Acute Compartment Syndrome Following Lower Leg Vascular Injury: A Big-Data Approach to Estimating Incidence and Risk Factors

Acute Compartment Syndrome (ACS) is a limb- and life-threatening complication of lower leg fractures. Rapid recognition and fasciotomy can prevent irreversible ischemic injury, but ACS is often under-recognized. Vascular injury may increase the risk of ACS by impairing perfusion and exacerbating swelling. This study aimed to determine the incidence, risk factors, and outcomes of ACS in patients with lower leg fractures, with particular emphasis on the impact of vascular injury. This retrospective cohort study used data from the 2017 American College of Surgeons Trauma Quality Programs database to perform a multicenter analysis of patients with lower leg fractures. Patients were excluded if they had non-traumatic etiologies; extreme body mass index (BMI) values (< 15 kg/m2 or > 40 kg/m2); or comorbidities that limited care, including disseminated cancer or active chemotherapy, congenital malformations, major psychiatric illness, advance directives restricting treatment, or functional dependence. The primary outcome was the fasciotomy rate, a surrogate marker of ACS. Multivariable logistic regression was used to identify predictors of both vascular injury and fasciotomy. Among 55,945 patients with lower leg fractures, 1,410 (2.52%) had vascular injuries. Fasciotomy was performed in 29.79% of patients with vascular injury versus 3.16% in patients without vascular injury. Predictors of vascular injury included open fractures (odds ratio [OR], 4.40; P < .0001), crush injuries (OR, 4.25; P < .0001), dislocations (OR, 3.26; P < .0001), higher BMI (OR, 1.02; P = 0.003), and male sex (OR, 1.96; P < .0001). Among patients with vascular injury, key predictors of fasciotomy were popliteal artery injury (OR, 3.63; P < .0001), popliteal vein injury (OR, 2.27; P = .003), and proximal tibia fractures (OR, 1.66; P < .001). Vascular injury significantly increases the risk of ACS in lower leg fractures, as reflected by higher fasciotomy rates. Fracture location (proximal tibia) and specific vessel involvement (popliteal artery or vein) are critical risk factors and should prompt heightened surveillance for ACS.