J Orthopaed Traumatol (2015) 16:185–192

DOI 10.1007/s10195-014-0330-y

ORIGINALARTICLE

Risk factors for acute compartment syndrome of the leg associated

with tibial diaphyseal fractures in adults
Babak Shadgan • Gavin Pereira • Matthew Menon •
Siavash Jafari • W. Darlene Reid • Peter J. O’Brien

Received: 19 April 2014 / Accepted: 25 November 2014 / Published online: 28 December 2014
The Author(s) 2014. This article is published with open access at Springerlink.com

Abstract in 87 (7.73 %) of all tibial diaphyseal fractures. The mean

Background We sought to examine the occurrence of acute age of those patients that developed ACS (33.08 ± 12.8)
compartment syndrome (ACS) in the cohort of patients was significantly lower than those who did not develop it
with tibial diaphyseal fractures and to detect associated (42.01 ± 17.3, P \ 0.001). No significant difference in
risk factors that could predict this occurrence. incidence of ACS was found in open versus closed frac-
Materials and methods A total of 1,125 patients with tibial tures, between anatomic sites and following IM nailing (P
diaphyseal fractures that were treated in our centre were = 0.67). Increasing pain was the most common symp-tom
included into this retrospective cohort study. All patients in 71 % of cases with ACS.
were treated with surgical fixation. Among them some Conclusions We found that younger patients are defi-nitely
were complicated by ACS of the leg. Age, gender, year at a significantly higher risk of ACS following acute tibial
and mechanism of injury, injury severity score (ISS), diaphyseal fractures. Male gender, open fracture and IM
fracture characteristics and classifications and the type of nailing were not risk factors for ACS of the leg asso-ciated
fixation, as well as ACS characteristics in affected patients with tibial diaphyseal fractures in adults.
were studied. Level of evidence Level IV.
Results Of the cohort of patients 772 (69 %) were male
(mean age 39.60 ± 15.97 years) and the rest were women Keywords Tibia fracture Compartment syndrome
(mean age 45.08 ± 19.04 years). ACS of the leg occurred Fracture fixation intramedullary

B. Shadgan P. J. O’Brien S. Jafari

Trauma Orthopaedic Division, Department of Orthopaedics, School of Population and Public Health, Faculty of Medicine,
University of British Columbia, #110-828W 10th Ave, University of British Columbia, 2206 East Mall, Vancouver,
Vancouver, BC V5Z 1L8, Canada e-mail: BC V6T 1Z3, Canada
Peter.OBrien@vch.ca e-mail: sjafarimd@yahoo.ca

B. Shadgan (&) W. Darlene Reid

5440-ICORD, Blusson Spinal Cord Centre, 818 West 10th Department of Physical Therapy, University of Toronto, 160-
Avenue, Vancouver, BC V5Z-1M9, Canada 500 University Avenue, Toronto, ON M5G 1V7, Canada e-mail:
e-mail: shadgan@alumni.ubc.ca darlene.reid@ubc.ca

G. Pereira
University Hospital Coventry and Warwickshire, Clifford Bridge
Road, Coventry CV2 2DX, UK
e-mail: GPer11@aol.com

M. Menon
Division of Orthopaedic Surgery, University of Alberta,
10150-121 Street, Edmonton, AB T5N 1K4, Canada e-
mail: mattmenon@hotmail.com

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Introduction symptoms and, where necessary, by intra-compartmental

