or negative-pressure wound therapy.

The choice depends on wound size, swelling, contamination, and institutional practice.

Postoperative Elevation

After decompression, the limb is usually elevated appropriately to reduce swelling while maintaining adequate perfusion.

Leg Fasciotomy

Two-Incision Technique

The leg is commonly decompressed through one lateral and one medial incision.

The lateral incision releases the anterior and lateral compartments.

The medial incision releases the superficial and deep posterior compartments.

Thigh Fasciotomy

Lateral Approach

A lateral incision is commonly used to release the anterior compartment.

The posterior compartment can often be released through the same exposure if necessary.

Medial Compartment

A separate medial incision may be required to decompress the medial thigh compartment.

Hand Fasciotomy

Dorsal Incisions

Two dorsal incisions, commonly placed over the second and fourth metacarpals, can be used to decompress the interosseous compartments.

Palmar Incisions

Additional palmar incisions may be required to decompress the thenar compartment and carpal tunnel.

A separate incision may be used for the hypothenar compartment when necessary.

Forearm Fasciotomy

Volar Release

The volar compartment is commonly released through an extended lazy-S incision.

This approach can be continued distally to release the carpal tunnel if necessary.

Dorsal Compartment

A separate dorsal release may be required when the dorsal compartment is involved, although it is not always necessary.

Foot Fasciotomy

Medial and Dorsal Approaches

The foot may be decompressed through a medial incision, with additional dorsal incisions over the second and fourth metatarsals as required.

Because compartment anatomy of the foot is complex, complete decompression requires careful surgical planning.

Arm Fasciotomy

Medial Approach

The arm may be decompressed through a medial approach, particularly when associated vascular exploration is required.

Both anterior and posterior compartments should be addressed when involved.

Finger Decompression

For digital compartment syndrome, release is generally performed on the ulnar side of the index and middle fingers and the radial side of the ring and little fingers to reduce risk to the dominant neurovascular structures.

Gluteal Fasciotomy

Gluteal compartment syndrome is treated with decompression through an incision over the gluteus maximus region, with release of the involved compartments.

Rehabilitation

Physical Therapy

Postoperative rehabilitation depends on the severity of the soft-tissue, nerve, muscle, and bony injuries.

Physical therapy may focus on range of motion, strengthening, gait training, mobility, and prevention of contracture.

Occupational Therapy

Occupational therapy is particularly useful after upper-extremity compartment syndrome.

Treatment may include hand strengthening, dexterity training, adaptive equipment, and specialized splinting.

Orthotic Referral

Persistent weakness such as foot drop may require an ankle-foot orthosis or another supportive brace.

Prosthetic Referral

If irreversible tissue damage results in limb loss, early prosthetic rehabilitation may improve long-term functional recovery.

Plastic Surgery

Plastic surgical consultation may be required for difficult fasciotomy wounds, soft-tissue coverage, skin grafting, or reconstructive procedures.

Follow-Up

Prognosis

The best outcomes occur when diagnosis is made rapidly and fasciotomy is performed before irreversible muscle and nerve injury develops.

Delay in treatment substantially increases the risk of permanent disability.

Fasciotomy Morbidity

Fasciotomy itself is not a minor procedure.

Large open wounds, painful scars, skin grafting, infection, and chronic venous problems may occur.

Nevertheless, these risks are outweighed by the consequences of untreated acute compartment syndrome.

Motor Recovery

Established paresis caused by prolonged nerve or muscle ischemia frequently has limited recovery.

Motor deficits that are already present at the time of delayed decompression may become permanent.

Sensory Recovery

Persistent numbness from advanced nerve ischemia may also fail to improve.

Sensory loss can predispose the limb to secondary injuries.

Complications

Motor Deficit

Permanent motor complications include weakness, paresis, and foot drop.

These deficits may result from muscle necrosis, nerve injury, or both.

Volkmann Ischemic Contracture

Untreated or inadequately treated forearm compartment syndrome can lead to Volkmann ischemic contracture.

Fibrosis and shortening of necrotic flexor muscles produce a characteristic fixed deformity of the wrist and hand.

Sensory Deficit

Permanent sensory loss may leave the extremity insensate.

Patients are then at increased risk of pressure ulcers, burns, infections, and repetitive unnoticed trauma.

Kidney Failure

Severe rhabdomyolysis can produce myoglobin-mediated renal injury and acute kidney failure.

Aggressive recognition and systemic management are therefore important.

Infection

Necrotic muscle and large fasciotomy wounds increase the risk of infection.

Repeated debridement may be required when nonviable tissue is present.

Chronic Venous Stasis

Chronic swelling and venous insufficiency may develop after severe compartment syndrome or fasciotomy.

Limb Loss

Extensive irreversible ischemia, infection, or vascular injury may ultimately require amputation.

Complex Regional Pain Syndrome

Some patients develop complex regional pain syndrome, historically referred to as reflex sympathetic dystrophy.

This may cause persistent pain, autonomic disturbance, stiffness, and functional impairment.

Patient Monitoring

Intraoperative Monitoring

Compartment pressures can be remeasured after fasciotomy when necessary to confirm that adequate decompression has been achieved.

The surgeon should also directly assess muscle viability.

Post-Closure Monitoring

After delayed wound closure, continued monitoring is necessary because recurrent swelling can recreate elevated compartment pressures.

Serial Neurovascular Examination

Ongoing assessment should include pain, motor strength, sensation, compartment firmness, pulses, capillary refill, renal function, and evidence of systemic rhabdomyolysis.

Any deterioration requires immediate reassessment.

Orthopaedic Surgery - Clubfoot

Basics

Clubfoot, also known as talipes equinovarus, is a complex congenital deformity of the foot that is present at birth.

The deformity consists of three major components: equinus of the heel, varus with internal rotation of the hindfoot, and adduction of the forefoot.

Components of the Deformity

Equinus describes a plantarflexed position of the ankle and heel.

Varus refers to inward turning of the hindfoot, while forefoot adduction causes the front of the foot to deviate medially.

Together, these abnormalities cause the foot to point downward and inward.

Weight-Bearing Pattern

If the deformity remains untreated, the child may bear weight along the lateral border or even the dorsolateral aspect of the foot rather than on the plantar surface.

This abnormal loading can eventually lead to callus formation, pain, and gait difficulty.

Classification

Clubfoot can be divided broadly into two categories.

The first is isolated or idiopathic clubfoot, in which no other congenital abnormality is identified.

The second is syndromic or secondary clubfoot, occurring in association with other congenital or neuromuscular disorders.

Syndromic Clubfoot

Associated conditions include amniotic band syndrome, arthrogryposis, myelodysplasia, diastrophic dysplasia, Larsen syndrome, Freeman–Sheldon syndrome, Möbius syndrome, and Loeys–Dietz syndrome.

Clubfeet associated with these conditions are usually more rigid, more severe, and more resistant to nonoperative treatment than idiopathic clubfeet.

They therefore have a greater likelihood of requiring surgical correction.

Bony Anatomy

The talar neck is characteristically directed medially and plantarward.

The talonavicular relationship is also abnormal, contributing substantially to the medial and plantar displacement of the foot.

Foot Size

The involved foot is usually smaller than normal.

In unilateral cases, the affected foot may be slightly shorter than the contralateral side, generally by less than approximately 1 cm.

The calf may also remain smaller because of associated muscle hypoplasia.

Epidemiology

Clubfoot occurs in approximately 1 in every 1,000 live births.

Males are affected about twice as often as females, producing a male-to-female ratio of roughly 2:1.

Risk Factors

A positive family history substantially increases the likelihood of clubfoot.

Important risk factors include having an affected parent or sibling and the presence of congenital disorders known to be associated with clubfoot.

Associated Congenital Disorders

Conditions linked with clubfoot include amniotic band syndrome, arthrogryposis, myelodysplasia, Möbius syndrome, Freeman–Sheldon syndrome, Larsen syndrome, diastrophic dysplasia, and Loeys–Dietz syndrome.

Certain teratogenic drug exposures during pregnancy, historically including aminopterin, have also been associated with congenital foot deformities.

Genetics

Idiopathic clubfoot is believed to have a multifactorial or polygenic inheritance pattern with variable penetrance.

No single genetic abnormality explains most idiopathic cases.

Familial Risk

When one child has clubfoot, the risk to a subsequent sibling has historically been estimated at approximately 2–6%.

If a parent has clubfoot, the risk to each child has been estimated at approximately 10%.

Etiology

The exact cause of idiopathic clubfoot remains uncertain.

A genetic contribution is strongly suspected, although environmental and developmental factors may also participate.

