A Salter-Harris (SH) type III fracture is an intra-articular physeal fracture in which the fracture line extends through the growth plate (physis) and into the epiphysis, exiting through the articular surface, without involving the metaphysis. [1-2] This is a relatively uncommon but clinically significant injury in skeletally immature patients, accounting for only ~2% of all physeal fractures in large series. [3] Because it involves the joint surface and the growth plate, it carries a high risk of both growth disturbance and posttraumatic arthritis if not anatomically reduced. [4-6]
The following figure demonstrates the SH classification system, including a Type III fracture of the distal femur:
1. History
- Mechanism of injury: falls, sports (especially contact/pivoting sports), motor vehicle accidents, or twisting injuries [2-3]
- At the ankle (most common SH III location), the classic mechanism is external rotation of the foot on the leg — this produces the juvenile Tillaux fracture pattern [2][8]
- At the knee, a valgus force (medial femoral condyle SH III) or hyperextension mechanism is typical [7][9]
- Symptom characterization: acute onset of pain, swelling, inability to bear weight, and deformity
- Timing: immediate pain and functional limitation after trauma
- Important negatives: absence of paresthesias, pallor, or pulselessness (to rule out neurovascular compromise); no history of prior fracture or bone disease
2. Alarm Features
- Neurovascular compromise: diminished or absent distal pulses, pallor, paresthesias, paralysis — particularly with distal femoral and proximal tibial fractures where the popliteal artery and peroneal nerve are at risk [7]
- Compartment syndrome: pain out of proportion, pain with passive stretch, tense swelling
- Open fracture: skin breach overlying the fracture site
- Significant displacement on radiographs: displaced SH III fractures have a 4-fold increased risk of growth arrest compared to nondisplaced fractures [7]
- Physeal gapping >3 mm after reduction raises suspicion for entrapped periosteum, increasing risk of premature physeal closure [4]
3. Medications
- Acute pain management: weight-based ibuprofen (10 mg/kg PO q6h) and/or acetaminophen (15 mg/kg PO q4-6h); intranasal fentanyl (1.5–2 mcg/kg) for severe pain in the ED
- Procedural sedation agents (if closed reduction attempted): ketamine, propofol, or midazolam/fentanyl per institutional protocol [10]
- Avoid: repeated manipulation attempts — multiple reduction attempts should be avoided as they increase physeal damage [4]
- NSAIDs are generally safe short-term for pediatric fracture pain; concerns about impaired bone healing are not well-supported in the pediatric literature
4. Diet
- No specific acute dietary restrictions unless procedural sedation is planned (NPO guidelines apply)
- Adequate calcium and vitamin D intake during healing
- Ensure adequate caloric intake for growing children during immobilization
5. Review of Systems
- MSK: pain localization (over the physis vs. joint line vs. metaphysis), range of motion, ability to bear weight
- Neurologic: numbness, tingling, weakness distal to injury
- Vascular: color changes, temperature changes in the extremity
- Constitutional: fever (consider infection if atraumatic or subacute presentation)
- Skin: open wounds, abrasions overlying the fracture
6. Collateral History and Family History
- Witnessed mechanism of injury (especially in younger children or non-verbal patients)
- In non-accidental trauma (NAT) considerations: inconsistency between history and injury pattern, delay in presentation, prior fractures
- Skeletal maturity status: age, pubertal stage, prior growth plate injuries
- Family history of bone disorders (osteogenesis imperfecta, metabolic bone disease) if the mechanism seems trivial
7. Risk Factors
- Age: peak incidence in adolescents; physeal fractures peak during the adolescent growth spurt [3]
- Sex: male predominance (~2:1) [3]
- Sports participation: contact sports, basketball, football, gymnastics [3]
- Transitional period (ages 12–16): the distal tibial physis closes asymmetrically over ~18 months, creating vulnerability to Tillaux (SH III) and triplane fractures [2][11]
- Falls are the most common cause overall (64% of physeal fractures) [3]
8. Differential Diagnosis
- Salter-Harris Type IV fracture: fracture crosses the physis involving both epiphysis and metaphysis — distinguished by metaphyseal fragment on imaging [1]
- Ligamentous sprain: in skeletally immature patients, the physis is weaker than ligaments, so what appears to be a "sprain" may actually be a physeal fracture. A high index of suspicion is critical [7]
- Osteochondral fracture/osteochondritis dissecans: intra-articular fragment without physeal involvement
- Juvenile Tillaux fracture: a specific SH III pattern of the anterolateral distal tibial epiphysis — must be distinguished from triplane fractures [2][12]
