A Salter-Harris (SH) type II fracture is a fracture through the growth plate (physis) and metaphysis of a long bone, sparing the epiphysis. It is the most common physeal fracture type, accounting for approximately 75–85% of all growth plate injuries in children. [1-2] The mnemonic "SALTR" (Straight Across, Above, beLow, Through, Rammed/cRush) helps recall the classification. SH-II corresponds to "Above" — the fracture exits through the metaphysis, producing a characteristic triangular metaphyseal fragment known as the Thurston-Holland fragment.
The following figure demonstrates the radiographic appearance of SH type II and III fractures of the distal femur:
1. History
- Mechanism: Falls (most common cause overall), sports injuries (43% of distal tibial SH-II), twisting/rotational injuries, hyperextension, and motor vehicle collisions [1][4]
- Key HPI questions:
- Exact mechanism (fall from height, FOOSH, twisting, direct blow, hyperextension)
- Timing of injury and onset of pain
- Ability to bear weight or use the extremity since injury
- Prior injuries to the same extremity
- Any deformity noted at the scene
- Symptom characterization: Acute onset of pain localized near a joint, swelling, inability to use the limb
- Important negatives: Numbness/tingling (neurovascular compromise), open wound (open fracture), history of minimal or no trauma (pathologic fracture, non-accidental trauma)
2. Alarm Features
- Open fracture (skin breach over fracture site)
- Neurovascular compromise: Absent or diminished distal pulses, pallor, paresthesias, paralysis — particularly concerning in distal femoral and proximal tibial fractures where the popliteal artery and peroneal nerve are at risk [3]
- Compartment syndrome: Severe pain out of proportion, pain with passive stretch, tense compartment
- Significant displacement or angulation suggesting need for emergent reduction
- Inconsistent mechanism with injury pattern — consider non-accidental trauma (NAT), especially in non-ambulatory children
- Distal femoral physeal fractures carry a particularly high risk of growth arrest (40–52%) and warrant urgent orthopedic involvement [3]
3. Medications
- First-line analgesia: Ibuprofen 10 mg/kg (max 600 mg) — supported as the optimal first-line analgesic for pediatric musculoskeletal injuries by the AAP and systematic reviews. Short-term NSAID use has not been shown to affect fracture healing. [5-6]
- Adjunctive: Acetaminophen 15 mg/kg (max 1000 mg) can be combined, though recent RCTs (No OUCH trials) showed no additional benefit of adding acetaminophen or hydromorphone to ibuprofen [5]
- Procedural sedation for reduction: Ketamine, propofol, or midazolam/fentanyl per institutional protocol
- Intranasal options for acute severe pain: IN fentanyl (1.5–2 mcg/kg) or IN ketamine (1 mg/kg) to avoid IV placement [7]
- Avoid: Codeine and tramadol in children <12 years (FDA black box warning for respiratory depression risk) [7]
- Caution: Opioids offer no significant additional pain reduction over ibuprofen for musculoskeletal injuries and carry more adverse effects [5][8]
4. Diet
- NPO if procedural sedation for closed reduction is anticipated
- Adequate calcium and vitamin D intake during healing phase
- No specific acute dietary restrictions otherwise
5. Review of Systems
- Musculoskeletal: Pain, swelling, deformity, inability to bear weight or use extremity
- Neurologic: Numbness, tingling, weakness distal to injury (nerve injury)
- Vascular: Coolness, pallor, delayed capillary refill (vascular compromise)
- Constitutional: Fever (if concern for infection or pathologic fracture)
- Skin: Open wounds, abrasions, ecchymosis pattern (NAT screening)
6. Collateral History and Family History
- Collateral: Witnessed mechanism, caregiver account consistency (critical for NAT evaluation), prior ED visits for injuries
- Family history: Osteogenesis imperfecta, metabolic bone disease, bleeding disorders
- Social context: Developmental stage (ambulatory vs. non-ambulatory), sports participation, child protective concerns if mechanism inconsistent with injury
7. Risk Factors
- Age: Peak incidence in adolescents (growth plate is the weakest link in the musculoskeletal chain in skeletally immature children) [1][3]
- Sex: Boys > girls (~2:1 ratio) [1]
- Sports participation: Most common mechanism for distal tibial SH-II fractures (43%) [4]
- Skeletal immaturity: The physis has decreased tensile strength compared to surrounding ligaments, making it the point of failure [3]
- High-energy mechanisms: Motor vehicle accidents, falls from height — associated with higher displacement and greater risk of premature physeal closure (PPC) [9]
8. Differential Diagnosis
- SH type I fracture: Fracture through the physis only — may be radiographically occult; diagnosed clinically by physeal tenderness [10]
- SH type III, IV, or V fractures: Involve the epiphysis (III), both epiphysis and metaphysis (IV), or crush injury (V) — higher risk of growth disturbance and joint incongruity [2]