Associated Conditions

Clubfoot may occur together with other congenital musculoskeletal or neurologic abnormalities.

The presence of other deformities should prompt evaluation for an underlying syndrome or neurologic disorder.

Diagnosis

Signs and Symptoms

The diagnosis is usually evident from the appearance of the newborn foot.

The foot is excessively turned downward and inward, often with a deep medial crease.

Older Children

Untreated clubfoot in an older child can cause difficulty walking, poor shoe fit, painful callosities, and abnormal weight-bearing.

Severe untreated cases may result in walking on the lateral or dorsal aspect of the foot.

Pain

Pain is uncommon in infancy but may develop in older children or adults if the deformity remains uncorrected or becomes rigid.

Physical Examination

The typical examination demonstrates heel equinus, hindfoot varus or supination, and adduction of the midfoot and forefoot.

Together, these findings produce the characteristic appearance of a curved or “kidney-shaped” foot.

Medial Crease

A prominent medial or plantar crease is commonly present.

The foot projects medially from the leg and may resemble the shape of a club.

Flexibility

The examiner should determine how much of the deformity can be passively corrected.

Flexibility is important for assessing severity and planning treatment.

Muscle Function

Ankle and toe muscle activity should be evaluated.

The absence of active toe dorsiflexion may indicate more severe neuromuscular involvement and is associated with a less favorable prognosis.

Calf Hypoplasia

A smaller calf is a characteristic feature.

Even after successful correction of the foot position, some degree of calf hypoplasia usually persists.

Imaging

General Role of Radiographs

Radiographs are not routinely necessary for the diagnosis or early treatment of typical idiopathic clubfoot.

They may be useful when there is concern for underlying bony fusion, atypical anatomy, or when operative treatment is being planned.

Simulated Weight-Bearing Views

When imaging is obtained in a young child who cannot stand, simulated standing AP and lateral radiographs may be used.

Obtaining adequate images can be difficult because of the rigid deformity.

Positioning

The foot should be corrected as close to neutral as possible during imaging.

A Plexiglas plate or similar device may be used to hold the foot in position.

AP Radiograph

On the AP view, the forefoot is typically markedly adducted.

In a normal foot, the talus roughly aligns with the first metatarsal and the calcaneus with the fifth metatarsal.

Kite Angle

The angle between the longitudinal axes of the talus and calcaneus is known as the talocalcaneal or Kite angle.

On an AP radiograph, the normal angle is approximately 20–40°.

Kite Angle in Clubfoot

In clubfoot, the talus and calcaneus are nearly parallel.

As a result, the AP talocalcaneal angle is substantially reduced.

Lateral Radiograph

The lateral view demonstrates the equinus position of the foot.

In a normal foot, the lateral talocalcaneal angle is approximately 35–50°.

Lateral Talocalcaneal Angle in Clubfoot

In clubfoot, the talus and calcaneus remain relatively parallel in the sagittal plane, producing a markedly decreased talocalcaneal angle.

These angular relationships can help assess the adequacy of correction.

Pathological Findings

The principal bony abnormality is medial deviation of the talar neck with subluxation of the talonavicular joint.

Soft-tissue abnormalities are also prominent.

Muscle Abnormalities

Histologic studies have demonstrated that muscle fibers on the affected side may be smaller than normal.

This contributes to the characteristic calf hypoplasia.

Soft-Tissue Contracture

The fascia, tendons, and joint capsules on the medial and posterior aspects of the foot are thickened and contracted.

These soft-tissue abnormalities contribute to the rigidity of the deformity.

Differential Diagnosis

Metatarsus Adductus

Severe metatarsus adductus can resemble clubfoot because the forefoot is turned inward.

The key difference is that metatarsus adductus does not have the fixed hindfoot equinus component characteristic of true clubfoot.

Treatment

General Principles

Treatment should begin as soon as practical after birth.

The current standard for most idiopathic clubfeet is serial manipulation and casting using the Ponseti method.

Ponseti Method

The Ponseti technique gradually corrects the deformity through a specific sequence of gentle manipulations followed by long-leg casting.

Correction proceeds progressively rather than attempting to force the foot immediately into a normal position.

Correction Sequence

The forefoot is gradually abducted while the heel and talus are stabilized.

This corrects the cavus, adduction, and hindfoot varus components.

Equinus is corrected last, after the foot has been brought into appropriate alignment.

Long-Leg Casting

A cast is applied from the toes to above the knee to maintain each stage of correction.

The cast is typically changed at approximately weekly intervals until adequate correction is achieved.

Duration of Casting

Correction often requires approximately 6–8 weeks, although the number of casts varies with the severity and rigidity of the deformity.

Achilles Tenotomy

Persistent equinus is very common after correction of the other components.

A percutaneous Achilles tenotomy is therefore frequently performed to obtain adequate ankle dorsiflexion.

Post-Correction Bracing

After successful correction, maintenance bracing is essential to reduce recurrence.

A foot-abduction brace, commonly consisting of shoes attached to a Denis Browne-type bar, is used.

Brace Schedule

The brace is generally worn essentially full-time during the initial post-correction period and subsequently during sleep and naps for several years.

Adherence to bracing is one of the most important factors in preventing recurrence.

Physical Therapy

Stretching

Stretching of the heel cord and medial soft tissues may be helpful.

However, stretching alone is usually insufficient to correct a true clubfoot.

Maintenance of Correction

Exercises are most useful after casting as an adjunct to preserve ankle and foot flexibility.

They should not substitute for appropriate casting and bracing.

Medication

Medication has little role in the routine correction of clubfoot.

Botulinum toxin has been investigated as an adjunct to casting and splinting in selected cases, but it is not a standard substitute for established Ponseti treatment.

Surgery

Indications

Surgery is reserved primarily for persistent or recurrent deformity that cannot be adequately corrected with repeat casting and less invasive measures.

Modern Ponseti treatment has substantially reduced the need for extensive surgical release.

Treatment of Relapse

Recurrent deformity can frequently be managed with repeat casting, repeat Achilles tenotomy, or anterior tibialis tendon transfer.

The specific treatment depends on the pattern and flexibility of the recurrence.

Anterior Tibialis Tendon Transfer

An anterior tibialis tendon transfer may be useful in a child with recurrent dynamic supination after initial successful correction.

The tendon is repositioned to rebalance the foot during gait.

Extensive Surgical Release

If casting fails completely, more extensive surgery may be necessary.

The goal is to release contracted structures while avoiding excessive dissection that could lead to stiffness and scarring.

Medial Release

Medial procedures may include lengthening or release of the posterior tibial tendon and flexor tendons, together with release of contracted medial structures.

Posterior Release

Posterior correction may require Achilles tendon lengthening and release of contracted posterior joint capsules.

Minimize Capsular Dissection

Extensive capsular release should be minimized whenever possible because over-dissection increases the risk of postoperative stiffness, scarring, weakness, and later pain.

Temporary Fixation

Pins may occasionally be used to maintain correction after surgical release.

When used, they may remain in place for several weeks while the soft tissues heal.

Repeat Surgery

A minority of children treated surgically may require additional procedures later because of recurrent deformity or residual imbalance.

Historically, repeat surgery has been required in approximately 10–20% of surgically treated patients.

Follow-Up

Referral

Children with suspected clubfoot should be referred to an orthopaedic surgeon experienced in pediatric foot deformity and Ponseti treatment.

Early specialist management improves the likelihood of successful nonoperative correction.

Prognosis

With appropriate treatment, most children achieve a plantigrade, functional foot that allows normal or near-normal walking and activity.

Residual Differences

Certain features cannot be fully corrected.

The affected foot often remains somewhat smaller, the calf may remain thinner, and slight limb or foot shortening may persist.

These differences usually have little effect on overall function.

Complications

Residual Deformity

Incomplete correction may leave persistent equinus, varus, adduction, or cavus.

Residual deformity may interfere with shoe wear or gait.

Rocker-Bottom Foot

Overly forceful correction, particularly dorsiflexion before adequate correction of hindfoot and forefoot alignment, can produce a rocker-bottom deformity.

This should be avoided through proper sequential correction.

Overcorrection

Excessive correction can result in hindfoot valgus or other alignment abnormalities.

Stiffness

Extensive surgical treatment may result in a stiff foot.

This is one reason modern management emphasizes serial casting and limited procedures whenever possible.

Pain

Pain can develop later in childhood or adulthood, particularly if residual deformity, overcorrection, stiffness, or degenerative changes are present.

Patient Monitoring

Long-Term Follow-Up

Children require regular follow-up for several years because recurrence may occur even after an initially successful correction.