pressure measurements, using a handheld intra-compart-
Fracture of the tibia is the most common long-bone mental pressure monitoring system (Stryker Surgical,
fracture worldwide [1]. Acute compartment syndrome Kalamazoo, MI), but confirmed at fasciotomy and entered
(ACS) is considered to be one of the most serious com- prospectively into the data base as ‘Acute Compartment
plications of tibial fractures, and failure to diagnose and Syndrome’. Patients who were treated with non-surgical
treat it in time can lead to catastrophic consequences that fixation methods or primary amputation, or patients who
are devastating to patients, surgeons and health care had open fractures requiring vascular repair or intra-
providers. Giannoudis et al. [2] have shown that patients articular fractures, were excluded.
who sustained a tibial fracture followed by an ACS, Information regarding gender, age, year of injury,
performed worse on the EuroQol score than those who had mechanism of injury, injury severity score (ISS), fracture
uncomplicated fractures. Delayed or missed diagnosis of side, state of skin/soft tissue injury [6], site of fracture
ACS following tibial shaft fracture negatively affects the along the tibial shaft and method of fixation were
health care team as well. In addition to the psycho-logical abstracted from the data base. For the purpose of this
stress for health care givers associated with poor patient study, mechanism of injury was subdivided into twisting,
outcome, the average indemnity paid for missed ACS is fall, direct blow, crushing injury, vehicle accident, bicycle
high and the rate of successful defence of cases is lower accident, motorcycle accident, and pedestrian vs motor
than with other orthopaedic medico legal cases [3, 4]. The vehicle accident. The site of fracture was classified as
cost of ACS is significant, resulting in prolonged hospital being in the proximal, middle or distal third of the tibial
stays and charges that are more than doubled in patients diaphysis. When the fracture crossed 2 zones, it was
with tibial fractures affected by ACS [5]. Physi-cians entered as such. Extensive fractures were those that
treating patients with traumatic injuries are normally aware crossed all 3 zones. Methods of surgical fixation were
of ACS. However, due to the low incidence of this classified into intramedullary (IM) nailing (dynamic
condition, a high index of suspicion is usually required to locking nail, static locking nail, unlocked nail) and non-IM
initiate one’s thought processes towards making a diag- nailing (screw, plate, external fixator) methods. The choice
nosis of ACS. There has been no large-scale study on the of fixation was based on the pattern of fracture, the soft
epidemiology of lower leg compartment syndrome so far. tissue involvement, and the general condition of the patient
It is therefore difficult to appreciate the burden of this before and after the injury as well as surgeon’s preference.
problem. The mean lengths of hospital stays of patients with and
The purpose of this study, therefore, was to examine the without ACS were also compared.
relationship between the development of ACS in the cohort In addition we undertook a chart review of the 87 cases
of patients presenting to our hospital with tibial diaphyseal of ACS and recorded levels of consciousness, clinical
fractures and specific demographic, injury, and operative symptoms and signs, intra-compartmental pressure mea-
characteristics that could predict this occurrence. A thor- sures as well as time interval between occurrence of tibial
ough understanding of these risk factors and their relative fracture and surgical fixation to fasciotomy.
influence on development of lower leg ACS may provide The incidence of ACS following tibia diaphyseal frac-tures
better insight into the recognition of high risk individuals, was determined from the data. Data on demographics, type of
which is critical in an effort to optimize patient outcomes. trauma, side of tibia fracture, year of fracture, open vs closed
fracture, anatomical classification of the fracture, fracture
pattern, mechanism of fracture, method of internal fixation,
Materials and methods clinical symptoms at admission, and intra-com-partmental
pressure measures of all cases were collected. Student’s t-test
This retrospective cohort study was conducted at a level- was used to compare the means of two groups. Pearson’s chi
one trauma centre attended by five full-time orthopaedic square test or Fisher’s exact tests were used to compare
trauma surgeons. All tibial diaphyseal fractures that were categorical variables. Relative risks and 95 % confidence
treated between January 1997 and December 2011 were interval (95 %CI) were calculated to assess the association
retrieved from the orthopaedic trauma prospective data between potential risks factors and development of ACS.
base. Patients developing ACS in this group were Statistical significance at 5 % was selected in this study and
identified and relevant information on demographics and the relative risk (RR) with 95 % confidence interval (CI) is
risk factors were collected. reported where appropriate. STATA statistical software
ACS of the lower leg was defined for the purpose of this (StataCorp 2011. Stata Statis-tical Software: release 12.
study as being an acute event following a tibial diaphyseal College Station, TX: StataCorp LP) was used for data
fracture diagnosed by clinical signs and analysis.

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Results developed ACS are summarized in Tables 1 and 2,

respectively.
For the 14-year period 1997–2011, inclusive, 1,125 tibial The mean age of all participants was 41.32 (±17.2) with
fractures were identified in 1,100 patients. Table 1 lists the a range of 16–99 years. Male patients were overall younger
characteristics of patients with tibia fractures inclu-ded in than female patients with a mean age of 39.60 (±15.97)
this study. ACS of the leg occurred as an immediate or compared with 45.08 (±19.04) for female patients, and this
early complication in 87 limbs, 7.73 % of all tibia difference was statistically significant (t = 5.0143;
fractures. Henceforth in this paper, all statistics will refer
to the tibial fractures and not patients. Char-acteristics of Table 2 Characteristics of patients with tibial fractures who devel-
oped ACS
patients with tibial fractures and those who
N %

