A Salter-Harris (SH) type V fracture is a crush or compression injury of the growth plate (physis) without fracture through the epiphysis or metaphysis. [1-2] It is the rarest of all Salter-Harris types — representing only 1 out of 1,147 epiphyseal fractures in one large series — and carries the [3] worst prognosis for growth disturbance among all SH types, with only poor or fair outcomes reported in distal femoral series. [4] The diagnosis is notoriously difficult because initial radiographs are typically normal, and the injury is often recognized only retrospectively when premature physeal closure becomes apparent. [1][5]
The following figure illustrates the Salter-Harris classification system for physeal fractures:
1. History
- Mechanism: High-energy axial loading or compression force transmitted through the joint (e.g., fall from height landing on feet, high-velocity motor vehicle accident, crush injury) [1][4]
- Key HPI questions:
- Exact mechanism — was there an axial/compressive force?
- Timing of injury and onset of symptoms
- Ability to bear weight immediately after injury
- Prior injuries to the same extremity
- Skeletal maturity status — age, pubertal stage, growth velocity
- Symptom characterization: Pain localized over the physis, swelling, inability to bear weight despite "normal" radiographs
- Important negatives: No visible fracture line on X-ray, no displacement — this is the hallmark diagnostic challenge [1][6]
2. Alarm Features
- Pain and swelling localized directly over the physis with a high-energy mechanism and negative radiographs — this combination should raise suspicion [6]
- Inability to ambulate or bear weight despite normal-appearing X-rays [6]
- Neurovascular compromise (especially popliteal artery/peroneal nerve in knee injuries) [6]
- Progressive angular deformity or limb length discrepancy developing weeks to months after injury — indicates growth arrest [2][6]
- Open fracture or high-velocity mechanism (motor vehicle accident) — associated with universally poor outcomes in SH V injuries [4]
3. Medications
- Acute pain management: Weight-appropriate NSAIDs (ibuprofen 10 mg/kg q6-8h) and/or acetaminophen (15 mg/kg q4-6h); opioids for severe pain in the acute setting
- Avoid: Repeated corticosteroid injections near the physis (theoretical concern for further physeal damage)
- No specific medications alter the natural history of physeal crush injury
- Ensure adequate calcium and vitamin D intake to support bone health during healing
4. Diet
- Adequate calcium (1,000–1,300 mg/day for children/adolescents) and vitamin D (600 IU/day)
- Protein-rich diet to support bone healing
- Hydration for overall recovery
- No specific dietary triggers or restrictions
5. Review of Systems
- Musculoskeletal: Pain with weight-bearing, joint stiffness, swelling, deformity
- Neurologic: Numbness, tingling, or weakness distal to injury (peroneal nerve distribution if knee/ankle involved) [6]
- Vascular: Coolness, pallor, diminished pulses distally (popliteal artery injury) [6]
- Constitutional: Fever (consider infection if delayed presentation)
- Growth concerns: Parental observation of limb asymmetry, gait changes, or angular deformity over subsequent months
6. Collateral History and Family History
- Witnessed mechanism of injury — critical for understanding energy of impact
- Prior fractures or growth plate injuries in the same or contralateral limb
- Family history of skeletal dysplasias, metabolic bone disease, or connective tissue disorders
- Social context: Non-accidental trauma must be considered in young children with physeal injuries, especially if the mechanism is inconsistent with the injury pattern
- Sports participation history and level of activity
7. Risk Factors
- Age: Skeletally immature children and adolescents with open physes; the physis is the weakest link in the musculoskeletal chain [6]
- High-energy trauma: Motor vehicle accidents, falls from height, crush injuries [4]
- Sports: Contact sports, gymnastics, football, basketball [3]
- Sex: Males > females (~2:1 ratio for physeal fractures overall) [3]
- Anatomic location: Distal femur and proximal tibia physes are most consequential due to their contribution to longitudinal growth (distal femur contributes 70% of femur length and 40% of total limb length) [6]
- Peak age for clinically significant growth disturbance: ~10.2 years in males, ~9.1 years in females [7]
8. Differential Diagnosis
- Salter-Harris type I fracture (most important mimic) — physeal separation without compression; also may have normal radiographs; distinguished by mechanism (shearing vs. axial compression) [1][6]
- Bone contusion/occult fracture — MRI shows marrow edema without physeal disruption [8]
- Ligamentous sprain — in older adolescents near skeletal maturity; ligaments fail before physis in adults [6]