Timing of Recurrence

Idiopathic clubfoot may recur through approximately 6–7 years of age, although most relapses occur during the first several years of life.

Monitoring for Relapse

Follow-up should assess ankle dorsiflexion, hindfoot alignment, forefoot adduction, dynamic supination, brace adherence, gait, and shoe fit.

Management of Recurrence

Early recurrence can often be successfully treated with repeat Ponseti casting, Achilles tenotomy, or anterior tibialis tendon transfer, avoiding the need for extensive surgery.

Orthopaedic Surgery - Clinodactyly

Basics

Clinodactyly is a congenital deformity in which a finger is angulated in the radioulnar plane.

The little finger is affected most often and typically deviates toward the radial side.

The deformity usually results from an abnormally short, delta-shaped or trapezoidal middle phalanx.

Clinodactyly may occur as an isolated finding or as part of a congenital syndrome such as Down syndrome.

Synonym

Clinodactyly is sometimes referred to simply as a bent finger.

General Prevention

There is no known method for preventing clinodactyly.

There is also no evidence that early nonsurgical intervention alters its natural history when the deformity is caused by abnormal bony growth.

Epidemiology

Clinodactyly is usually apparent at birth or during early childhood.

It is more common in males, and when present in boys it is frequently bilateral.

Incidence

The reported frequency in otherwise healthy children varies widely, from approximately 1–19.5%.

It appears to be least common among Caucasian populations.

Risk Factors

Clinodactyly is strongly associated with several chromosomal and congenital syndromes.

In children with Down syndrome, the reported incidence is approximately 35–70%.

It may also be seen in Klinefelter syndrome, trisomy 18, and other congenital disorders.

Genetics

Clinodactyly may follow an autosomal dominant inheritance pattern with variable expressivity.

Some cases occur sporadically without a known family history.

Etiology

The deformity develops because of asymmetric longitudinal growth of the involved phalanx.

This is commonly related to formation of a physeal bracket, in which the growth plate extends abnormally around part of the phalanx.

Unequal growth on opposite sides of the bone causes progressive angulation.

Associated Conditions

Clinodactyly may be associated with symphalangism, brachydactyly, chromosomal trisomies, Treacher Collins syndrome, Silver syndrome, Holt–Oram syndrome, and Prader–Willi syndrome.

When other skeletal or systemic abnormalities are present, evaluation for an underlying syndrome may be appropriate.

Diagnosis

Signs and Symptoms

The affected finger, usually the fifth digit, is visibly deviated in either the radial or ulnar direction.

The deformity can arise at the PIP joint, middle phalanx, or DIP joint.

Distal involvement is particularly common.

Pain

Clinodactyly is typically painless.

Most patients present because of cosmetic appearance rather than discomfort.

Functional Limitation

Mild deformities usually do not interfere with hand function.

More severe angulation can occasionally cause difficulty with grasp, finger overlap, or interaction with adjacent digits.

Physical Examination

The degree of angulation should be measured carefully.

The examiner should document whether the deformity occurs primarily at the PIP joint, middle phalanx, or DIP joint.

Range of Motion

Both active and passive movement of each finger joint should be recorded.

This helps determine whether the deformity is purely bony or whether associated joint stiffness is present.

Examination for Associated Abnormalities

The remainder of the hand and skeleton should also be examined.

Additional congenital abnormalities may suggest an underlying syndromic diagnosis.

Laboratory Testing

Routine laboratory studies are not required for isolated clinodactyly.

If a chromosomal or congenital syndrome is suspected, chromosome analysis or appropriate genetic testing may be indicated.

Imaging

Plain Radiographs

Conventional radiographs of the affected finger are useful for defining the underlying bony anatomy.

Imaging is particularly important when surgical correction is being considered.

Normal Angulation

Angulation of less than approximately 10° may fall within normal anatomical variation.

Greater deformity should be interpreted in relation to symptoms, function, and progression.

Radiographic Findings

Radiographs may show a shortened, wedge-shaped, delta-shaped, or trapezoidal phalanx.

The joint surface may be oblique because of asymmetric development.

Pathological Findings

The underlying abnormality is maldevelopment of one of the phalanges.

Unequal growth causes angulation of the bone and its associated joint surface.

Differential Diagnosis

Delta Phalanx

A delta phalanx is a wedge-shaped phalanx with an oblique articular surface.

It is closely related to the underlying developmental mechanism of many cases of clinodactyly.

Fracture Malunion

A previously fractured finger that heals in an angulated position may resemble clinodactyly.

History of trauma and radiographic evidence of prior fracture help distinguish malunion from congenital deformity.

Treatment

General Measures

Most cases of clinodactyly are primarily cosmetic and do not require treatment.

Mild deformity without functional impairment should generally be observed.

Manipulation and Casting

Manipulation or casting is usually ineffective because the deformity arises from abnormal bone growth rather than a flexible soft-tissue contracture.

These methods can also be difficult for children to tolerate.

Indications for Surgery

Surgical correction may be considered when there is substantial persistent deformity, functional impairment, overlap with adjacent fingers, or unacceptable appearance, particularly after approximately 6 years of age.

Expectations From Surgery

Surgery can improve finger alignment and appearance.

However, correction may come at the cost of scarring, stiffness, and possible loss of motion.

These trade-offs should be considered carefully in a condition that is often asymptomatic.

Activity

No activity restrictions are necessary for uncomplicated clinodactyly.

Children may participate normally in play, sports, and daily activities.

Physical Therapy

Physical or hand therapy is not usually required before surgery.

After operative correction, therapy may help restore range of motion, strength, and hand function.

Surgery

General Principles

Surgical treatment depends on the child’s age, skeletal maturity, severity of deformity, and underlying physeal abnormality.

Procedures include osteotomy and reconstruction of the abnormal growth plate region.

Young Children

In children younger than approximately 6 years, correction may involve excision of the abnormal central portion of the continuous epiphysis and underlying physis.

A free-fat graft is then inserted to prevent reformation of the physeal bracket and allow more symmetric growth.

Free-Fat Graft Procedure

The aim of fat-graft interposition is to remove the tethering growth abnormality while preserving the remaining growth potential of the phalanx.

Gradual improvement in alignment can then occur as the finger continues to grow.

Older Children

After approximately 6 years of age, a corrective closing-wedge osteotomy can usually be performed more predictably.

The bone is surgically realigned to improve the axis of the digit.

Osteotomy

Corrective osteotomy provides relatively immediate correction of the deformity.

It is generally technically straightforward but still carries risks of stiffness, scar formation, recurrence, or incomplete correction.

Follow-Up

Prognosis

The overall prognosis is excellent.

Clinodactyly does not usually cause pain, progressive disability, or degenerative joint disease.

Observation

Many patients require only periodic observation.

Progression of angulation can be followed clinically as the child grows.

Patient Monitoring

Patients or families can monitor the degree of finger angulation and functional effect over time.

Reassessment is appropriate if the deformity becomes more pronounced, interferes with function, causes finger overlap, or becomes cosmetically unacceptable enough to consider surgical correction.

Orthopaedic Surgery - Claw Toes

Basics

Claw toes are deformities of the lesser toes characterized by hyperextension at the metatarsophalangeal (MTP) joint together with flexion of the proximal interphalangeal (PIP) joint.

The distal interphalangeal joint may be either flexed or extended, depending on the specific deformity and underlying muscle imbalance.

Epidemiology

The frequency of claw-toe deformity increases with advancing age.

It occurs more commonly in women than men.

Genetics

When claw toes result from a hereditary motor and sensory neuropathy, the underlying disorder may follow an autosomal dominant inheritance pattern.

This is particularly relevant in patients with disorders such as Charcot–Marie–Tooth disease.

Pathophysiology

The most common mechanism is an imbalance between the intrinsic and extrinsic muscles of the foot.

Weakness or loss of the intrinsic muscles allows the long flexor and extensor tendons to act without their normal balancing forces.

Development of the Deformity

The process may begin with synovitis and attenuation of the plantar plate at the MTP joint.

As the plantar plate weakens, the proximal phalanx progressively hyperextends at the MTP joint.

Role of MTP Hyperextension

Hyperextension at the MTP joint displaces the intrinsic tendons dorsally relative to the axis of the joint.

This changes their mechanical action and contributes further to flexion of the interphalangeal joints, producing the characteristic claw configuration.

Extrinsic Muscle Contracture

Concurrent tightness or contracture of the long toe flexors and extensors can worsen the deformity.

Without effective intrinsic muscle opposition, the toe becomes progressively hyperextended at the MTP joint and flexed distally.

Underlying Disorders

Claw toes frequently develop secondary to neurologic or inflammatory conditions that disrupt normal muscle balance or weaken passive ligamentous restraints.

