ORIGINAL ARTICLE
Predictors of Compartment Syndrome After Tibial Fracture
Margaret M. McQueen, MD, FRCSEd (Orth),*
Andrew D. Duckworth, MBChB, BSc (Hons), MSc, MRCSEd,* Stuart A. Aitken, MD, FRCSEd (Tr&Orth),*
Rowena A. Sharma, MBChB, BSc (Hons), MRCSEd, MRCOG,†
and Charles M. Court-Brown, MD, FRCSEd (Orth)*
Objectives: The aim of our study was to identify the risk factors
associated with the development of acute compartment syndrome
(ACS) after a fracture of the tibia.
Design: Retrospective cohort study.
Setting: Orthopaedic trauma unit, university teaching hospital.
Patients: From our trauma database, we identified all patients who
sustained an acute tibial diaphyseal fracture over a 13-year period. A
retrospective analysis of 1407 patients was performed to record and
analyze the OTA fracture classification, open fracture grade accord-
ing to Gustilo, soft tissue injury classification according to Tscherne,
treatment, development of ACS, and other patient demographics
including smoking, occupation, and socioeconomic deprivation.
Main Outcome Measure: A diagnosis of ACS was made using
clinical signs, compartment pressure monitoring, or a combination of
the 2.
Results: One thousand three hundred eighty-eight patients were
included with a mean age of 39 (12–98) years, and 957 (69%) were
male. One hundred sixty patients (11.5%) were diagnosed with ACS.
On initial analysis, age, male gender, blue-collar occupation, sporting
injury, fracture classification, and treatment with intramedullary nails
were predictive of ACS (all P , 0.05). Age was the strongest pre-
dictor of developing ACS (P , 0.001), with the highest prevalence
between 12–19 years and 20–29 years. Occupation (P = 0.01) and
implant type (P = 0.004) were the only factors that remained signif-
icant after adjusting for age. On further subanalysis, implant type was
not predictive when stratified by Tscherne class (P = 0.11).
Conclusions: We have documented the risk factors for the
development of ACS after an acute tibial diaphyseal fracture, with
youth the strongest predictor.
Accepted for publication March 31, 2015.
From the *Department of Orthopaedic Trauma, Edinburgh Orthopaedic
Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom;
and †Obstetrics and Gynaecology, North West London Hospitals, London,
United Kingdom.
Presented in part at the 28th Annual Meeting of the Orthopaedic Trauma
Association (OTA), October 2012, Minneapolis, MN.
The authors report no conflict of interest.
Reprints: Andrew D. Duckworth, MBChB, BSc (Hons), MSc, MRCSEd,
Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51
Little France Crescent, Edinburgh EH16 4SU, United Kingdom (e-mail:
andrew.duckworth@yahoo.co.uk).
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J Orthop Trauma  Volume 29, Number 10, October 2015
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Key Words: predictors, acute compartment syndrome, tibial diaph-
yseal fracture, trauma
Level of Evidence: Prognostic Level II. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2015;29:451–455)
INTRODUCTION
Acute compartment syndrome (ACS) is a potentially
devastating complication of a tibial diaphyseal fracture. It
usually occurs as a result of injury when swelling occurs in
muscle groups contained within fascial compartments. As
swelling progresses, the pressure within the compartment
rises. If not treated promptly, the pressure reaches critical
levels resulting in ischemia of the contained tissues, princi-
pally muscle, nerve, or bone.1–6 Potential sequelae include
infection, muscle necrosis, neurologic deficits, contractures,
fracture nonunion, chronic pain, and in the most severe cases
amputation or death.7–12
It has been acknowledged for more than 40 years that
the single cause of a poor outcome in ACS is delay in
diagnosis.6,13–15 A possible cause of such a delay is a lack of
knowledge regarding those patients at increased risk of devel-
oping ACS after a fracture of the tibia. A method of predict-
ing the likelihood of ACS occurring would raise awareness of
the diagnosis and possibly lead to earlier diagnosis. This
study aimed to identify the factors associated with the devel-
opment of ACS.