Table 1 Characteristics of the patients included in the study Age mean 33.08 (±12.8)
N (1,125) % Gender Male 66 76
Female 21 24
Age mean 41.32 (±17.2)
Gender Male 772 69 Skin Closed 66 75.86
Female 353 31 Open 21 24.14

Trauma type Single injury 662 58.84 Fracture classification Proximal/3 11 12.64
Multiple injury 179 15.91 Middle/3 43 49.43
Multiple system trauma 284 25.24 Distal/3 25 28.74
Extensive 8 9.2
Side of tibia Right 553 49.16
fracture Left 572 50.84 Clinical signs and Severe pain 31 35.23
symptoms Paresthesia 7 7.95
Skin Close fracture 776 68.98
Motor weakness 4 4.55
Open fracture 349 31.02
Unconscious 6 6.82
Fracture Proximal/3 147 13.07 Pain and paresthesia 17 19.32
classification Middle/3 632 69.24 Pain and paresthesia and motor 14 15.91
Distal/3 265 23.56 weakness
Extensive 81 7.2 Paresthesia ? motor weakness 8 9.09
Pressure 1 1.14
Mechanism of Fall 399 35.47
fracture Pedestrian vs motor vehicle 305 27.11 Mechanism of injury Fall 26 29.89
accident Pedestrian vs motor vehicle 22 25.29
Motorcycle accident 188 16.71 Motor accident 19 21.84
Twisting injury 80 7.11 Twisting injury 6 6.9
Direct blow 72 6.4 Blow 6 6.9
Crushing injury 40 3.56 Crushing injury 5 5.75
Bicycle accident 23 2.04 Motorized accident 2 2.3
Motorized accident 18 1.6 Bicycle 1 1.15

Internal fixation Screw 21 1.87 Fracture pattern Comminuted 23 26.14

method Plate 186 16.53 Oblique 17 19.32
External fixator 3 0.27 Segmental 8 9.09
Dynamic locking nail 22 1.96 Spiral 16 18.18
Static locking nail 886 78.76 Transverse 24 27.27
Unlocked nail 7 0.62
Involved Anterior 37 42.53
Early local None 1,014 90.13 compartments Lateral 4 4.6
complication Compartment syndrome 87 7.73 Posterior 3 3.45
Reduction/fixation failure 13 1.16 Not specified 19 21.84
Wound infection 7 0.62 Anterior ? lateral 13 14.94
Neurovascular loss 4 0.36 All 11 12.64

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Table 3 Comparison of patients with ACS with those without ACS

Tibial fracture no ACS Tibial fracture with ACS Test statistics P value

Age 42.01 (17.3) 33.08 (12.8) t = 4.7037; df = 1123 \0.001

Gender Male 706 66 v2 = 2.29; df = 1 0.13

Female 332 21

Skin Closed 710 66 v2 = 2.0884; df = 1 0.148

Open 328 21

Fracture classification Proximal/3 136 11 v2 = 2.3738; df = 3 0.499

Middle/3 589 43
Distal/3 240 25
Extensive 73 8

Trauma type Single injury 608 54 v2 = 1.0464; df = 2 0.593

Multiple system trauma 266 18
Multiple injury 164 15

Fracture side Left 529 43 v2 = 0.0760; df = 1 0.783

Right 509 44

Fixation method Static locking nail 812 74 v2 = 3.1695; df = 5 0.674

Mechanism of injury Plate 176 10
Dynamic locking nail 21 1
Screw 20 1
Unlocked nail 6 1
External fixator 3 0
Fall 399 26 v2 = 4.4011; df = 7 0.733
Pedestrian vs motor vehicle 305 22
Motor accident 188 19
Twisting injury 80 6
Blow 72 6
Crushing injury 40 5
Motorized accident 18 2
Bicycle 23 1

ISS 01–10 802 76 v2 = 4.8735; df = 3; 0.181

11–20 109 5
21–30 74 4
[30 53 2

df = 1,123, P \ 0.0001). The mean age of those patients In this study we did not find a significant relationship
who developed ACS was 33.08 (±12.8), which was much between type of fracture (open vs closed), anatomical site
lower than the mean age of patients who did not develop of tibia fracture, type of trauma, fixation method, or
ACS (42.01 ± 17.3) and this difference was statistically mechanism of injury and development of ACS. Although
significant (P \ 0.001). Of the 1,125 tibial fractures, 772 the relative risk of development of ACS was lower among
were in males and 353 in females. Sixty-six out of 772 patients with open fractures (RR = 0.76; 95 %CI: 0.52–
men (8.55 %) and 21 out of 353 women (5.95 %) 1.12), this relationship was not statistically significant (v2
developed ACS. Male gender was found to be a risk factor = 2.0884; df = 1; P = 0.148). Among both groups, the
for development of ACS (RR = 1.11; 95 %CI: 0.98–1.26) distribution of the ISS was heavily influenced by the
but this risk was not statistically significant (Pearson’s v2 = number of subjects with ISS 9. No difference could be
2.2971, df = 1, P = 0.130) (Table 3). found between these groups though.