They may also occur without an identifiable underlying disease.

Causative Factors

Associated or contributing factors include tight footwear, hallux valgus, inflammatory arthropathy, peripheral neuropathy, diabetes mellitus, hereditary sensorimotor neuropathy, neuromuscular disease, spasticity, and delayed or missed compartment syndrome.

Diagnosis

Signs and Symptoms

A prominent feature is a dorsal prominence of the PIP joint of the affected lesser toe.

This prominence may rub against footwear and produce pain, callus formation, or skin irritation.

Callosities

Repeated pressure from shoes can produce painful callosities over the dorsal PIP joint.

Plantar calluses may also form beneath the metatarsal heads because of abnormal forefoot loading.

Pain

Pain may occur over the dorsum of the toe or beneath the ball of the foot.

Pain beneath the metatarsal heads is commonly described as metatarsalgia.

Difficulty With Footwear

Patients often have difficulty finding comfortable shoes because the elevated toe rubs against the upper portion of the shoe.

This problem tends to become more severe as the deformity becomes rigid.

History

Patients may seek treatment because of pain, difficulty wearing shoes, or dissatisfaction with the appearance of the toes.

A painful bursa may develop over the dorsal PIP prominence.

Plantar Fat Pad Migration

As the MTP joint hyperextends, the plantar fat pad may shift distally away from the metatarsal head.

Loss of normal cushioning beneath the metatarsal head can contribute to painful plantar calluses.

Ulceration

In patients with loss of protective sensation, particularly those with diabetic or hereditary neuropathy, pressure points can progress to skin breakdown and ulceration.

This is an important reason for close monitoring.

Physical Examination

Claw toes often involve several adjacent digits and may be bilateral.

They are frequently associated with cavus foot deformity or Achilles tendon contracture.

Neuromuscular Examination

A complete neuromuscular examination should be performed to identify an underlying cause.

Muscle strength, reflexes, gait, and associated deformities should be assessed.

Sensory Examination

Sensation in the foot should be tested carefully.

Loss of protective sensation substantially changes treatment decisions because it increases the risk of pressure injury and ulceration.

Diabetic Neuropathy Assessment

In patients with diabetes, a Semmes–Weinstein monofilament examination can be used to assess protective sensation and identify peripheral neuropathy.

Vascular Examination

The vascular status of the foot should be assessed, particularly when surgery is being considered.

Poor circulation increases the risk of wound-healing complications and may limit operative options.

Flexible Versus Rigid Deformity

The toes should be manipulated to determine whether the deformity is flexible or fixed.

This distinction is central to treatment planning.

MTP Joint Assessment

The MTP joint should be assessed for alignment, stability, subluxation, dislocation, and pain with manipulation.

Instability at this joint may indicate advanced plantar plate insufficiency.

Imaging

Plain Radiographs

Plain radiographs may show MTP joint subluxation or dislocation and flexion deformity at the PIP joint.

Weight-bearing images can help demonstrate the severity of alignment abnormalities.

Differential Diagnosis

Hammer Toe

Hammer toe can resemble claw toe but typically involves PIP flexion without the characteristic MTP hyperextension pattern seen in a true claw toe.

Mallet Toe

Mallet toe primarily involves a flexion deformity of the distal interphalangeal joint.

The MTP joint is not characteristically hyperextended.

Treatment

General Measures

Initial treatment is usually nonoperative and directed toward relieving pressure, reducing pain, and accommodating the deformity.

Options include bracing, taping, padding, cushions, and shoe modification.

Budin Splint

A Budin splint may help maintain improved toe alignment in patients with a flexible deformity.

It is less effective once the deformity becomes rigid.

Silicone Padding

Silicone or other soft padding can protect prominent areas of the toes from friction and pressure.

This may reduce callus formation and discomfort.

Cushioned Insoles

Cushioned insoles can decrease plantar pressure and help relieve metatarsalgia.

They are particularly useful when plantar calluses are present.

Footwear Modification

Shoes with a wide forefoot and high toe box can reduce rubbing over the elevated toes.

Footwear modification is one of the most useful conservative treatments.

Geriatric Considerations

Claw toes are particularly common in older women.

When significant comorbidities such as diabetes mellitus or peripheral vascular disease are present, conservative treatment is preferred whenever possible.

Surgery should be approached cautiously because wound and infection risks may be increased.

Pediatric Considerations

Congenital curly toes may be present from birth and can resemble lesser-toe deformities.

They are usually asymptomatic and commonly managed with observation.

Surgery

General Principles

Surgical treatment depends primarily on whether the deformity is flexible or rigid.

Associated hindfoot or midfoot pathology should also be addressed because persistent proximal deformity can contribute to recurrence.

Flexible Deformity

Flexible claw toes often correct when the ankle is plantarflexed or when the toe is manually manipulated.

These deformities are primarily caused by muscle imbalance rather than fixed joint contracture.

Flexor-to-Extensor Tendon Transfer

A flexor-to-extensor tendon transfer may be used to correct a flexible claw toe.

The transferred tendon helps rebalance the toe and reduce PIP flexion and MTP hyperextension.

Rigid Deformity

Rigid claw toes require correction of contracted soft tissues and, in some cases, bone procedures.

The MTP capsule and collateral ligaments may need to be released.

Extensor Tendon Release or Lengthening

A tight extensor tendon can maintain MTP hyperextension.

Release or lengthening may therefore be necessary as part of correction.

MTP Joint Dislocation

Claw toes associated with MTP dislocation may require an oblique distal metatarsal shortening osteotomy, such as a Weil-type osteotomy.

Shortening the metatarsal reduces tension and facilitates reduction of the MTP joint.

Rigid PIP Contracture

A fixed PIP joint deformity may require partial phalangectomy or PIP joint arthrodesis.

Fusion provides stable correction when the joint can no longer be passively straightened.

Associated Hindfoot and Midfoot Deformity

Underlying cavus, hindfoot varus, Achilles contracture, or other deformities should be treated when they contribute to the forefoot abnormality.

Failure to correct these problems can increase the likelihood of recurrence.

Follow-Up

Indications for Referral

Specialist referral is appropriate when pain persists despite conservative treatment or when the deformity causes significant functional limitation.

Difficulty Wearing Shoes

Inability to wear appropriate footwear despite shoe modification is a common reason to consider operative correction.

Skin Ulceration

Ulceration or impending ulceration over a pressure point warrants prompt assessment.

This is particularly important in patients with neuropathy or diabetes.

Prognosis

Claw-toe deformity is usually progressive.

Without treatment, both the structural deformity and associated pain may gradually worsen.

Flexible deformities may eventually become fixed as capsular and tendon contractures develop.

Complications

Stiffness

Postoperative stiffness can occur, particularly after joint release or fusion procedures.

Wound Infection

Surgical treatment carries a risk of wound infection.

This risk is greater in patients with diabetes, neuropathy, or peripheral vascular disease.

Persistent Pain

Pain may continue despite technically successful correction, especially when associated metatarsalgia or neuropathy is present.

Incomplete Correction

The deformity may not be fully corrected if significant contracture or unrecognized contributing pathology remains.

Recurrence

Claw toes can recur, particularly when the underlying muscle imbalance or proximal foot deformity persists.

Floating Toe

A floating toe deformity may develop after a distal metatarsal shortening procedure such as a Weil osteotomy.

The affected toe may fail to contact the ground normally during standing or gait.

Patient Monitoring

Follow-up should assess toe alignment, flexibility, skin integrity, shoe tolerance, plantar pressure symptoms, sensation, and vascular status.

Patients with diabetes or neuropathy require especially careful surveillance for calluses, pressure injury, and ulceration.

Orthopaedic Surgery - Chronic Exertional Compartment Syndrome

Basics

Chronic exertional compartment syndrome (CECS) is an important cause of exercise-related leg pain, particularly in athletes and physically active individuals.

Because many disorders can produce similar symptoms, exertional leg pain requires a careful diagnostic evaluation.

Important alternative diagnoses include stress fracture, medial tibial stress syndrome, deep vein thrombosis, popliteal artery entrapment syndrome, and peripheral nerve entrapment.

Typical Compartment Involvement

The anterior and lateral compartments are affected most frequently and account for approximately 95% of symptomatic cases.

Symptoms are often bilateral, occurring in both legs in approximately 60–80% of patients.

Deep Posterior Compartment

The deep posterior compartment may also be involved.

Some series have reported deep posterior symptoms in as many as 40% of patients.

This form can be more difficult to diagnose and may respond less predictably to surgery.