- Metaphyseal fracture (buckle/torus): Does not involve the physis
- Ligamentous sprain: In adolescents nearing skeletal maturity, adult-pattern ligament injuries become more common [3]
- Pathologic fracture: Bone cyst, tumor — suspect with minimal trauma
- Non-accidental trauma: Especially classic metaphyseal lesions ("corner" or "bucket-handle" fractures) in infants/toddlers
- Osteomyelitis/septic joint: If fever, erythema, or subacute presentation
9. Past Medical History
- Prior fractures (recurrent fractures raise concern for metabolic bone disease)
- Previous physeal injuries to the same bone
- Osteogenesis imperfecta, rickets, renal osteodystrophy
- Chronic steroid use
- Developmental/neurologic conditions affecting mobility
10. Physical Exam
- Vital signs: Tachycardia (pain, blood loss in high-energy injuries)
- Inspection: Swelling, deformity, ecchymosis, skin integrity (open vs. closed)
- Palpation: Point tenderness over the physis is the hallmark finding — tenderness at the growth plate rather than over ligaments [10]
- Range of motion: Limited by pain; do not force
- Neurovascular exam: Distal pulses, capillary refill, sensation, motor function — mandatory before and after any reduction or splinting [3]
- Compartment assessment: Palpate compartments for tenseness; pain with passive stretch
- Skin survey: If NAT is a concern, full skin exam for bruising in various stages
11. Lab Studies
- Routine labs are generally not indicated for isolated SH-II fractures
- Consider if operative management anticipated:
- CBC, BMP, coagulation studies (pre-operative)
- Type and screen for high-energy injuries
- If concern for pathologic fracture: Calcium, phosphorus, alkaline phosphatase, vitamin D, PTH
- If concern for NAT: Skeletal survey, consider coagulation studies
12. Imaging
- First-line: AP and lateral plain radiographs of the affected joint — the Thurston-Holland metaphyseal fragment is the classic finding [2][10]
- CT: Useful for surgical planning in displaced fractures, particularly to assess displacement and intra-articular involvement [10]
- MRI: Most sensitive for detecting occult physeal injuries, periosteal entrapment, and early physeal bar formation during follow-up. Consider when radiographs are negative but clinical suspicion is high (physeal tenderness, effusion, inability to bear weight) [3][11]
- When imaging is unnecessary: Routine delayed follow-up radiographs in asymptomatic patients with uncomplicated distal radius SH-II fractures have low yield (1.3% physeal bridge detection rate) [12]
13. Special Tests
- Salter-Harris Classification (SALTR mnemonic): Determines prognosis and management — higher types carry greater risk of growth disturbance [2]
- Ottawa Ankle/Knee Rules: Can be applied in older children to guide need for radiographs (validated in children >5 years)
- Point-of-care ultrasound: May identify cortical irregularity, periosteal elevation, and effusion at the bedside
- Doppler ultrasound or CT angiography: If vascular injury suspected (diminished pulses, expanding hematoma)
14. ECG
- Not routinely indicated for isolated SH-II fractures
- Consider if procedural sedation is planned (per institutional sedation protocol)
- Obtain if high-energy polytrauma with concern for cardiac contusion
15. Assessment
SH-II fractures are the most common physeal fracture type and generally carry a favorable prognosis compared to types III–V, as the fracture does not cross the epiphysis or joint surface. [2] However, prognosis is site-dependent:
- Distal radius (most common site): Low complication rate; physeal bridge formation ~1.3% [1][12]
- Distal tibia: Overall PPC rate of 12–43% depending on displacement; displaced fractures carry higher risk. Repeated reduction attempts (>2) increase PPC risk 8.5-fold [13-14]
- Distal femur: Highest risk — growth arrest rates of 40–58% for SH-II, with displaced fractures having 4-fold increased odds of growth disturbance [3]
Key prognostic factors for PPC include initial displacement ≥4 mm, high-energy mechanism, younger age at injury, and number of reduction attempts. [9][14]
16. Treatment Plan
Initial stabilization (ED)
- Splint in position of comfort; ice and elevation
- Adequate analgesia (ibuprofen 10 mg/kg first-line) [5]
- Neurovascular check before and after splinting
Nondisplaced or minimally displaced (<3 mm)
- Cast immobilization (long-leg cast for lower extremity, short- or long-arm cast for upper extremity depending on location) [4][15]
- Non-weight-bearing status for lower extremity fractures
Displaced (≥3 mm)
- Closed reduction in the ED with procedural sedation, followed by cast immobilization [4][16]
- Consensus supports nonoperative management if postreduction translation is <3 mm [15]
- If closed reduction fails or residual displacement >3 mm with coronal plane angulation: orthopedic consultation for possible ORIF [4][15]