PATIENTS AND METHODS
All tibial diaphyseal fractures presenting to our trauma
unit between January 1, 1995, and December 31, 2007, were
included. There were 1407 patients with a tibial diaphyseal
fracture in the 13-year period. Nineteen patients were
excluded because they had a primary amputation for reasons
other than ACS (n = 13) or in whom there were missing data
on the diagnosis of ACS (n = 6). This left 1388 patients for
study, of whom 160 (11.5%) had ACS.
Demographic details including age, gender, date, and
mode of injury were recorded prospectively. Low-energy
injury was defined as a fall from standing height or a sporting
injury. High-energy injury was defined as a fall from a height
or a road traffic accident. The method of management of the
tibial fracture was recorded as was the presence or absence of
an ACS. ACS was diagnosed using clinical symptoms and
www.jorthotrauma.com | 451
 McQueen et al
signs, compartment pressure monitoring, or a combination of
the 2. The pressure threshold for decompression on the
grounds of compartment monitoring was a ΔP of less than 30
mm Hg, showing no improvement for at least 2 hours.16 From
a retrospective review of our trauma database, the diagnosis
was confirmed by escape of muscle groups, documented evi-
dence of color change in the muscles, or muscle necrosis at
fasciotomy.11,17 Patients who underwent fasciotomy but did
not have these signs were classified as not having ACS, as
were those patients where it was possible to close the fasciot-
omy wounds primarily at 48 hours. For those patients who did
not undergo fasciotomy, absence of ACS was confirmed by
a record of absence of neurologic abnormality or contracture
at final review, that is, the sequelae of missed ACS, with cases
excluded if the review period did not extend beyond the time
of fracture healing, which is routinely a minimum of 3
months.
A retrospective case note and radiograph review was
performed to record whether the fracture was closed or open
and its Gustilo18,19 or Tscherne20 class. The OTA classifica-
tion21 was recorded from available radiographs (n = 716,
52%), with the classification agreed by consensus between
the 2 senior authors. Retrospective case note review also
recorded the smoking status (n = 713, 51%) and occupation
(n = 973, 70%) of the patient where available. White-collar
workers were defined as salaried professional or educated
workers and blue-collar workers as those performing manual
labor. A service worker was defined as working in a service
industry.
Social deprivation was calculated from postcodes using
the Carstairs score.22 The Carstairs score is a z-score created
from each postcode based on overcrowding, male unemploy-
ment, low social class, and car ownership, which has been
used extensively for the analysis of deprivation in many
branches of medicine.23–26 Missing data numbers are shown
in Table 1.
Statistical Methods
Factors were tested for univariate association with ACS
using chi-squared or t-tests, and multiple logistic regression or
Mantel–Haenszel testing was used to test factors for prognos-
tic significance after adjusting for one another. Two-tailed P
values were reported throughout and significance was taken
to be P , 0.05.
RESULTS
There were 1388 patients in the study cohort, of whom
160 (11.5%) had ACS. There were 957 males and 431
females with a mean age of 39 (range, 12–98) years. The
number of patients who underwent fasciotomy but did not
fit the diagnostic criteria for ACS was 6 (0.4%). The number
of patients who did not undergo fasciotomy but were later
confirmed as a missed ACS was 8 (0.6%). Table 1 shows the
prevalence of ACS in relation to levels of selected preopera-
tive and perioperative factors.
There was a very strong association between ACS and
age, with the highest prevalence in patients in their teens and
twenties (Table 1). Male gender, blue-collar occupation,
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J Orthop Trauma  Volume 29, Number 10, October 2015
sporting injury, and treatment with intramedullary nails also
showed an association with the occurrence of ACS, but these
were strongly confounded with age. There was no evidence of
an association with time, social deprivation, smoking, or the
energy of the injury.
