Abstract
Background
Acute compartment syndrome (ACS) is a relatively rare complication in pediatric patients which can result in significant morbidity and mortality. Although studies with limited patient cohorts exist, knowledge gaps remain regarding the epidemiology and associated clinical factors with ACS. This study utilized a large database to investigate demographic variables, national trends, and clinical factors associated with pediatric patients undergoing fasciotomies for ACS.
Methods
The TriNetX US Collaborative Network database was queried using International Classification of Disease, 10th Revision and Current Procedural Terminology codes to identify patients aged 18 years and younger undergoing fasciotomy for ACS between 2015 and 2024. Patients were further stratified based on upper or lower extremity compartment syndrome. The primary outcome was the incidence proportion (IP) of pediatric ACS requiring fasciotomy. Cohort characteristics were collected including age, sex, race, body mass index (BMI), comorbidities, orthopaedic complications, compartment syndrome location, and geographic distribution of patients.
Results
A total of 28,532,251 patients aged 18 years and younger were identified, of which 1,345 patients underwent fasciotomies for ACS. The mean age was 14.7 ± 4.0 years with a mean BMI of 24.7 ± 5.9. A majority of the cohort were male (59%) and White (62%). Fewer than 10% of patients had pre-existing comorbidities. The most common associated fracture for pediatric ACS was tibial shaft fracture (19%). The most common associated fracture characteristics were open fractures (27%) and necessity for surgical fixation of fractures (28%). The most common medical complications were inpatient readmission at 30 days (17%) and acute kidney injury at 30 days (6%). The rate of mortality was 1% at 7 days and 2% at 30 days. The IP within the TriNetX pediatric population in 2024 was approximately 17 cases per one million patients compared to 14 cases per million in 2015 (P = .35).
Conclusions
The incidence of pediatric ACS within the TriNetX cohort has remained relatively consistent since 2015, with most cases occurring in open, tibial shaft fractures. Lower extremity injuries comprised a vast majority of cases. Future studies are needed to further delineate factors associated with an ACS presentation.
Key Concepts
-
(1)
The incidence proportion of pediatric acute compartment syndrome has remained relatively consistent since 2015, with most cases occurring in lower extremity trauma, particularly open, tibial shaft fractures.
-
(2)
Although prevalence have increased over the past decade, this likely reflects better detection, not rising disease.
-
(3)
While this study explores national trends and epidemiologic patterns, future studies are needed to explore causal links for specific factors contributing to pediatric acute compartment syndrome.
Level of Evidence
III, Retrospective cohort study
Keywords: Acute compartment syndrome, Pediatric acute compartment syndrome, Incidence, Outcomes, Complications
Introduction
Acute compartment syndrome (ACS) is a rare but potentially limb- and life-threatening condition with an estimated incidence of 8 per 100,000 people annually [1]. Initially described in 1881 by Volkmann as an ischemic muscle contracture due to external pressures leading to irreversible muscle necrosis, prompt diagnosis and treatment is crucial to prevent the significant morbidity and mortality associated with ACS [2,3]. Although the etiology of ACS is multifactorial, traumatic injuries are the most frequent inciting event, followed by nontraumatic causes including vascular injuries, overexertion, surgical positioning, infections, and toxin exposure from animal bites or stings, which is referred to as envenomation [4].
Although pediatric ACS has a similar mechanism and shares many etiologies, it must be carefully distinguished from its adult counterpart [5]. As in all cases of ACS, time to decompressive fasciotomy is crucial in order to prevent ongoing tissue ischemia, neurovascular injury, and muscle death [6]. While numerous studies have investigated adult ACS since its initial description, pediatric ACS has only more recently received greater attention in the literature, in part because it is less common and may be more difficult to recognize clinically than adult ACS [[7], [8], [9], [10]].
Although studies with limited patient cohorts exist, there remains limited evidence describing the epidemiology, injury pattern, and outcomes of pediatric ACS from national-level data. This study descriptively characterizes these national trends in demographic and injury-related factors in pediatric patients undergoing fasciotomy for ACS.