Characteristic Symptom Pattern

The classic presentation is transient leg pain triggered by exercise and relieved by rest.

Symptoms typically recur at a predictable level of activity, such as after a certain running distance, duration, or intensity.

Epidemiology

Patients with CECS are generally young, with an average age of approximately 20–24 years.

The condition is particularly associated with running and other repetitive endurance activities.

Civilian Risk Factors

Within civilian populations, women and endurance runners have been reported to have a higher risk of developing CECS.

Military Risk Factors

Among military personnel, increased risk has been associated with older age within the military population, female sex, Caucasian race, and junior enlisted rank.

Repetitive high-volume physical training likely contributes to the development of symptoms.

Associated Conditions

No specific disease has been shown to have a direct causal relationship with CECS.

However, because many affected patients are young female endurance athletes, associated conditions such as stress fracture or components of the female athlete triad/relative energy deficiency spectrum may coexist and should be considered when clinically appropriate.

Diagnosis

Signs and Symptoms

The principal complaint is exercise-induced leg pain.

Pain usually develops predictably after a reproducible amount of physical activity and gradually resolves once exercise stops.

Predictable Exertional Pain

Patients often describe pain that begins at approximately the same distance, running speed, duration, or training intensity during each episode.

The reproducibility of symptoms is an important clinical clue.

Progression of Symptoms

In more advanced or longstanding cases, the threshold required to provoke symptoms may decrease.

Pain may eventually occur with ordinary walking and, in severe cases, may occasionally persist even at rest.

Muscle Weakness

Neuromuscular symptoms may accompany pain.

Progressive compression can result in weakness of muscles within the affected compartment.

Foot Drop

When the anterior compartment is involved, weakness of the ankle dorsiflexors may develop.

This can cause transient or, in chronic severe cases, more persistent foot drop.

Physical Examination

The physical examination may be completely normal when the patient is evaluated at rest.

For this reason, examination immediately after exercise may be more informative.

Swelling

Postexercise swelling or increased firmness of the involved compartment may be present.

This finding is more dramatic in acute compartment syndrome but may also be observed in CECS.

Neurovascular Examination

A thorough neurovascular examination should evaluate the muscles, sensory territories, and pulses related to each compartment of the leg.

Findings should be compared before and after symptom-provoking exercise whenever possible.

Compartment Tenderness

The involved compartments may become tender after activity.

The muscles may also feel tense or firm.

Pain With Passive Stretch

Passive stretching of muscles within the affected compartment may reproduce discomfort.

For example, stretching the ankle or toes opposite the action of the involved muscles may provoke pain.

Sensory Changes

Paresthesias may occur because of transient nerve compression.

In anterior compartment involvement, sensory disturbance may be noted in the first dorsal web space, corresponding to the deep peroneal nerve distribution.

Muscle Herniation

Occasionally, a focal fascial defect allows muscle to bulge through the fascia.

A palpable muscle herniation may therefore be present, particularly after exercise.

Laboratory Tests

Routine laboratory testing does not diagnose CECS.

If surgery is planned, standard preoperative blood tests may be obtained according to the patient’s age, comorbidities, and general health.

Imaging

Plain Radiographs

AP and lateral radiographs may be obtained when there is focal bony tenderness or concern for a fracture.

Their main role is to exclude other causes of exertional leg pain rather than to confirm CECS.

MRI

MRI is particularly useful for excluding stress fractures and other structural abnormalities.

It is one of the most sensitive imaging studies for stress injury of the tibia and other lower-extremity bones.

Postexercise MRI

Postexercise T2-weighted MRI may demonstrate increased muscular edema in the symptomatic compartment.

These signal changes may correlate with increased intracompartmental pressures.

Near-Infrared Spectroscopy

Near-infrared spectroscopy can assess tissue oxygenation by measuring relative amounts of oxygenated and deoxygenated blood.

Persistent elevation of the deoxygenated-to-oxygenated blood ratio after exercise may support the diagnosis.

Compartment Pressure Testing

Gold Standard

Direct intramuscular compartment pressure measurement has traditionally been considered the diagnostic gold standard for CECS.

Pressures are measured at rest and after a symptom-provoking exercise protocol.

Four-Compartment Testing

When clinically indicated, pressures may be measured in each of the four major compartments of the leg.

Testing should target the compartments suggested by the patient’s symptoms and examination.

Pedowitz Criteria

The commonly cited Pedowitz criteria use pressure measurements obtained at rest and at specific times following exercise.

A test is considered positive when one or more of the following thresholds are reached:

Resting pressure greater than 15 mm Hg

Pressure greater than 30 mm Hg at 1 minute after exercise

Pressure greater than 20 mm Hg at 5 minutes after exercise

These findings should be interpreted together with the patient’s clinical presentation.

Differential Diagnosis

Medial Tibial Stress Syndrome

Medial tibial stress syndrome commonly produces exercise-related pain along the posteromedial tibial border.

Unlike CECS, symptoms are usually associated with diffuse bony tenderness rather than a tense muscular compartment.

Tibial Stress Fracture

Stress fracture may cause focal exertional pain that eventually persists at rest.

MRI is particularly useful when radiographs are normal but clinical suspicion remains high.

Popliteal Artery Entrapment Syndrome

Popliteal artery entrapment can cause exercise-related calf pain and vascular symptoms.

Diminished pulses or abnormal vascular testing during provocative maneuvers may help distinguish it from CECS.

Deep Vein Thrombosis

Deep vein thrombosis should be considered when leg pain is associated with persistent swelling, risk factors for thrombosis, or symptoms not directly linked to exercise.

Nerve Entrapment

Peripheral nerve entrapment may produce pain, paresthesias, or weakness.

The neurologic distribution and lack of a characteristic pressure-dependent exercise pattern may help differentiate it from CECS.

Achilles Tendon Tightness

A tight gastrocnemius-soleus complex or Achilles tendon can alter lower-extremity mechanics and produce exertional discomfort.

It should be evaluated during the physical examination.

Treatment

General Measures

The most effective conservative strategy is to reduce or stop the activity that predictably produces symptoms.

Complete symptom relief is often possible if the patient permanently avoids the provoking activity.

Activity Modification

Patients may benefit from changing running distance, intensity, training surface, frequency, or type of exercise.

Transition to lower-impact activities may allow continued fitness while reducing symptoms.

Ice and Anti-Inflammatory Measures

Ice and NSAIDs may provide temporary symptomatic relief.

However, because CECS is primarily a pressure-related mechanical problem, medication alone rarely provides durable resolution when provoking activities continue.

Massage

Massage and soft-tissue techniques are sometimes used as adjunctive treatment.

Evidence for lasting benefit is limited, but some patients report temporary improvement in discomfort.

Footwear Modification

Changing shoes may alter lower-extremity mechanics and reduce symptoms in selected patients.

Footwear should be appropriate for the athlete’s foot type, running surface, and training demands.

Gait Modification

Modification of running technique may reduce compartment loading.

Changes in cadence, foot-strike pattern, and running mechanics have been explored as nonoperative strategies in selected athletes.

Limitations of Nonoperative Treatment

Conservative management has a relatively high failure rate.

This is partly because diagnosis is often delayed and many athletes are unwilling or unable to permanently reduce the activity that causes their symptoms.

Surgery

Indications

Surgical treatment is considered when symptoms remain significant despite an adequate trial of nonoperative management and the diagnosis has been supported clinically and, when appropriate, by pressure testing.

Fasciotomy

The standard surgical procedure is fasciotomy of the involved compartment or compartments.

The fascia is opened to increase the available volume and prevent pathologic rises in pressure during exercise.

Selective Compartment Release

Only compartments demonstrated to be symptomatic should generally be released.

The decision is based on the patient’s history, physical examination, and compartment pressure findings.

Surgical Approaches

Both single-incision and limited two-incision techniques have been described.

Endoscopic assistance may also be used.

No approach has clearly demonstrated universal superiority.

Superficial Peroneal Nerve

During anterior and lateral compartment release, particular care is required to protect the superficial peroneal nerve.

The nerve can be injured during surgical exposure or fasciotomy.

Fascial Bands and Nerve Compression

The superficial peroneal nerve should be identified when necessary, and constricting fascial bands or adhesions should be released.

Failure to recognize persistent nerve compression may result in incomplete symptom relief after surgery.

Follow-Up

Prognosis

Outcomes are generally better after release of the anterior and lateral compartments than after surgery involving the deep posterior compartment.

Anterior and Lateral Compartment Outcomes

Symptom resolution after isolated anterior and/or lateral compartment release has been reported in approximately 80% of patients.