Multiple logistic regressions were performed to see if
any of these factors still predicted ACS after adjusting for age
(Table 2). When each factor was entered on its own with age,
it was found that gender was not significant (P = 0.09) nor
was Gustilo class (P = 0.26) or injury mode (P = 0.52) but
that occupation (P = 0.011) and implant type (P = 0.004)
remained significant after adjusting for age. This is further
illustrated in Table 3, which shows that males had broadly
similar rates of ACS to females within age groups and there-
fore that the higher overall rate in males is largely explained
by their being younger on average than the females. Con-
versely, Table 3 also shows a tendency toward higher ACS
rates even within age groups for blue-collar workers, closed
fractures, and those treated with intramedullary nails. Similar
analyses on the fracture classifications with incomplete data
showed that the OTA subgroup 0.3 (fractures with the fibular
fracture at the same level or the more severely comminuted
fractures) (P = 0.052) and the Tscherne score (P = 0.10) were
approaching significance adjusted for age group. Overall, age
remained a highly significant predictor after adjusting for any
other factor.
The strongest age-independent effect was for implant
type, and indeed, a further series of multiple logistic
regressions showed that the effects of occupation and OTA
subgroup were no longer significant after adjusting for both
age and implant type. However, this was confounded by the
fact that of the 160 patients, 77 patients developed ACS
before treatment was instituted. We therefore performed
a secondary analysis excluding those patients, as the treat-
ment method could not have influenced the development of
ACS. To investigate further the possibility that the apparent
implant effect was confounded with fracture type, we
analyzed those patients with closed tibial fractures with
Tscherne class recorded and confirmed first that there was
indeed a large difference, with nailed patients tending to have
higher Tscherne scores than those given casts. This is shown
in Table 4, based on patients younger than 30 years, which
also shows that within Tscherne classes, there was still some
difference in the prevalence of ACS between those with nails
and casts. Because there were no cases of ACS in the cast
group, logistic regression cannot be used for testing the sig-
nificance of this difference, but a Mantel–Haenszel test, strat-
ified by Tscherne class, was not significant at P = 0.11. The
difference in the distribution of Tscherne class between pa-
tients aged younger than 30 years with closed tibial fractures
treated by casts or intramedullary nails therefore appears to at
least partially explain the difference in the prevalence of ACS
between the 2 treatment methods. Although the power to
detect a significant implant effect adjusted for Tscherne class
was quite low because of the missing Tscherne data, there
was a strong association of treatment with Tscherne class and
the selection of subgroups. There were insufficient numbers
of patients treated with external fixation to comment on any
differences.
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 J Orthop Trauma  Volume 29, Number 10, October 2015 Predictors of ACS

TABLE 1. Prevalence of Compartment Syndrome According TABLE 1. (Continued ) Prevalence of Compartment Syndrome
to Preoperative and Perioperative Factors According to Preoperative and Perioperative Factors
Number (%) Number (%)
Number With Number With
of Compartment Univariate of Compartment Univariate
Factor Level Patients Syndrome P Factor Level Patients Syndrome P
Age, y 12–19 222 45 (20) ,0.001 OTA 1 149 15 (10) ,0.001
20–29 335 70 (21) subgroup
30–39 264 31 (12) 2 239 23 (10)
40–49 188 8 (4) 3 224 51 (23)
50–59 153 5 (3) Tscherne 0 67 3 (4) 0.005
$60 226 1 (0.4) class
Sex Male 957 134 (14) ,0.001 1 404 52 (13)
Female 431 26 (6) 2 108 23 (21)
3 20 81 (13)
Year of 1995–1997 355 45 (13) 0.80
injury Missing 689
1998–2000 397 41 (10) RTA, road traffic accident.
