A Salter-Harris (SH) type IV fracture is a fracture through the epiphysis, physis (growth plate), and metaphysis — the most clinically significant physeal fracture pattern due to its intra-articular involvement and the highest rate of growth disturbance among all SH types (up to 64% at the distal femur). [1-2] Almost all displaced SH IV fractures require open reduction and internal fixation (ORIF) to restore articular congruity and minimize physeal arrest. [3-4]
The following figure illustrates the Salter-Harris classification system:
1. History
- Mechanism of injury: falls, sports, motor vehicle collisions, direct trauma to an extremity [5]
- Characterize the force: axial loading, rotational, hyperextension, or valgus/varus stress
- Timing: when did the injury occur? Any delay >72 hours increases risk of complications [5]
- Ability to bear weight or use the extremity after injury
- Prior injuries to the same extremity or growth plate
- Skeletal maturity: age, pubertal stage (Tanner staging), and remaining growth potential are critical
- Associated symptoms: numbness, tingling, or color change distally (neurovascular compromise)
2. Alarm Features
- Neurovascular compromise: absent distal pulses, pallor, paresthesias, paralysis — particularly with distal femoral and proximal tibial fractures where the popliteal artery is at risk [1]
- Open fracture with exposed bone or wound communicating with fracture site
- Compartment syndrome: pain out of proportion, pain with passive stretch, tense compartment
- Significant displacement or angulation on initial radiographs
- Physeal gapping >3 mm after reduction (suggests entrapped periosteum, increasing risk of premature physeal closure) [3]
- Any SH IV fracture in a young child with significant remaining growth — higher risk of long-term deformity
3. Medications
- Acute pain management: weight-based ibuprofen (10 mg/kg q6h) and acetaminophen (15 mg/kg q4-6h) for mild-moderate pain; opioids (e.g., morphine 0.1 mg/kg IV) for severe pain or procedural sedation
- Procedural sedation agents for reduction if attempted (ketamine, propofol per institutional protocol)
- Perioperative antibiotics if open fracture (first-generation cephalosporin ± aminoglycoside depending on Gustilo grade)
- Avoid: repeated NSAID use in the immediate perioperative period is debated; no strong contraindication in pediatric fracture healing, but some surgeons prefer to limit
- DVT prophylaxis is generally not indicated in pediatric patients unless adolescent with significant immobility and additional risk factors
4. Diet
- Ensure adequate calcium and vitamin D intake during healing
- Adequate caloric and protein intake to support bone healing
- Hydration for perioperative management
- No specific acute dietary restrictions unless NPO for surgical planning
5. Review of Systems
- MSK: pain, swelling, deformity, inability to bear weight, range of motion limitation
- Neurologic: numbness, tingling, weakness distal to injury
- Vascular: color changes, temperature changes, capillary refill
- Constitutional: fever (concern for infection if open fracture or delayed presentation)
- Other injuries: head injury, abdominal pain, chest pain if high-energy mechanism (polytrauma screen)
- In young children: consider non-accidental trauma if mechanism is inconsistent with injury pattern
6. Collateral History and Family History
- Witnessed mechanism vs. unwitnessed (important for non-accidental trauma screening in young children)
- Caregiver account consistency with injury pattern
- Family history of bone disorders: osteogenesis imperfecta, metabolic bone disease
- History of prior fractures — multiple fractures in a young child should raise concern
- Social context: sports participation level, child protective concerns if warranted
7. Risk Factors
- Age: peak incidence in adolescents; the physis is mechanically weaker than surrounding ligaments in skeletally immature patients [1]
- Sports participation (football, basketball, gymnastics, skateboarding)
- High-energy mechanisms (MVCs, falls from height)
- Most common sites: distal radius, phalanges, distal humerus (lateral condyle), distal tibia [5]
- The distal humerus is a particularly common location for SH IV fractures (lateral condyle fractures) [5]
- Male predominance (~2:1) [5]
8. Differential Diagnosis
- Other Salter-Harris types (I, II, III, V) — classification depends on fracture line trajectory through physis, epiphysis, and metaphysis [2]
- Tillaux fracture (SH III variant of the anterolateral distal tibial epiphysis in adolescents)
- Triplane fracture (complex SH IV variant of the distal tibia occurring during transitional physeal closure) [6-7]
- Ligamentous injury — in older adolescents with closing physes, adult-pattern sprains become more likely [1]
- Avulsion fracture of the tibial spine or tibial tubercle