- Triplane fracture: a complex transitional fracture with components in 3 planes (sagittal through epiphysis, axial through physis, coronal through metaphysis) — may appear as SH III on AP view but has a metaphyseal component on lateral [12]
- Non-accidental trauma: always consider in young children with inconsistent history
9. Past Medical History
- Prior physeal injuries or fractures (increases risk of growth disturbance)
- Metabolic bone disease, renal osteodystrophy, rickets
- Chronic steroid use
- Previous surgical hardware near the physis
- Underlying connective tissue disorders
10. Physical Exam
- Vital signs: assess for tachycardia/hypotension (hemorrhage from long-bone fractures)
- Inspection: swelling, ecchymosis, deformity, skin integrity (open vs. closed)
- Palpation: point tenderness directly over the physis is the hallmark finding and helps distinguish physeal fractures from ligament injuries [11]
- Neurovascular exam: mandatory — assess distal pulses (dorsalis pedis, posterior tibial for ankle; popliteal for knee), capillary refill, sensation, and motor function [7]
- Joint effusion: a lipohemarthrosis (fat globules in aspirated joint fluid) confirms intra-articular fracture
- Range of motion: typically markedly limited by pain
- Compartment assessment: palpate compartments for tenseness; pain with passive stretch
11. Lab Studies
- Labs are generally not required for isolated SH III fractures
- If surgical intervention is planned: CBC, BMP, type and screen per institutional protocol
- If concern for NAT: skeletal survey, vitamin D, calcium, phosphorus, alkaline phosphatase, PTH
- If open fracture: CBC, blood cultures if febrile
12. Imaging
- First-line: AP, lateral, and oblique plain radiographs of the affected joint [11][13]
- SH III fractures show a fracture line through the epiphysis extending to the articular surface, with the physis involved but the metaphysis intact
- Plain films may significantly underestimate displacement — one study found mean displacement of 0.42 mm on plain films vs. 2.70 mm on CT/MRI (p = 0.005) [13]
- CT scan: recommended for all displaced SH III fractures, especially at the ankle (Tillaux, triplane) and distal femur, to accurately assess articular step-off and guide surgical planning [11-13]
- MRI: most sensitive for detecting occult physeal injury, physeal bar formation, and associated soft tissue injuries; recommended when plain films are negative but clinical suspicion is high [7][14]
- When imaging may be unnecessary: if the patient has a clearly nondisplaced SH III on adequate orthogonal views and is near skeletal maturity with minimal growth remaining
13. Special Tests
- Salter-Harris Classification (mnemonic: SALTR — Straight across/Slip, Above, Lower/beLow, Through, Rammed/cRush):
- Type I: through the physis only
- Type II: through physis + metaphysis (most common, ~87%) [3]
- Type III: through physis + epiphysis (intra-articular)
- Type IV: through metaphysis + physis + epiphysis
- Type V: crush injury to the physis [1]
- Fat pad sign / lipohemarthrosis on cross-table lateral radiograph confirms intra-articular fracture [9]
- Stress views under anesthesia may be needed for occult SH III fractures of the medial femoral condyle [9]
- Point-of-care ultrasound: can identify joint effusion and cortical irregularity at the bedside
14. ECG
- Not routinely indicated for isolated SH III fractures
- Consider if procedural sedation is planned (per institutional sedation protocols)
- Obtain if polytrauma or hemodynamic instability
15. Assessment
A Salter-Harris type III fracture is an intra-articular physeal fracture that demands anatomic reduction to restore joint congruity and minimize growth plate damage. Key clinical considerations:
- Growth arrest occurs in approximately 49% of SH III fractures of the distal femur; rates vary by location but are substantial across all sites [7]
- Displaced fractures carry a 4-fold increased risk of growth disturbance compared to nondisplaced fractures [7]
- The juvenile Tillaux fracture (SH III of the anterolateral distal tibial epiphysis) is the classic SH III pattern at the ankle, occurring during the transitional period of physeal closure [2][15]
- Complications include: premature physeal closure, angular deformity (valgus/varus), limb-length discrepancy, posttraumatic arthritis, and joint stiffness [6-7]
- Poor outcomes have been reported in 29–32% of SH III and IV fractures of the distal femur [5]
16. Treatment Plan
Initial stabilization (ED)
- Immobilize in a well-padded posterior splint in the position of comfort
- Ice, elevation, strict non-weight-bearing
- Adequate analgesia
Nondisplaced SH III fractures
- May be treated nonoperatively with cast immobilization and strict non-weight-bearing [4][16]
- Close orthopedic follow-up within 5–7 days with repeat imaging
Displaced SH III fractures (≥2 mm articular step-off)