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Fig. 1 Frequency distribution

of tibial fractures and ACSs
during the study period

The number of tibial fractures admitted to our hospital Table 4 Summary of studies on ACS in tibial diaphyseal fractures
decreased over the 14-year period of observation. How- Author Number of Number of Incidence
ever, the incidence of ACS following tibial fractures did subjects ACS (%)
not show a significant decline (Fig. 1).
DeLee (open) [38] 104 6 6
A retrospective review of the charts showed that 7 % of
patients with ACS had an altered level of con-sciousness. Blick SS [24] 198 18 9
The clinical features in the awake patients with ACS McQueen (open) [33] 67 1 1.5
included increasing pain in 70 %, paresthesia in 52 %, McQueen [23] 1,349 59 4.3
motor weakness in 29 % and tense swelling of the calf in 1 Mullett H [34] 626 17 2.7
%. Thirty-five percent of patients with ACS had pain as Ogunlusi JD [39] 52 3 5.7
their only symptom, 8 % had only paras-thesia, 4 % had Park S [21] 173 14 8
only motor weakness and 1 % had only tense calf. Wind T [26] 626 34 5.4
This study 1,125 87 7.7
Out of 87 patients with ACS, 23 patients underwent
fasciotomy at the time of fracture fixation, while 64
patients received fasciotomy as a second surgical pro- Discussion
cedure after initial fixation. The mean time interval
between occurrence of tibia fracture and fasciotomy was Over the last four decades, much research has been pub-
30.10 (±23.72) h. The mean time interval between sur- lished with regards to the pathophysiology [7–11], diag-
gical fixation of fracture and fasciotomy was 16.27 (22.58) nosis [12–14], monitoring [13–15], and treatment of ACS
h. The mean length of hospitalization of those patients who [16–20]. However, there is little literature regarding the
developed ACS was 14.88 (±11.80) days, which was epidemiology of lower leg ACS and its associated risks
higher than the mean length of hospitalization of patients factors [21, 22].
who did not develop ACS (12.26 ± 10.28) and this This epidemiological study on lower leg ACS is a ret-
difference was statistically significant (P = 0.03). rospective cohort study, but we believe that the data
quality is good, as the data was entered prospectively by
Using an intra-compartmental pressure monitoring the treating surgeons themselves and the data base was
instrument, compartment pressures were measured in 60 man-aged by a dedicated research staff. Our results are
out of 87 patients with ACS and 92 % had an absolute com-pared with other studies in Table 4.
reading of greater than 30 mmHg. This raised intra-com- Acute compartment syndrome from any cause occurs
partmental pressure occurred in the anterior compartment most commonly in the lower leg and most often follows a
in 87 %, lateral compartment in 35 % and posterior com- fracture of the tibia. McQueen et al. [23] reported in their
partments in 37 % of cases. All patients with ACS have epidemiological study that 36 % of all compartment syn-
positive intra-operative findings. dromes occurred in association with a tibial shaft fracture.