Methods
Study design
The TriNetX United States Collaborative Network (Cambridge, Massachusetts, United States) was used to perform a retrospective cohort study of aggregated and deidentified data collected from more than 130 million patients and 68 health care organizations [11]. The platform incorporates biomedical and clinical research data from both insured and uninsured patients from a variety of organizations including hospitals and primary and specialty care centers. Access to clinical data including demographics, diagnoses, procedures, medications, laboratory values, and genomic information facilitates analysis of complex data sets [12]. Patient confidentiality is maintained through expert-certified methods such as obfuscation and minimum thresholds, guaranteeing that each query includes at least 10 individuals. Institutional review board approval was not required for this study as TriNetX follows the Health Insurance Portability and Accountability Act and General Data Protection Regulation guidelines for deidentification.
Study population
The United States Collaborative Network was queried on July 17, 2025, identifying all patients aged 18 years and younger who were diagnosed with compartment syndrome between January 1, 2015, and December 31, 2024. Patients were identified using Current Procedural Terminology (CPT) and International Classification of Disease, 10th Revision (ICD-10) codes. Inclusion criteria required patients to be under 18 years of age at the time of diagnosis. Additionally, included patients had to have undergone a fasciotomy within one month of an ACS diagnosis. This time window was selected to improve capture of relevant ACS cases due to the constraints of a claims database and to correct for delayed coding across encounters, although it is apparent that true ACS requires emergent treatment. Both traumatic (ICD-10: T79.A) and nontraumatic (ICD-10: M79.A) cases were included in the analysis. Fasciotomy procedures within one month of the diagnosis were identified using the following CPT codes: 25020, 25023, 25024, 25025, 27600, 27601, 27602, 27892, 27893, and 27894. Patients were further stratified based on upper or lower extremity compartment syndrome (Fig. 1).
Figure 1.
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) diagram depicting the patient selection process.
Data collection and outcomes
A diagnosis of compartment syndrome was indicated as the index event. Cohort characteristics collected included age, sex, race, body mass index (BMI), comorbidities, associated fractures, fracture characteristics, medical and orthopaedic complications, compartment syndrome anatomic location, and geographic distribution of patients and were collected within one month of diagnosis. The primary outcome was annual incidence proportion (IP) of compartment syndrome within the TriNetX database, defined as the number of new pediatric ACS cases requiring fasciotomy occurring each year divided by the TriNetX pediatric population for that year. The secondary objective was to describe various factors associated with an ACS presentation, including demographics, comorbidities, orthopaedic complications, compartment syndrome anatomic location, and geographic distribution of patients.
Data analysis
The TriNetX platform was utilized for all statistical analyses using built-in statistical tools. Descriptive statistics were calculated for all continuous and categorical variables. Continuous variables were reported as mean ± standard deviation, whereas categorical variables were reported as frequencies with percentages. A chi-squared (χ2) test was used to analyze categorical variables, and an independent samples t-test was used to analyze the difference in means for continuous variables. A P value ≤.05 was considered statistically significant.
Results
Demographics
A total of 28,532,251 pediatric patients were identified from the initial query, of whom 1,345 patients underwent fasciotomy for ACS. The mean age of the cohort was 14.7 ± 4.0 years. A majority of the cohort were male (59%). By race, most patients were White (62%), followed by Black patients (19%). The mean BMI of the cohort was 24.7 ± 5.9 kg/m2. Fewer than 10% of patients had pre-existing comorbidities, with essential hypertension being the most common at 5%. The most common fracture type resulting in compartment syndrome was tibial shaft fracture (19%). Open injuries and surgical fixation of fractures were present in 27% and 28% of cases, respectively. The most common medical complication was acute kidney injury at 30 days (6%), while the 30-day inpatient readmission rate was 17%. The rate of mortality was 1% at 7 days and 2% at 30 days. The fracture, injury, and complication variables reported here represent selected characteristics of the cohort rather than an exhaustive list of associated pathologies. Most cases involved the lower extremity (86%). A majority of cases were present in Southern Healthcare Organizations (474 cases) followed by the Midwest (397 cases). A more detailed breakdown can be found in Table 1.
Table 1.