Deep Posterior Compartment Outcomes

Release of the deep posterior compartment has a less predictable result, with symptom resolution reported in approximately 60% of cases.

The deeper anatomy and diagnostic difficulty may contribute to the lower success rate.

Return to Sport

In studies of elite athletes, approximately 84% returned to their previous level of sport after surgical fasciotomy.

One reported average return-to-sport time was approximately 10.6 weeks.

Actual recovery time depends on the compartments released, wound healing, rehabilitation, and sport demands.

Complications

Nerve Injury

Peripheral nerve injury is one of the most important surgical complications.

The superficial peroneal nerve is particularly vulnerable during anterior or lateral compartment release.

Deep Vein Thrombosis

Deep vein thrombosis can occur following surgery, although it is uncommon.

Persistent calf swelling or pain after surgery should therefore be evaluated appropriately.

Infection

Surgical-site infection may complicate fasciotomy.

Appropriate wound care and postoperative monitoring are required.

Wound Dehiscence

The operative wound may separate or heal slowly, particularly when swelling is significant.

Activity progression should therefore be coordinated with wound healing.

Complex Regional Pain Syndrome

A small number of patients may develop complex regional pain syndrome, characterized by disproportionate pain, sensory disturbance, autonomic changes, and functional limitation.

Patient Monitoring

Patients managed nonoperatively should be reassessed for progression of pain, weakness, sensory disturbance, or decreasing exercise tolerance.

Following surgery, monitoring should focus on wound healing, nerve function, recurrent symptoms, ankle strength, and gradual return to activity.

Persistent or recurrent exertional pain should prompt reassessment for incomplete release, involvement of another compartment, or an alternative diagnosis.

Orthopaedic Surgery - Clavicle Fractures

Basics

Clavicle fractures are among the most common upper-extremity fractures encountered in the emergency department.

They occur most frequently in males younger than 20 years, while among older adults, particularly those over 65 years, women account for a greater proportion of cases.

Clavicle fractures are classified according to their location, displacement, comminution, and possible intra-articular extension.

Classification

Several classification systems are available, including the Neer, Edinburgh, and Müller AO systems.

From an anatomic perspective, fractures are divided into middle-third, lateral-third, and medial-third injuries.

Middle-third fractures are by far the most common, followed by lateral and then medial clavicle fractures.

Open Fractures

Open clavicle fractures are uncommon.

When they occur, they are often associated with substantial trauma involving the head, thorax, or major vessels.

Clavicle fractures are also frequently encountered in patients with multiple traumatic injuries.

Fracture Displacement

The characteristic displacement of a midshaft clavicle fracture is produced by opposing muscular and gravitational forces.

The sternocleidomastoid muscle pulls the medial fragment superiorly, while the pectoralis major and the weight of the arm tend to pull the lateral fragment inferiorly and medially.

These forces may create visible shortening or deformity.

Neurovascular Anatomy

The clavicle lies directly over the subclavian vein and is close to the subclavian artery and brachial plexus.

Although injury to these structures is uncommon, neurovascular damage may occur at the time of trauma or during operative fixation.

A careful neurovascular examination is therefore essential.

Lateral Clavicle Fractures

The displacement pattern of lateral clavicle fractures depends strongly on the integrity of the coracoclavicular ligaments, acromioclavicular joint, and surrounding ligamentous structures.

Disruption of these stabilizers may make the fracture unstable and increase the risk of nonunion.

General Prevention

Fall prevention is particularly important in patients with impaired balance or a history of recurrent falls.

Assistive devices, home-safety assessment, and nursing or rehabilitation evaluation may help reduce future injury.

In older adults sustaining a clavicle fracture after a low-energy fall, evaluation and treatment of possible osteoporosis may reduce the risk of subsequent fragility fractures.

Epidemiology

Clavicle fractures occur more often in men than women among patients younger than 65 years, with a reported male-to-female ratio of approximately 2.2:1.

The mean age at the time of fracture has been reported to be approximately 48 years.

Fractures occur more frequently during weekends and summer months, probably reflecting increased recreational and sporting activity.

Incidence

Reported incidence varies between populations.

One epidemiologic study found approximately 5.8 clavicle fractures per 10,000 people, while a recent U.S. study reported approximately 24.4 fractures per 100,000 person-years.

The highest incidence occurs between approximately 10 and 19 years of age.

Risk Factors

Risk factors include male sex, young age, recurrent falls, osteoporosis, participation in sports, bicycle accidents, motor vehicle collisions, and other forms of trauma.

Sports account for a substantial proportion of emergency-department presentations involving clavicle fractures.

Genetics

Genetic disorders that weaken bone may increase susceptibility to clavicle fracture.

Examples include Ehlers-Danlos syndrome and fibrous dysplasia, although most clavicle fractures occur without an underlying hereditary disorder.

Etiology

The most common mechanism is a fall, frequently directly onto the shoulder.

Other mechanisms include bicycle and motorcycle accidents, motor vehicle collisions, and contact-sport injuries.

Sports-Related Injuries

Among sporting activities, bicycling is particularly commonly associated with clavicle fracture.

Football and soccer are other frequent causes.

Age and Injury Mechanism

Men are more likely to sustain clavicle fractures through higher-energy mechanisms, whereas women, particularly older women, more often sustain fractures after falls or other relatively low-energy trauma.

Associated Conditions

Associated injuries are common, particularly after high-energy trauma.

Important associated conditions include rib fractures, pneumothorax, cervical spine injury, head injury, scapular fracture, vascular injury, and nerve injury.

Polytrauma

Patients with a clavicle fracture after major trauma require a complete trauma assessment.

Concurrent fractures may involve the spinal column, scapula, cranium, forearm, proximal humerus, or other parts of the shoulder girdle.

Spinal column fractures are among the important associated skeletal injuries.

Scapulothoracic Dissociation

A widely displaced clavicle fracture in a high-energy injury should raise concern for scapulothoracic dissociation.

This severe shoulder-girdle injury may be associated with major vascular and brachial plexus injury.

Diagnosis

Signs and Symptoms

Typical findings include pain with movement of the affected upper extremity, visible or palpable deformity over the clavicle, swelling, bruising, and ecchymosis.

Patients often support the injured arm with the opposite hand.

Skin Tenting

The displaced fracture fragment may push against the overlying skin, producing skin tenting.

Marked tenting or blanching indicates threatened skin integrity and may represent an indication for urgent operative treatment.

Physical Examination

The clavicular region and the entire upper extremity should be inspected carefully.

The examiner should look for open wounds, abrasions, skin tenting, expanding hematoma, abnormal alignment, or evidence of additional injury.

Neurovascular Examination

A careful neurovascular examination is essential.

Motor function and sensation throughout the upper extremity should be evaluated and compared with the opposite side.

Vascular Examination

Although vascular injury is rare, the examiner should confirm symmetric distal pulses and brisk capillary refill.

An expanding hematoma, diminished pulse, cool extremity, or other evidence of vascular compromise requires urgent assessment.

Examination for Associated Injuries

The remainder of the injured extremity should be palpated and the major joints examined.

Additional fractures, shoulder dislocation, or other injuries may coexist and should not be overlooked.

Trauma Examination

Patients injured through high-energy mechanisms require a complete trauma examination to identify associated thoracic, spinal, abdominal, cranial, or extremity injuries.

Elderly Patients After Falls

Older adults who sustain a clavicle fracture after a fall should also be evaluated for head and cervical spine injury.

This is particularly important in patients with recurrent falls or those taking anticoagulant medication.

Imaging

Dedicated Clavicle Radiographs

Standard evaluation includes dedicated radiographs of the clavicle.

An anteroposterior view and approximately 20° cephalad view are commonly obtained.

Chest Radiograph

An AP chest radiograph can help assess fracture displacement and compare the injured clavicle with the opposite side.

It may also reveal associated injuries such as rib fractures or pneumothorax.

Shoulder Radiographs

Dedicated shoulder radiographs can help exclude associated injuries involving the scapula, acromioclavicular joint, or proximal humerus.

CT

CT is not routinely required for uncomplicated midshaft fractures.

It may be helpful for medial clavicle fractures, complex fracture patterns, or when the relationship to adjacent thoracic structures is unclear.

Vascular Imaging

If vascular injury is suspected, angiographic imaging may be required to evaluate the subclavian or other nearby vessels.

Additional Imaging

Additional radiographs or advanced imaging should be obtained according to the mechanism of injury and clinical suspicion for associated trauma.

Pathologic Fracture Evaluation

Pathologic testing is not routinely necessary.

A pathologic fracture should be considered when the injury occurs after an unusually minor mechanism, when there is a personal or strong family history of malignancy, or when radiographs demonstrate a suspicious underlying bony lesion.