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They found that the occurrence of ACS following tibial is likely to occur at a lower compartment pressure when
fractures was 4.3 %. In North America, the prevalence has the diastolic is lower: causing a lowered perfusion pressure
been reported in the range of 5.4–11 % [24–26]. There has (DP) [13]. In addition, polytrauma patients are often
been no other epidemiological study on compartment aggressively resuscitated with high volumes of fluid that
syndromes in a particular population. can then enter the extravascular space in injured com-
In our study, over a 14-year period, we found that the partments and increases the intra-compartmental pressure.
average incidence of ACS in tibial fractures was 7.73 %. In This was not seen in our study. In the study by Park et al.,
spite of significant improvement in management of frac-tures the arterial blood pressure of patients at admission was
and their related complications during recent years, the recorded and the authors found no correlation between
incidence of ACS following tibial fracture is not sig-nificantly hypotension and the incidence of ACS.
reduced. This is likely to be multifactorial. One reason could Although there is a risk of ACS with any type of tibia
be the increased trend to internally fix tibial shaft fractures in fracture, an open fracture is anecdotally considered to have
more recent times. In addition, continuous improvement in the de facto decompressed the compartments, and is therefore
survivability of patients with multiple injuries might lead to a unlikely to cause an ACS. The auto decompression phe-
larger number of patients surviving with ACS when they may nomenon that occurs with a high-grade open tibia fracture
have died before. is hypothesized to cause an effect similar to a fasciotomy
The popular belief is that ACS is more likely to occur in [23, 27]. Our study showed that ACS is just as likely to
young males. In our study we found that women were just occur in open fractures as it is in closed fractures. These
as likely as men to get ACS following their tibial fractures. results are similar to those found by Park et al. [21].
However, we also found that ACS occurred more readily We looked at the site of the fracture as a potential risk
in younger patients. This we think is due to younger people factor because the tibial shaft has various muscle attach-ments
having larger muscle bulk within a tight fascia with very and varying bulk of muscle at different levels. The gastro-
little room to expand before the intra-compartmental soleus complex is bulkier more proximally than distally.
pressure rises. Park et al. [21] also found age as a risk There is also less muscle and more tendinous structures more
factor. They suggested that the young male is not only distally. If one considers that ACS can occur from bleeding
likely to have a larger muscle bulk, but the fascia and the alone, (as opposed to ischemic swell-ing), then it should be
inter-muscular septa are likely to be thicker, due to a larger more common in more proximal fractures. In contrast, the
collagen content. This can cause the pressure to rise peroneus tertius, whose muscle belly is alongside the distal
rapidly within a compartment with a small increase in third of the tibia, has a single arterial supply. It is conceivable
volume. We would agree with their hypothesis; however, that any fractures in the distal third of the tibia, which might
we did not find a higher incidence of ACS in males. damage the only blood supply to the muscle could cause
Therefore, we do not assume gender to be risk factor for ischemia, capillary leak and swelling followed by ACS. In
ACS following tibial fracture. this study, we could not show that the site of the fracture
Many physicians believe that high-energy trauma should made any difference to the occurrence of ACS. Fractures that
be a risk factor for ACS. The perceived wisdom is that the are more extensive along the length of the bone suggest a
soft tissue damage that occurs with a high energy transfer is higher energy transfer. Similar to our findings for mechanism
likely to produce more necrosis, hypoxia, lactic acidosis, of injury, we did not find any correlation between ‘extensive’
capillary leak and more interstitial fluid collection, leading to fractures and ACS.
swelling of the compartment. However, this was not borne out There are reports confirming a significant correlation
in our study. This observation is similar to what Court-Brown between intramedullary nailing and ACS development [29–
et al. [27] reported. 34]. These reports argue that: (1) the incidence of ACS in
There is no doubt that multiple injuries that affect a open reduction and internal fixation is likely to be lower due
number of anatomical sites have a profound effect on the to the pari passu decompression of the compartment and
homeostasis of the body and the ensuing ‘‘chemical evacuation of the fracture haematoma; (2) intramed-ullary
storm’’: systemic inflammatory response syndrome (SIRS) nailing is known to increase the compartment pres-sures
vs compensatory anti-inflammatory response syndrome during reaming as well as insertion of the nail; and
(CARS) and endothelial damage is linked with occurrence (3) the position of the limb during the procedure has shown
of ACS [28]. However, ACS could be both one of the to change the compartment pressures. Patients put on
triggering factors for SIRS or indeed an effect of the traction tables with traction applied to the limb during
endothelial damage and subsequent capillary leak. We nailing have raised intra-compartmental pressures [35]. In
assumed that those patients with a higher ISS score were this study we did not find a significantly higher rate of
more likely to get ACS. Polytrauma patients with high ISS ACS development in those who were treated by
scores are likely to be hypotensive and, theoretically, ACS intramedullary nailing, though.

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J Orthopaed Traumatol (2015) 16:185–192 191

Our data indicated that the length of hospital stays of 2. Giannoudis PV, Nicolopoulos C, Dinopoulos H et al (2002) The
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Conflict of interest None.
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Open Access This article is distributed under the terms of the niques in acute compartment syndrome of the leg. J Orthop
Creative Commons Attribution License which permits any use, dis- Trauma 22:581–587
tribution, and reproduction in any medium, provided the original
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