Pediatric compartment syndrome cohort characteristics (n = 1,345).
| Age (years) | 14.7 ± 4.03 |
| Sex | n (%) |
| Male | 795 (59) |
| Female | 507 (38) |
| Unknown | 43 (3) |
| Race | n (%) |
| White | 828 (62) |
| Unknown | 162 (12) |
| Black or African-American | 257 (19) |
| Asian | 19 (1) |
| Other | 79 (6) |
| Body mass index | 24.7 ± 5.91 |
| Comorbidities | n (%) |
| Diabetes mellitus | 24 (2) |
| Essential (primary) hypertension | 79 (5) |
| Overweight, obesity, and other hyperalimentation | 71 (5) |
| Associated fractures | n (%) |
| Supracondylar humerus fracture | 26 (2) |
| Tibial shaft fracture | 255 (19) |
| Forearm fractures | 81 (6) |
| Tibial tuberosity fractures | 41 (3) |
| Fibula shaft fracture | 197 (15) |
| Femoral fracture | 110 (8) |
| Fracture characteristics | n (%) |
| Open injuries | 361 (27) |
| Surgical fixation of fractures | 377 (28) |
| Arterial injury | 249 (19) |
| Nerve dysfunction | 70 (5) |
| Location of compartment syndrome | n (%) |
| Upper extremity | 198 (15) |
| Lower extremity | 1,158 (86) |
| Outcomes | n (%) |
| Readmission rate | |
| 7 days | 168 (12) |
| 30 days | 230 (17) |
| Rhabdomyolysis | |
| 7 days | 50 (4) |
| 30 days | 57 (4) |
| Acute kidney failure | |
| 7 days | 63 (5) |
| 30 days | 76 (6) |
| Mortality | |
| 7 days | 20 (1) |
| 30 days | 288 (21) |
| Amputation | |
| 7 days | 25 (2) |
| 30 days | 49 (4) |
| Geographic distribution | n (%) |
| Northeast | 360 (27) |
| Midwest | 397 (29) |
| South | 474 (35) |
| West | 112 (8) |
| Unknown | 2 (<1) |
Overall rates of pediatric compartment syndrome
In 2024, the IP was approximately 17 cases per one million patients, compared to 14 cases per million in 2015; however, this difference was not statistically significant (P = .35). Overall, the IP has remained relatively stable over the study period, with the highest rate observed in 2020 at 20 cases per million. Statistically significant differences in IP were noted only when comparing 2015 to 2020 (P = .035) and 2015 to 2021 (P = .040).
Rates of pediatric compartment syndrome by location
In 2024, the IP of both upper and lower extremity pediatric compartment syndrome remained relatively stable from 2015 to 2024. The IP for lower extremity compartment syndrome was 13 cases per million pediatric patients, significantly higher than the 3 cases per million observed for upper extremity cases (P < .05). The peak IP for lower extremity cases reached 17 per million pediatric patients in 2021, while upper extremity IP reached a peak of 4 cases per million pediatric patients in 2020 (Fig. 2).
Figure 2.
Incidence proportion of pediatric acute compartment syndrome in the TriNetX database in the TriNetX US collaborative database over time.
Discussion
This study characterized temporal trends in pediatric ACS with fasciotomy within a large national database. The primary finding was that annual incidence remained relatively stable from 2015 to 2024 within the TriNetX network. These findings indicate that the rates of pediatric ACS have not meaningfully changed over the last decade.
Findings showed that 86% of cases occurred in the lower extremity. The most common associated fracture was tibial shaft fracture (19%), while open injuries and surgical fixation of fractures were also frequently present. These associations are in line with prior literature, including multiple studies that identified tibial fractures as carrying the highest risk for ACS in children [[13], [14], [15]]. Interestingly, the study population experienced a 30-day mortality rate of 2%, which is confounded by the fact that ACS is often the result of multisystem trauma and thus likely to have a higher mortality in those cases. This claim is substantiated by the fact that established mortality rates in pediatric ACS are low in otherwise healthy children [16].