Differential Diagnosis

The differential diagnosis includes acromioclavicular joint separation, rib fracture, scapular fracture, shoulder dislocation, sternoclavicular joint dislocation, and proximal humerus fracture.

Treatment

General Principles

Treatment depends on both patient factors and fracture characteristics.

Most clavicle fractures can be managed nonoperatively, although operative fixation has become more common in selected displaced fractures.

Nondisplaced Fractures

Nondisplaced or minimally displaced fractures usually heal successfully with nonoperative care.

A sling, pain control, and gradual restoration of shoulder motion are typically sufficient.

Medial and Lateral Fractures

Many medial and lateral clavicle fractures can also be managed without surgery when alignment and stability are acceptable.

However, unstable lateral fractures require closer assessment because the risk of nonunion is higher.

Children Versus Adults

Children have greater remodeling potential and a higher likelihood of healing displaced fractures than adults.

Consequently, substantial displacement that might prompt surgery in an adult may still be treated successfully without surgery in a younger child.

Monitoring Displaced Fractures

Displaced fractures treated nonoperatively should undergo repeat radiographs during the first several weeks to ensure that alignment has not worsened.

Sleeping Position

During the painful acute phase, patients may find it more comfortable to sleep in a chair or recliner rather than lying flat.

Activity

Sling Immobilization

A sling is commonly used for approximately 2–4 weeks.

During the early period, the involved upper extremity is generally kept non-weight-bearing.

Early Joint Motion

The sling should be removed several times each day for gentle elbow, wrist, and hand range-of-motion exercises.

This helps prevent stiffness in uninvolved joints.

Shoulder Motion

Gentle shoulder range of motion can usually begin after approximately 2–4 weeks, depending on pain, fracture stability, and clinical progress.

More strenuous motion and strengthening are delayed until healing has progressed.

Figure-of-Eight Brace

A figure-of-eight clavicle brace may be used, but it has not shown a clear advantage over a simple sling.

It may also produce greater discomfort during the early treatment period.

Axillary Care

When using a sling, the axillary fold should be kept clean and dry to prevent irritation, moisture accumulation, and skin breakdown.

Preoperative Activity

Patients awaiting surgery should generally remain non-weight-bearing in a sling.

After fixation, activity restrictions depend on the surgical construct, implant, and surgeon’s postoperative protocol.

Physical Therapy

Nonoperative Rehabilitation

Formal physical therapy is not necessary for every patient.

For nonoperatively treated fractures, gentle motion can begin after approximately 2–4 weeks.

Early Exercises

Rehabilitation may begin with pendulum and pulley exercises.

These are gradually advanced toward full shoulder range of motion as pain decreases and healing progresses.

Postoperative Therapy

The timing of physical therapy after surgery varies according to fixation stability, patient factors, and surgeon preference.

Stable fixation often allows earlier controlled motion.

Medication

First-Line Treatment

Pain management may include ice, acetaminophen, and NSAIDs when appropriate.

Some surgeons limit NSAID use because of theoretical concerns regarding bone healing, although practice varies.

Additional Analgesics

Tramadol may be considered for selected patients.

Short courses of opioid analgesics are sometimes required during the acute painful period.

Opioid Considerations

Before prescribing opioids, factors such as patient age, comorbidities, concurrent medications, fall risk, and overall health should be considered.

Surgery

Indications

Operative treatment may be considered for an open fracture, threatened skin, floating shoulder, severe displacement, significant shortening, or other unstable fracture patterns.

Shortening greater than approximately 2 cm may contribute to the decision for surgery in selected displaced midshaft fractures.

Floating Shoulder

A floating shoulder refers to major disruption of the shoulder suspensory complex, often involving an ipsilateral scapular neck fracture together with clavicular injury.

This pattern may warrant operative stabilization depending on displacement and overall injury severity.

Open Reduction and Internal Fixation

Surgery commonly involves open reduction and internal fixation (ORIF) with plates, screws, or other internal fixation devices.

The goals are restoration of length and alignment, stable fixation, and facilitation of earlier functional rehabilitation.

Follow-Up

Prognosis

Most clavicle fractures heal successfully.

Outcome depends on fracture location, displacement, age, soft-tissue condition, and whether the fracture is treated surgically or nonoperatively.

Operative Treatment of Displaced Midshaft Fractures

Surgical fixation of appropriately selected displaced midshaft fractures can reduce the rates of nonunion and symptomatic malunion compared with nonoperative treatment.

It may also permit a quicker early return to work and improved short-term functional recovery.

Hardware Removal

One disadvantage of operative fixation is the relatively high rate of subsequent procedures.

Many patients request hardware removal because the clavicle is subcutaneous and plates can be prominent or irritating.

Nonunion

Some displaced midshaft fractures treated nonoperatively progress to nonunion.

Not all nonunions are sufficiently symptomatic to require further treatment.

Lateral Clavicle Nonunion

Nonunion is relatively common after certain lateral clavicle fractures.

However, some radiographic nonunions remain minimally symptomatic and do not require surgery.

Complications

Infection

Surgical fixation carries a risk of wound infection and deep implant-related infection.

Hardware Failure

Internal fixation devices may loosen, break, or fail, especially if union is delayed or excessive loading occurs too early.

Nonunion

Failure of the fracture to unite is more likely with marked displacement, shortening, comminution, smoking, and certain unstable lateral fracture patterns.

Symptomatic Malunion

A clavicle fracture that heals with substantial shortening or deformity may produce pain, weakness, altered shoulder mechanics, or cosmetic dissatisfaction.

Symptomatic malunion is more commonly encountered after markedly displaced fractures treated nonoperatively.

Shoulder Stiffness

Prolonged immobilization or associated shoulder injury may result in post-traumatic stiffness.

Early controlled motion after an appropriate period of fracture protection can reduce this risk.

Supraclavicular Nerve Symptoms

Numbness over the clavicle or upper chest may occur because the cutaneous supraclavicular nerve branches can be stretched or injured during the initial trauma.

They may also be cut or stretched during surgical exposure.

Neurovascular Injury

Although rare, injury to the brachial plexus or subclavian vessels can occur because of their close relationship to the clavicle.

These complications can occur from the initial fracture or during operative treatment.

Patient Monitoring

Early Radiographic Monitoring

Radiographs should be obtained every few weeks during the early post-injury or postoperative period to confirm maintenance of alignment.

This is especially important for displaced fractures treated without surgery.

Healing Surveillance

After the acute period, imaging may be repeated approximately every 4–6 weeks until satisfactory clinical and radiographic union is demonstrated.

Clinical Monitoring

Follow-up should assess pain, skin condition, neurovascular status, shoulder range of motion, tenderness at the fracture site, and functional recovery.

Increasing pain, new neurologic symptoms, skin compromise, or progressive deformity should prompt earlier reassessment.

Orthopaedic Surgery - Chordoma

Basics

Chordoma is a low-grade malignant bone tumor arising from remnants of the embryologic notochord.

It accounts for approximately 1–4% of primary malignant bone tumors and is one of the most important primary malignant tumors involving the axial skeleton, particularly the spine and sacrum.

Anatomic Distribution

Chordomas most commonly arise in the sacrococcygeal region, which accounts for approximately 55% of cases.

Around 30% occur in the skull base, particularly the sphenoid or clival region, while approximately 15% develop within the cervical, thoracic, or lumbar spine.

Delayed Diagnosis

Diagnosis is frequently delayed because symptoms are often nonspecific.

Sacral chordoma may present simply as chronic low back, pelvic, or sacral pain and may therefore be mistaken for much more common degenerative musculoskeletal disorders.

Dedifferentiation

Although conventional chordoma is generally considered a low-grade malignancy, a small proportion of tumors, historically reported at less than 5%, may undergo dedifferentiation into a high-grade spindle-cell sarcoma.

Dedifferentiated chordoma behaves much more aggressively than the conventional form.

General Precautions

One of the most important diagnostic pitfalls is failure to consider sacrococcygeal chordoma in a patient with persistent unexplained low back or sacral pain.

Chronic symptoms that are progressive, atypical, or associated with neurologic, bowel, or bladder dysfunction warrant further investigation.

Epidemiology

Chordoma is extremely rare.

The reported annual incidence is approximately 0.08 cases per 100,000 people.

It most commonly presents in adulthood, with a peak incidence around the fourth to fifth decades of life, although it may occur outside this age range.

Risk Factors

No established environmental or lifestyle risk factors have been identified.

Most cases occur sporadically.

Genetics

No common hereditary predisposition is recognized in the majority of patients.

The disease is generally not associated with a typical familial pattern.