- Pathologic fracture through a bone lesion (unicameral bone cyst, aneurysmal bone cyst)
- Non-accidental trauma in young children with inconsistent history
- Osteochondral fracture — intra-articular fragment without physeal involvement
9. Past Medical History
- Prior fractures or physeal injuries to the same or contralateral extremity
- Known bone disorders (osteogenesis imperfecta, rickets, renal osteodystrophy)
- Previous growth disturbance or leg length discrepancy
- Chronic steroid use or other medications affecting bone health
- Surgical history involving the affected extremity
- Baseline functional status and activity level
10. Physical Exam
- Inspection: swelling, deformity, ecchymosis, open wounds, skin tenting
- Palpation: point tenderness directly over the physis (distinguishes physeal fracture from ligament sprain); tenderness over the metaphysis and epiphysis [7]
- Neurovascular exam: distal pulses (dorsalis pedis, posterior tibial for lower extremity; radial, ulnar for upper extremity), capillary refill, sensation, motor function — mandatory and must be documented [1]
- Range of motion: typically limited by pain; do not force
- Compartment assessment: palpate compartments for tenseness; pain with passive stretch
- Comparison to contralateral side: assess for asymmetry, leg length discrepancy
- Skin integrity: rule out open fracture (even small puncture wounds)
11. Lab Studies
- Routine labs are generally not required for isolated SH IV fractures
- Pre-operative labs if surgery planned: CBC, BMP, type and screen per institutional protocol
- If concern for non-accidental trauma: skeletal survey, vitamin D level, calcium, phosphorus, alkaline phosphatase, PTH
- If open fracture: CBC, blood cultures if febrile
- Consider coagulation studies if bleeding disorder suspected
12. Imaging
- First-line: Plain radiographs (AP, lateral, and oblique views) of the affected joint — oblique views are critical for SH IV fractures as the metaphyseal extension may only be visible on oblique projections [6]
- CT scan: Recommended for displaced SH III and IV fractures, particularly at the distal tibia, to accurately assess articular step-off, fragment displacement, and surgical planning. CT changed fracture classification in 30% of cases and altered treatment decisions significantly [8-9]
- MRI: Most sensitive for detecting physeal bar formation during follow-up; useful acutely if radiographs are equivocal or to assess cartilaginous injury not visible on plain films [1][10]
- When imaging is unnecessary: CT is generally not needed for SH I or II fractures [11]
- Comparison views of the contralateral extremity may be helpful in younger children with largely cartilaginous epiphyses
13. Special Tests
- Salter-Harris classification (mnemonic: SALTR — Type I: Slip/Separation; Type II: Above the physis; Type III: Lower/beLow; Type IV: Through/Through all; Type V: Rammed/cRush) [2]
- Ottawa Ankle Rules: used by >50% of practitioners for ankle injuries in children, though sensitivity for physeal fractures is debated [11]
- Scanograms/leg length films: for follow-up assessment of limb length discrepancy
- Tomography in two planes: historically used to detect physeal bar formation; now largely replaced by MRI [6]
- Point-of-care ultrasound may identify effusion and cortical irregularity but is not standard for SH IV diagnosis
14. ECG
- Not routinely indicated for isolated SH IV fractures
- Consider if procedural sedation is planned (per institutional sedation protocols)
- Obtain if high-energy polytrauma mechanism with concern for cardiac contusion
15. Assessment
A Salter-Harris type IV fracture is a high-risk physeal injury that traverses the articular surface, epiphysis, physis, and metaphysis. [2] It carries the highest rate of growth disturbance among SH fracture types — up to 64% at the distal femur and 20% at the distal tibia. [1][12] Displaced fractures have a 4-fold increased risk of growth arrest compared with nondisplaced fractures. [1] Key complications include:
- Premature physeal closure (partial or complete) → angular deformity and/or limb length discrepancy [6][13]
- Posttraumatic arthritis from articular incongruity
- Physeal bar formation — reported in 30% of SH III/IV medial malleolus fractures, with 47% of those requiring secondary surgery [14]
- Neurovascular injury — particularly with distal femoral and proximal tibial locations [1]
Greater fracture displacement and greater coronal plane physeal involvement are significant predictors of both surgical management and physeal bar formation. [14]
16. Treatment Plan
- Initial stabilization: Splint in position of comfort, ice, elevation, analgesia. Strict non-weight-bearing
- Nondisplaced SH IV fractures: May be treated with casting and close follow-up, though this is uncommon as most SH IV fractures have some displacement [3]