The findings in this study also build on recent database investigations into pediatric ACS, including studies by Hegazi et al. and Bhogadi et al. that found tibial fractures to be an important associated factor for fasciotomy, which is concordant with the high proportion of tibial fractures in the present cohort [17,18]. Additionally, this study expands on previous pediatric ACS registry studies; in that we used a national dataset spanning nearly a decade, which supports commentary on temporal trends in addition to associated cohort characteristics. Finally, our cohort definition required both ACS and fasciotomy codes in this analysis, which likely increased specificity over previous methodologies focusing on fasciotomy alone. However, this may underestimate the broader burden of ACS in pediatric populations [19].
Beyond describing short-term outcomes and injury proportions, this study offers a large database reference for pediatric ACS requiring fasciotomy. Previous studies have relied on single-institution cohorts or trauma-specific registries, which may be influenced by practice patterns or a severity-based selection bias. While this analysis is specific to the TriNetX network, this large database encompasses multiple geographic regions and care environments. Therefore, the observed stability in IP over time and associated risk patterns in this database may serve as a baseline for comparison for future database-based studies.
The findings in this study reiterate the findings of previous studies, including that care teams should maintain a sufficient level of suspicion for ACS following tibial shaft and open fractures in children. Additionally, the associations found here indicate that the development of standardized monitoring guidelines for certain pediatric trauma presentations may be warranted. Finally, the high mortality finding supports the idea that ACS often occurs because of severe trauma, which should serve as a contextual marker for clinicians to be aware of potential systemic issues during management decision-making.
The present study is not without limitations. This study utilized a large, deidentified database to collect data, thereby leading to the inability to access individual patient records and subjecting the accuracy of our results to appropriate ICD-10 and CPT coding. Since coding practices, institution type, and referral patterns may impact the reported incidence of this study, it is important to note that these findings may not be fully generalizable to the broader US pediatric population. Additionally, since TriNetX is continuously refreshed, annual cohort counts and incidence estimates may change if the query is repeated later. Thus, the findings of this study should be interpreted as specific to the date of the initial query. In addition, variables such as differences in time to fasciotomy and care setting types are unable to be addressed. Finally, this study was designed as a descriptive analysis of temporal trends of pediatric ACS and thus did not evaluate independent risk factors for pediatric ACS within specific injury cohorts. Therefore, the reported demographic or injury patterns should not be interpreted as independent predictors of ACS requiring fasciotomy. Despite these limitations, a database enabled us to analyze a large cohort of patients and determine temporal trends for a relatively uncommon diagnosis to investigate differences in demographic variables and national trends among pediatric patients undergoing fasciotomies for ACS.
Conclusion
The IP of pediatric ACS has remained relatively consistent since 2015, with most cases occurring in lower extremity trauma, particularly open, tibial shaft fractures. This national retrospective study explores epidemiologic patterns and injury characteristics among pediatric patients with ACS. While this study may inform clinical awareness, future studies are needed to explore causal links for specific factors contributing to pediatric ACS.
Author contributions
Logan M. Good: Writing – review & editing, Writing – original draft, Validation, Project administration, Methodology, Investigation, Formal analysis, Conceptualization. Parshva A. Sanghvi: Writing – original draft, Methodology, Formal analysis, Data curation. Nathaniel F. Ruppert: Writing – review & editing, Writing – original draft, Methodology, Data curation. Jeremy M. Adelstein: Writing – original draft, Supervision, Formal analysis, Conceptualization. Samuel A. Florentino: Writing – review & editing, Methodology, Formal analysis, Conceptualization. Alexander N. Berk: Writing – original draft, Methodology, Formal analysis, Conceptualization. Robert J. Burkhart: Writing – original draft, Validation, Methodology. Raymond W. Liu: Writing – review & editing, Validation, Supervision, Conceptualization. Joshua K. Napora: Writing – review & editing, Visualization, Supervision, Conceptualization.
Previous communication
This article is not based on a previous communication to a society or meeting.
Ethics approval and consent
The authors declare that no patient consent was necessary as no images or identifying information is included in the article.
No institutional review board approval was required as our analysis does not contain human data.
Funding
No funding, grants, or in-kind support was received for the purposes of this research. None of the authors received financial support for this study.
Declaration of competing interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Footnotes
Supplementary material related to this article can be found at https://doi.org/10.1016/j.jposna.2026.100398.
Supplementary material
The following are the Supplementary data to this article.
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