Etiology

Chordoma develops from persistent notochordal remnants within the axial skeleton.

The notochord normally contributes to embryologic development of the spine and largely disappears before birth, but residual cells may persist and later undergo malignant transformation.

Tumor Growth

Chordomas often extend beyond the confines of bone.

Sacral tumors, in particular, may produce a large anterior soft-tissue mass extending into the pelvis.

Because the tumor may become very large before producing obvious symptoms, substantial local destruction can be present by the time of diagnosis.

Associated Conditions

No specific associated systemic disorders are typically present.

Diagnosis

Signs and Symptoms

Symptoms depend on tumor location but are usually slowly progressive and nonspecific.

Sacral lesions commonly produce low back pain, pelvic pain, sacral discomfort, or anal pain.

Difficulty Sitting

Patients with sacrococcygeal tumors may find prolonged sitting increasingly uncomfortable.

Pain may arise from direct pressure on the tumor or involvement of adjacent pelvic structures.

Bowel and Bladder Symptoms

Constipation, urinary disturbance, or other pelvic-organ symptoms may develop as the tumor enlarges.

These findings can result from compression or invasion of adjacent pelvic structures or sacral nerve roots.

Radiculopathy

Tumor extension around neural structures may compress or destroy adjacent nerve roots.

This can produce radicular pain, sensory loss, or motor dysfunction corresponding to the level of involvement.

In sacral chordoma, the S1, S2, and S3 roots are commonly at risk.

Physical Examination

Physical findings are often limited despite substantial tumor size.

There may be little to suggest an underlying bone malignancy on routine examination.

Rectal Examination

Large sacral chordomas frequently extend anteriorly into the pelvis.

A mass may be palpable during rectal examination in approximately half of patients with sufficiently advanced sacral disease.

Imaging

Plain Radiographs

Plain radiographs may appear normal or show only subtle abnormalities.

Findings can include bone destruction, cortical expansion, or a lytic sacral lesion.

Limitations of Radiography

Sacral tumors are particularly easy to miss on plain radiographs because bowel gas and fecal material may obscure the lesion.

A normal radiograph therefore does not exclude chordoma when clinical suspicion remains high.

CT

CT is highly sensitive for demonstrating the bony component of chordoma.

Typical findings include midline osseous destruction and an anterior soft-tissue mass.

Calcification

Scattered internal calcifications may be visible on CT.

These mineralized areas can help characterize the lesion but are not specific to chordoma.

MRI

MRI is the preferred modality for defining the full extent of the tumor and its relationship to surrounding structures.

Chordomas are typically low signal intensity on T1-weighted images and high signal intensity on T2-weighted images.

Contrast-Enhanced MRI

Contrast-enhanced MRI helps delineate the dimensions of the mass and its relationship to the spinal canal, nerve roots, pelvic organs, vessels, and surrounding soft tissues.

This information is essential for operative planning.

Imaging the Entire Sacrum

Sacrococcygeal lesions may lie at the extreme inferior edge of lumbar or pelvic MRI studies.

The tumor can therefore be overlooked if the imaging field does not extend far enough inferiorly.

When sacral chordoma is suspected, imaging should include the entire sacrum and coccyx down to the coccygeal tip.

Nuclear Medicine

Conventional technetium bone scans and PET have historically been less useful than CT and MRI for primary characterization of chordoma.

Cross-sectional imaging remains central to diagnosis, staging, and surveillance.

Differential Diagnosis

Destructive Spinal Lesions

Important alternative diagnoses include metastatic bone disease, multiple myeloma, and lymphoma, all of which can produce destructive lesions of the spine or sacrum.

Sacral Tumors

Chondrosarcoma and giant cell tumor may also arise in the sacrum.

Both can produce bone destruction, soft-tissue extension, and in some cases mineralization, making differentiation from chordoma necessary.

Chondrosarcoma

Chondrosarcoma may resemble chordoma radiographically, particularly when it occurs in the pelvis or sacrum.

Tumor location, pattern of calcification, MRI appearance, and histology help distinguish the two lesions.

Treatment

General Principles

The primary treatment for chordoma is complete surgical removal whenever technically feasible.

Because local recurrence strongly influences survival, achieving adequate margins is critical.

Wide En Bloc Resection

The preferred operative strategy is wide en bloc resection with negative surgical margins.

The tumor is removed as a single specimen together with a surrounding margin of uninvolved tissue when anatomy permits.

Importance of Surgical Margins

Incomplete excision or tumor contamination during surgery substantially increases the risk of local recurrence.

Unfortunately, chordomas often lie immediately adjacent to major nerves, blood vessels, bowel, bladder, or spinal structures, making wide margins difficult to achieve.

Chemotherapy

Conventional chemotherapy has little established role in the routine treatment of classic chordoma.

The relatively indolent biology of the tumor and limited chemosensitivity make surgery and local control the major therapeutic priorities.

Radiotherapy

High-dose radiation, particularly proton-beam or other conformal particle-based radiotherapy, may be considered in selected patients.

It can be used when surgical margins are limited, the tumor is unresectable, or as part of a combined treatment strategy.

Follow-Up

Prognosis

Chordoma has a prolonged but potentially aggressive natural history.

Historical series report a median survival of approximately 6.3 years.

Five-year survival has been reported in the range of approximately 50–67%, while 10-year survival has ranged from roughly 28–46%.

Metastatic Risk

The risk of distant metastasis has historically been estimated at approximately 10–40%.

Common metastatic sites include the lungs, bone, liver, and lymph nodes.

Importance of Local Recurrence

Chordoma is unusual among low-grade tumors because local recurrence can itself be a major cause of mortality.

Repeated local growth can progressively involve vital neural, vascular, gastrointestinal, and genitourinary structures.

Relationship Between Recurrence and Survival

Local recurrence is associated with poorer survival.

The best chance for durable control therefore comes from achieving adequate surgical margins during the initial operation whenever possible.

Complications

Wound-Healing Problems

Wound complications are common after major sacral resections.

Historical series have reported wound-healing problems in as many as 45% of patients.

Large incisions, dead space, radiation, extensive soft-tissue dissection, and contamination risk may all contribute.

Injury to Pelvic Structures

Sacral chordoma surgery may place important anterior pelvic structures at risk.

Potential injuries include damage to the iliac vessels, rectum, bladder, ureters, and other pelvic organs.

Sacral Nerve-Root Sacrifice

The functional consequences of surgery depend heavily on which sacral nerve roots must be sacrificed to achieve tumor clearance.

Higher-level bilateral sacrifice produces more severe neurologic deficits.

Bilateral S1 Sacrifice

Sacrifice of both S1 nerve roots, as may occur with total sacrectomy, can result in major lower-extremity motor and sensory deficits together with loss of bowel and bladder function.

Bilateral S2 Sacrifice

Historical data indicate that bilateral S2 root sacrifice is associated with an extremely high likelihood of bowel and bladder dysfunction.

Some patients may require permanent diversion procedures.

Bilateral S3 Sacrifice

Bilateral S3 sacrifice carries a substantial risk of bowel and bladder dysfunction.

Historical series have reported bowel dysfunction in approximately 60% and bladder dysfunction in approximately 75% of such patients.

Bilateral S4 Sacrifice

Sacrifice limited to both S4 roots is associated with a lower risk of bowel dysfunction, although bladder disturbance may still occur.

Historical series reported minimal bowel dysfunction but bladder dysfunction in approximately 31% of patients.

Sexual Dysfunction

Loss of sacral nerve function may also produce sexual dysfunction, depending on the level and extent of nerve-root sacrifice.

Spinopelvic Instability

Major sacral resections can disrupt continuity between the spine and pelvis.

This may produce spinopelvic instability or discontinuity and can require complex reconstruction.

Sacral Insufficiency Fracture

Remaining sacral or pelvic bone may be vulnerable to insufficiency fracture following extensive resection.

Mechanical reconstruction may be required when stability is compromised.

Patient Monitoring

Long-Term Surveillance

Patients require lifelong surveillance because chordoma can recur many years after initial treatment.

Follow-up commonly includes CT or MRI of the operative region once or twice each year, with intervals individualized according to recurrence risk and prior treatment.

Surveillance for Metastases

Imaging should also assess for distant metastatic disease, particularly involving the lungs.

Long-term chest surveillance is therefore commonly incorporated into follow-up.

Clinical Monitoring

Follow-up should assess for new pain, neurologic symptoms, bowel or bladder dysfunction, changes in sitting tolerance, and evidence of wound or reconstructive complications.

Any new or progressive symptom should prompt timely imaging because recurrent disease may initially be subtle.