- Displaced SH IV fractures: Open reduction and internal fixation (ORIF) is the standard of care to restore anatomic alignment of the physis and articular surface [3-4][15]
- Smooth K-wires or cannulated screws are typically used; hardware should avoid crossing the physis when possible, or cross it perpendicularly with smooth pins
- Anatomic reduction of the physis is critical — residual displacement is the most significant predictor of premature physeal closure [12]
- Avoid multiple reduction attempts (>2 attempts associated with 8.5× increased odds of premature physeal closure) [12]
- Post-operative: Long leg or short leg cast (depending on location), strict non-weight-bearing for 4–6 weeks
- Follow-up monitoring: Serial radiographs every 3–4 months for at least 6–12 months (and ideally until skeletal maturity in young children) to detect growth arrest, angular deformity, or limb length discrepancy [1][6]
- MRI if growth disturbance is suspected to detect physeal bar formation early [1][10]
- Secondary procedures if physeal bar develops: bar resection (if <50% of physis involved and >2 years growth remaining), contralateral epiphysiodesis, corrective osteotomy [6][14]
17. Disposition
- Admission criteria: Displaced SH IV fractures requiring ORIF; neurovascular compromise; open fractures; compartment syndrome; polytrauma
- Observation: Borderline displacement where surgical decision is pending orthopedic evaluation
- Discharge criteria: Truly nondisplaced SH IV fracture (rare) with adequate splinting, reliable follow-up within 5–7 days with orthopedics, and intact neurovascular exam
- Specialist consultation: Orthopedic surgery consultation is mandatory for all SH IV fractures — these are operative injuries in the vast majority of cases [3-4]
- Vascular surgery consultation if concern for vascular injury (particularly distal femur/proximal tibia)
18. Follow Up / Return Precautions
- Follow-up timing: Orthopedic follow-up within 5–7 days if discharged from ED; post-operative follow-up at 1–2 weeks for wound check, then serial radiographs every 3–4 months for at least 12 months [1][6]
- Return precautions (counsel family):
- Increasing pain, swelling, or tightness in the cast/splint
- Numbness, tingling, color change, or coolness of fingers/toes
- Fever or drainage from surgical site
- Inability to move fingers/toes
- Long-term counseling: Families must understand the risk of growth disturbance (angular deformity, limb length discrepancy) even with optimal treatment, and the need for prolonged follow-up potentially until skeletal maturity [1][13]
- Expected recovery: Fracture healing typically occurs in 6–8 weeks; return to full activity is guided by orthopedics and depends on location, severity, and evidence of healing. Growth complications may not manifest for months to years after injury
References
1. Acute Knee Injuries in Children and Adolescents: A Review. — MacDonald J, Rodenberg R, Sweeney E. JAMA Pediatrics. 2021.
2. Growth Plate Injuries: Salter-Harris Classification. — Brown JH, DeLuca SA. American Family Physician. 1992.
3. 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.
4. Growth Plate Fractures of the Distal Femur. — Wall EJ, May MM. Journal of Pediatric Orthopedics. 2012.
5. Clinical Characteristics of 1124 Children With Epiphyseal Fractures. — Deng H, Zhao Z, Xiong Z, et al. BMC Musculoskeletal Disorders. 2023.
6. Salter-Harris Type-Iv Injuries of the Distal Tibial Epiphyseal Growth Plate, With Emphasis on Those Involving the Medial Malleolus. — Cass JR, Peterson HA. The Journal of Bone and Joint Surgery. American Volume. 1983.
7. Pediatric Physeal Ankle Fracture. — Wuerz TH, Gurd DP. The Journal of the American Academy of Orthopaedic Surgeons. 2013.
8. The Role of CT in Diagnosis and Treatment of Distal Tibial Fractures With Intra-Articular Involvement in Children. — Nenopoulos A, Beslikas T, Gigis I, et al. Injury. 2015.
9. Growth Plate Fractures of the Distal Tibia: Is CT Imaging Necessary?. — Lemburg SP, Lilienthal E, Heyer CM. Archives of Orthopaedic and Trauma Surgery. 2010.
10. Imaging of Pediatric Growth Plate Disturbances. — Nguyen JC, Markhardt BK, Merrow AC, Dwek JR. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2017.
11. Is Cross-Sectional Imaging Necessary for Fractures of the Distal Lower Leg in Children and Adolescents: Results of a Nationwide Survey. — Strohm JA, Schubert I, Schneidmüller D, Strohm PC. European Journal of Trauma and Emergency Surgery : Official Publication of the European Trauma Society. 2024.
12. Physeal Fractures of Distal Tibia: A Systematic Review and Meta-Analysis. — Jalkanen J, Sinikumpu JJ, Puhakka J, et al. Journal of Pediatric Orthopedics. 2021.
13. Interventions for Treating Ankle Fractures in Children. — Yeung DE, Jia X, Miller CA, Barker SL. The Cochrane Database of Systematic Reviews. 2016.
14. 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.
15. 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.