2001–2003 264 29 (11)
2004–2007 372 45 (12)
Deprivation 1–3 541 59 (11) 0.67
4–5 625 75 (12) DISCUSSION
6–7 186 23 (12) This study shows clearly that youth is the strongest
Occupation White 329 50 (15) ,0.001 predictor of the likelihood of ACS developing after a tibial
Blue 318 57 (18) diaphyseal fracture with the highest risk occurring in
Service 71 11 (15) adolescents and young adults. We cannot make a comment
Retired 121 0 (0) on the risk in children as we do not treat tibial diaphyseal
Unemployed 133 10 (7) fractures in patients younger than 12 years, but scrutiny of the
Missing 415 32 (7) data demonstrates that the prevalence of ACS in adolescents
Smoking Yes 301 37 (12) 0.51 and young adults is 50 times that of the prevalence in the
No 412 52 (13) older than 60 years group. We have previously postulated that
Missing 675 71 (10) the increased risk in youth is related to the relative size of the
Implant Ex fix 64 3 (5) ,0.001 compartment and the muscle contained within it.27 Presum-
Nail 1172 155 (13) ably, when growth is complete, then the compartment size
Cast 137 1 (1) does not change. However, muscle size changes throughout
Other 11 1 (9) life, with muscles usually being largest in younger individuals
Missing 4 allowing less room for swelling to occur before intracompart-
Mode of Fall 389 19 (5) ,0.001 mental pressure reaches critical levels. We believe that this is
injury
the most likely explanation for the increased risk of ACS in
Fall height 146 13 (9)
younger patients. However, further data are required to clarify
Sport 378 75 (20)
these findings, and we would still recommend vigilance for
RTA 331 41 (12)
ACS in older patients.
Other 144 12 (8)
Previously, we reported the risk factors for a series of
Injury Low 839 101 (12) 0.51
energy
ACSs because of mixed causes and concluded that those at
High 549 59 (11)
highest risk were young males.27 However, there were not
Gustilo 0 1123 139 (12) 0.07
sufficient data to perform multiple logistic regression on these
class cases. This study has demonstrated that gender does not influ-
1 or 2 135 12 (9) ence the risk of compartment syndrome in tibial diaphyseal
3a or 3b 128 8 (6) fractures and that the previous finding was the result of the
Missing 2 bimodal distribution of tibial diaphyseal fractures with males
OTA type A 414 57 (14) 0.80 being younger than females.
B 138 22 (16) Initial analysis indicated the possibility that treatment
C 64 10 (16) with intramedullary nailing increased the risk of ACS
Missing 672 regardless of age. However, this was confounded by the
OTA group 1 273 32 (12) 0.18 treatment protocol in our unit where tibial fractures are almost
2 144 26 (18) all treated with intramedullary nailing. The only indication in
3 196 31 (16) our protocol for cast treatment is in completely undisplaced
fractures that are mostly classified as Tscherne C0, and given

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 McQueen et al J Orthop Trauma  Volume 29, Number 10, October 2015

We previously reported compartment pressure measurements

TABLE 2. 95% Confidence Limits for Estimated Odds Ratios
in a series of tibial diaphyseal fractures29 and found no differ-
From Multiple Logistic Regression of ACS on Age Group,
Implant Type, and Occupation ences in the mean pressure between open and closed fractures
or between low- and high-energy injuries. Others27,30 have
95% Confidence
Factor Group Odds Ratio Interval
also previously reported no differences in the rate of ACS
between these groups.
Age, years 10–19 12.09 6.41–22.79
Social deprivation does not increase the risk of ACS in
20–29 9.84 5.42–17.87
tibial diaphyseal fractures. Tibial fractures have been shown
30–39 4.64 2.41–8.93
to occur more commonly in the most deprived groups of the
$40 1.00
population, but there is no evidence that social deprivation
Type of implant Nail 5.44 2.34–12.65
increases any complications including infection, nonunion,
Other 1.00
and ACS.31
Occupation Blue collar 1.95 1.33–2.86
We recognize the primary limitation of our study is the
Other 1.00
lack of a universally agreed reference standard for the
diagnosis of ACS and that the fasciotomy could be a self-
fulfilling prophecy for the diagnosis of ACS. However, we
the small number of cases in our series, no definitive have applied stringent diagnostic criteria to confirm the
conclusions regarding the risk of ACS in relation to cast presence or absence of ACS, with any equivocal cases
treatment can be made. However, the risk of ACS in these resolved by consensus between the 2 senior authors. We feel
