Journal of Pediatric Orthopaedics - 2026-04-14 - Journal Article
Pediatric Acute Compartment Syndrome in Midshaft Tibia Fractures: Risk Factors for Overnight Observation.
Ball GA, Thompson EA, Bomar JD, Edmonds EW
Topics
Key Takeaway
Among 217 children admitted for overnight observation with isolated tibial diaphyseal fractures, PACS developed in only 2.8%, with older age (14.0 vs. 10.1 years) and lower sagittal angulation (2.2 vs. 6.3 degrees) as significant risk factors.
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Summary
This study asked whether overnight observation is warranted for all pediatric isolated tibial diaphyseal fractures and what risk factors predict PACS. Of 339 children reviewed from 2012–2023, the observation-only cohort (n=217) had a 2.8% PACS rate, with older age and paradoxically lower sagittal angulation as significant risk factors; the operative cohort (n=122) had a 3.3% PACS rate, with high-energy mechanism driving a 9% PACS rate versus 0% for low-energy injuries. All fasciotomies were performed at the time of initial treatment, suggesting no cases were missed during observation.
Key Limitation
Fracture displacement and AO-OTA complexity did not predict PACS, leaving clinicians without a reliable morphologic triage criterion and limiting the actionability of the findings.
Original Abstract
BACKGROUND
Pediatric acute compartment syndrome (PACS) is a challenging condition to diagnose and can result in significant morbidity for children. Our aims were to: (1) determine if overnight observation is warranted in isolated diaphyseal tibial fractures; (2) identify risk factors of PACS.
METHODS
Acutely managed children with isolated tibial diaphyseal fractures +/- fibula fractures from 2012 to 2023 were reviewed. This cohort was cross-referenced with a list of children undergoing fasciotomies. Demographic information and the mechanism of injury were documented. Fractures were classified using the AO-OTA system and measured for translation and angulation.
RESULTS
A total of 339 children were included for analysis, of whom 217 children were admitted for overnight observation without the intent to operate and developed PACS at a frequency of 2.8%. We observed that the children who developed PACS in this cohort were older (14.0±1.5 vs. 10.1±4.0 y, P=0.015) and had lower sagittal angulation (2.2±2.6 vs. 6.3±7.1 degrees, P=0.03). One hundred twenty-two children were admitted with the intent to operate, and developed PACS at a frequency of 3.3%. Among the children admitted with the intent to operate, those who sustained a high-energy injury developed PACS at a higher rate (9%) than those that sustainied a low-energy injury (0%) (P=0.017). All fasciotomies were performed at the time of initial treatment.
CONCLUSION
PACS in children is fortunately an uncommon condition, providing the clinician with an opportunity to manage their tibial diaphyseal fractures without an overnight observation, as long as appropriate nonoperative management is initiated. At this time, initial displacement or fracture complexity cannot guide the clinician's decision for admission, but future research in a multicenter, prospective fashion could hold the key to better understand which predictor is most important related to the development of pediatric acute compartment syndrome in tibial diaphyseal fractures.
LEVEL OF EVIDENCE
Level III.