- Notably, operative treatment has not been shown to reduce PPC rates compared to nonoperative management in distal tibial SH-II fractures — clinical equipoise exists [13][17-18]
Periosteal entrapment: Recent evidence suggests it is not an independent risk factor for growth disturbance, and routine periosteal stripping may be unnecessary [11]
17. Disposition
Discharge criteria (most SH-II fractures)
- Nondisplaced or successfully reduced fracture
- Adequate pain control
- Intact neurovascular status post-splinting
- Reliable follow-up arranged with orthopedics within 5–7 days
Orthopedic consultation in the ED
- Failed closed reduction
- Significant displacement or angulation
- Distal femoral or proximal tibial physeal fractures (high complication risk) [3]
- Open fractures
- Neurovascular compromise
- Concern for compartment syndrome
Admission criteria
- Open fracture requiring operative washout
- Neurovascular compromise
- Compartment syndrome
- Need for operative fixation
- Polytrauma or inability to manage pain as outpatient
- NAT concern requiring safe disposition planning
18. Follow Up / Return Precautions
- Orthopedic follow-up: Within 5–7 days for repeat radiographs and cast application/check [4]
- Growth monitoring: SH fractures should be monitored for 6–12 months to detect growth arrest and angular deformity. MRI is the most sensitive tool for early detection of physeal bar formation [3]
- Return precautions — instruct families to return immediately for:
- Increasing pain despite medication (compartment syndrome)
- Numbness, tingling, or color change in fingers/toes
- Cast becomes too tight, wet, or broken
- Fever or foul smell from cast
- Inability to move digits
- Expected recovery: Most SH-II fractures heal in 4–6 weeks; return to sports typically 6–12 weeks depending on site and sport
- Counseling: Explain the small but real risk of premature physeal closure leading to angular deformity or limb length discrepancy, particularly for displaced fractures and weight-bearing bones [13][18]
References
1. Clinical Characteristics of 1124 Children With Epiphyseal Fractures. — Deng H, Zhao Z, Xiong Z, et al. BMC Musculoskeletal Disorders. 2023.
2. Growth Plate Injuries: Salter-Harris Classification. — Brown JH, DeLuca SA. American Family Physician. 1992.
3. Acute Knee Injuries in Children and Adolescents: A Review. — MacDonald J, Rodenberg R, Sweeney E. JAMA Pediatrics. 2021.
4. Treatment and Outcomes of Distal Tibia Salter Harris II Fractures. — Thomas RA, Hennrikus WL. Injury. 2020.
5. Acetaminophen (Paracetamol) or Opioid Analgesia Added to Ibuprofen for Children’s Musculoskeletal Injury. — Ali S, Klassen TP, Candelaria P, et al. The Journal of the American Medical Association. 2026.
6. Oral Analgesic for Musculoskeletal Injuries in Children: A Systematic Review and Network Meta-Analysis. — Utsumi S, Amagasa S, Moriwaki T, Uematsu S. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine. 2024.
7. Best Practices Guidelines For Acute Pain Management In Trauma Patients. — Andrew Bernard, Douglas R. Oyler PharmD, Jeffrey O. Anglen MD FACS FAAOS, et al American College of Surgeons (2020). 2020.
8. An Observational Cohort Study Comparing Ibuprofen and Oxycodone in Children With Fractures. — Ali S, Manaloor R, Johnson DW, et al. PloS One. 2021.
9. Salter-Harris Type II Fractures of the Distal Tibia: Residual Postreduction Displacement and Outcomes-a STROBE Compliant Study. — Margalit A, Peddada KV, Dunham AM, Remenapp CM, Lee RJ. Medicine. 2020.
10. Pediatric Physeal Ankle Fracture. — Wuerz TH, Gurd DP. The Journal of the American Academy of Orthopaedic Surgeons. 2013.
11. A Retrospective Analysis of the Correlation Between Periosteal Entrapment and Growth Disturbances in Salter-Harris II Physeal Fractures of the Distal Tibia in Children. — Zhang H, Yang M, Tong X, et al. Journal of Pediatric Orthopedics. 2026.
12. Clinical Utility and Economic Impact of Routine Delayed Follow-Up Radiographs in Children With Uncomplicated Distal Radius Salter-Harris 2 Fractures. — Brahee DD, Smith EA. Pediatric Radiology. 2021.
13. Salter-Harris II Fractures of the Distal Tibia: Does Surgical Management Reduce the Risk of Premature Physeal Closure?. — Russo F, Moor MA, Mubarak SJ, Pennock AT. Journal of Pediatric Orthopedics. 2013.
14. Physeal Fractures of Distal Tibia: A Systematic Review and Meta-Analysis. — Jalkanen J, Sinikumpu JJ, Puhakka J, et al. Journal of Pediatric Orthopedics. 2021.
15. Variations in the Management of Closed Salter-Harris II Distal Tibia Fractures. — Swarup I, Pearce R, Sanborn R, Shore BJ. Journal of Pediatric Orthopedics. 2023.
16. Pediatric Fracture Reduction in the Emergency Department. — Bin K, Rony L, Henric N, Moukoko D. Orthopaedics & Traumatology, Surgery & Research : OTSR. 2022.
17. What Is the Best Treatment for Displaced Salter-Harris II Physeal Fractures of the Distal Tibia?. — Park H, Lee DH, Han SH, et al. Acta Orthopaedica. 2018.
18. Displaced Distal Tibial Salter-Harris II Fractures. — Peterson N, Perry DC. The Bone & Joint Journal. 2023.