cases is statistically significantly less than in those with that in the absence of a recognized gold standard for
displacement and more severe soft tissue injury. When this is diagnosing ACS, these criteria are the most suitable to use,
taken into account, there were no significant differences in the particularly given their use within the orthopaedic litera-
prevalence of ACS, indicating that treatment type may not ture.11,17 Furthermore, our reported rate of fasciotomy is in
after all influence the risk of ACS. However, the low power of keeping with other studies in the literature, although the rate
this secondary analysis leaves this question open and further is very wide ranging.32–35
data in particular on patients with Tscherne classes 1–3 trea- Another obvious limitation is the retrospective nature of
ted by cast would be required to clarify the situation. How- this study, with missing data and radiographs noted. This can
ever, this would likely be difficult, given the current routine lead to a possibility of bias and inaccuracy of the data
management of the majority of these injuries is with intra- collected. The diagnosis of missed ACS was performed
medullary nailing. through retrospective case note review, with no protocol-
We found no differences in the rate of ACS in low- or driven process for this. However, the case notes did routinely
high-energy injury or in open versus closed fractures. document a clinical examination of the patient, and we feel it
Previous authors28 have suggested that the more severe the is unlikely that any clinically significant contracture was not
soft tissue injury the more likely is the occurrence of ACS. noted. The limited number of available radiographs was due

TABLE 3. Prevalence of Compartment Syndrome According to Age Groups and Levels of Selected Other Preoperative and
Perioperative Factors
Factor Level Age 10–19 years Age 20–29 years Age 30–39 years Age ‡40 years
Sex Male 22 (13) 25 (11) 11 (6) 6 (2)
Female 5 (14) 3 (5) 5 (8) 2 (1)
Occupation White 20 (14) 4 (6) 5 (13) 1 (2)
Blue 5 (23) 10 (13) 6 (8) 6 (6)
Service 1 (20) 5 (21) 1 (6) 0 (0)
Retired NA NA 0 (0) 0 (0)
Unemployed 1 (25) 2 (8) 1 (4) 1 (1)
NA 0 (0) 7 (7) 3 (3) 0 (0)
Implant Ex fix 1 (12) 0 (0) 1 (8) 0 (0)
Nail 26 (17) 28 (11) 15 (7) 7 (1)
Cast 0 (0) 0 (0) 0 (0) 0 (0)
Other 0 (0) 0 (0) 0 (0) 1 (12)
Mode of injury Fall 2 (17) 5 (16) 1 (2) 1 (0)
Fall height 1 (8) 2 (10) 2 (5) 3 (4)
Sport 12 (12) 14 (10) 5 (7) 1 (3)
RTA 10 (14) 5 (6) 3 (5) 2 (2)
Other 2 (22) 2 (7) 5 (14) 1 (1)
Figures shown are number (%).
RTA, road traffic accident; NA, not available.

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 J Orthop Trauma  Volume 29, Number 10, October 2015
TABLE 4. Prevalence of Compartment Syndrome in Patients
Younger Than 30 Years and With Closed Fractures According
to Tscherne Class and Implant
Tscherne Class Ex fix Nail Cast
0 0/0 1/12 0/26
1 0/0 19/126 0/14
2+3 0/3 3/37 0/0
Figures shown are number of cases/number of patients.
to our local policy of culling radiographs greater than 5 years
old in patients not under regular clinical review. A further
limitation is the length of the review period for detecting
sequelae of ACS. However, it is recognized that the muscle
contracture will develop within weeks after the insult, and we
therefore do not believe that we missed any false negatives.
Although the study reviews a 13-year period with different
experienced and committed trauma surgeons involved, our
investigation and treatment protocol was defined and used
during the whole study period and was supervised throughout
by the senior authors. This explains the high collection rate of
data in our study, despite the retrospective design.
This study is the largest ever performed analyzing risk
factors for the development of ACS after tibial diaphyseal
fracture and has important implications for the assessment of
these cases. Prompt diagnosis is essential to avoid the long-
term sequelae of ACS that can be devastating. We believe that
awareness of the possibility of ACS developing is an
important factor in reducing delay to diagnosis and that this
information will allow targeting of patients at risk for closer
clinical observation and compartment pressure monitoring.
ACKNOWLEDGMENTS
The authors acknowledge the Scottish Orthopaedic
Research Trust into Trauma (SORT-IT) for their assistance
in performing this study. They also thank Dr Rob Elton for his
assistance with the statistical analysis.
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