- Open reduction and internal fixation (ORIF) is the standard of care to restore articular congruity and minimize physeal damage [4-6]
- Fixation is typically with smooth K-wires or cannulated screws placed parallel to the physis (avoiding crossing the growth plate when possible)
- At the ankle (Tillaux fractures), closed reduction may be attempted first; if articular gap remains ≥2 mm, ORIF is indicated [15]
- Avoid multiple closed reduction attempts — these increase the risk of further physeal injury [4]
Postoperative/post-reduction
- Non-weight-bearing in a short or long leg cast (depending on location) for 4–6 weeks
- Serial radiographs to monitor alignment and healing
17. Disposition
Admission criteria
- Displaced SH III fractures requiring operative fixation
- Neurovascular compromise or compartment syndrome
- Open fractures
- Polytrauma
- Concern for non-accidental trauma
Discharge criteria
- Nondisplaced SH III fracture with adequate splinting, pain control, and reliable follow-up
- Intact neurovascular exam
- Appropriate caregiver education
Orthopedic consultation triggers (from the ED)
- Any displaced SH III fracture — emergent orthopedic consultation is warranted [4-5]
- Neurovascular compromise
- Open fracture
- Failed closed reduction
- Uncertainty about fracture classification (consider CT before disposition) [12-13]
18. Follow Up / Return Precautions
- Orthopedic follow-up within 5–7 days for all SH III fractures, with repeat radiographs
- Long-term monitoring for 6–12 months minimum to detect growth arrest and angular deformity [7]
- MRI is the most sensitive tool for early detection of physeal bar formation if growth disturbance is suspected [7]
- Physeal bars developed in 30% of SH III/IV medial malleolus fractures at a mean of 8.4 months, with 47% of those requiring secondary surgery [17]
Return precautions (counsel caregivers)
- Return immediately for increasing pain, numbness/tingling, color change (blue/white) of fingers or toes, inability to move digits, worsening swelling not relieved by elevation, fever, or foul odor from the cast
- No weight-bearing until cleared by orthopedics
- Expected recovery: fracture healing typically 4–6 weeks; return to full activity 2–4 months depending on location and severity; growth monitoring continues for at least 1 year
References
1. Growth Plate Injuries: Salter-Harris Classification. — Brown JH, DeLuca SA. American Family Physician. 1992.
2. Interventions for Treating Ankle Fractures in Children. — Yeung DE, Jia X, Miller CA, Barker SL. The Cochrane Database of Systematic Reviews. 2016.
3. Clinical Characteristics of 1124 Children With Epiphyseal Fractures. — Deng H, Zhao Z, Xiong Z, et al. BMC Musculoskeletal Disorders. 2023.
4. Physeal Fractures of the Distal Tibia and Fibula (Salter-Harris Type I, II, III, and IV Fractures). — Podeszwa DA, Mubarak SJ. Journal of Pediatric Orthopedics. 2012.
5. Growth Plate Fractures of the Distal Femur. — Wall EJ, May MM. Journal of Pediatric Orthopedics. 2012.
6. Distal Tibial Physeal Fractures in Children That May Require Open Reduction. — Kling TF, Bright RW, Hensinger RN. The Journal of Bone and Joint Surgery. American Volume. 1984.
7. Acute Knee Injuries in Children and Adolescents: A Review. — MacDonald J, Rodenberg R, Sweeney E. JAMA Pediatrics. 2021.
8. Isolated Adult Tillaux Fracture: A Report of Two Cases. — Oak NR, Sabb BJ, Kadakia AR, Irwin TA. The Journal of Foot and Ankle Surgery : Official Publication of the American College of Foot and Ankle Surgeons. 2014.
9. Salter-Harris Type-Iii Fracture of the Medial Femoral Condyle Occurring in the Adolescent Athlete. — Torg JS, Pavlov H, Morris VB. The Journal of Bone and Joint Surgery. American Volume. 1981.
10. Pediatric Fracture Reduction in the Emergency Department. — Bin K, Rony L, Henric N, Moukoko D. Orthopaedics & Traumatology, Surgery & Research : OTSR. 2022.
11. Pediatric Physeal Ankle Fracture. — Wuerz TH, Gurd DP. The Journal of the American Academy of Orthopaedic Surgeons. 2013.
12. Review of Distal Tibial Epiphyseal Transitional Fractures. — Rosenbaum AJ, DiPreta JA, Uhl RL. Orthopedics. 2012.
13. Salter-Harris Type III Fractures of the Distal Femur: Plain Radiographs Can Be Deceptive. — Lippert WC, Owens RF, Wall EJ. Journal of Pediatric Orthopedics. 2010.
14. Imaging of Epiphyseal Injuries. — Rogers LF, Poznanski AK. Radiology. 1994.
15. Recognition and Management of Tillaux Fractures in Adolescents. — Koury SI, Stone CK, Harrell G, La Charité DD. Pediatric Emergency Care. 1999.
16. Diagnosis and Management of McFarland Fractures. — Birt M, Vopat B, Schroeppel P, et al. The American Journal of Emergency Medicine. 2018.
17. Risk Factors and Surgical Sequelae of Physeal Arrest in Pediatric Salter-Harris III and IV Medial Malleolus Fractures. — Roth OS, Gupta A, Adebayo T, Tretiakov M. Journal of Pediatric Orthopedics. 2025.