- Osteochondral fracture — intra-articular injury with possible loose body
- Stress fracture — repetitive microtrauma rather than acute compression
- Non-accidental trauma — must be considered in young children with unexplained physeal injury
- Infection (osteomyelitis/septic arthritis) — if delayed presentation with fever and swelling
- Pathologic fracture — underlying bone lesion weakening the physis
9. Past Medical History
- Previous fractures, especially physeal injuries
- Prior growth plate arrest or limb length discrepancy
- Metabolic bone disease (rickets, osteogenesis imperfecta)
- Chronic steroid use
- History of radiation therapy near the physis
- Surgical history involving the affected extremity
10. Physical Exam
- Vital signs: Generally normal unless polytrauma
- Inspection: Swelling over the physis; may appear deceptively benign; no visible deformity acutely
- Palpation: Point tenderness directly over the growth plate — the single most important exam finding [9]
- Range of motion: Pain with active and passive motion of the adjacent joint; inability to bear weight
- Neurovascular exam: Mandatory — assess distal pulses, capillary refill, sensation (especially peroneal nerve), and motor function [6]
- Comparison with contralateral limb: Assess for subtle asymmetry
- Focused maneuvers: Stress testing is generally avoided acutely to prevent further physeal damage
11. Lab Studies
- Routine labs are generally not indicated for isolated physeal fractures
- If concern for infection: CBC, ESR, CRP
- If concern for metabolic bone disease: Calcium, phosphorus, alkaline phosphatase, 25-OH vitamin D, PTH
- If non-accidental trauma suspected: Skeletal survey, appropriate labs per institutional protocol
12. Imaging
- First-line: Plain radiographs (AP and lateral) — typically normal in SH type V injuries acutely; this is the defining diagnostic challenge [1][6]
- May show subtle physeal narrowing compared to the contralateral side (comparison views are essential)
- Late findings: Premature physeal closure, physeal bar formation, angular deformity
- MRI — the most sensitive modality for:
- Detecting occult physeal injury when radiographs are negative [8][10]
- Identifying bone marrow edema adjacent to the physis
- Detecting early physeal bar (bone bridge) formation [6][11]
- MRI changed SH classification or staging in 2/9 patients and detected radiographically occult fractures in 5/14 patients in one series [10]
- CT — useful for surgical planning if intra-articular extension is suspected [9]
- Serial radiographs — comparison views at follow-up to detect developing growth arrest or angular deformity [6]
- When imaging is unnecessary: If the child is non-tender over the physis, bearing weight normally, and has a low-energy mechanism
13. Special Tests
- Comparison radiographs of the contralateral limb — to detect subtle physeal narrowing
- Scanogram/orthoradiograph — for leg length discrepancy measurement during follow-up [4]
- 3D MRI reconstruction — can map the configuration of physeal bars and bone bridges to guide surgical planning [11]
- Diffusion tensor imaging (DTI) tractography — emerging technique to quantify growth plate activity [12]
14. ECG
- Not routinely indicated for isolated physeal fractures
- Consider if polytrauma or if procedural sedation is planned for reduction/imaging
15. Assessment
Clinical summary: SH type V is a compression/crush injury of the physis that is almost always a retrospective diagnosis — recognized only when premature physeal closure and growth disturbance become apparent weeks to months after injury. [1][4] It is exceedingly rare (< 1% of all physeal fractures) and carries the [3] highest risk of growth arrest among all SH types. The prognosis is uniformly poor, with outcomes including limb length discrepancy, angular deformity (valgus, varus, procurvatum, recurvatum), joint stiffness, and secondary osteoarthritis. [2][4][6]
Severity stratification
- Younger patients with more growth remaining → higher risk of clinically significant deformity
- Location matters: distal femur and proximal tibia injuries are most consequential [6-7]
- All clinically significant growth disturbances occur within 2 years of initial injury [7]
16. Treatment Plan
Initial stabilization
- Immobilization (splint or cast) and strict non-weight-bearing status
- Ice, elevation, and analgesia
- Early orthopedic consultation is recommended [13]
Acute management
- No reduction is possible (there is no displacement to correct — the injury is a compression of the physis)
- Casting and non-weight-bearing for 3–6 weeks depending on location and clinical response
- Avoid repeated manipulation — repetitive closed reduction attempts increase the risk of physeal arrest [13-14]
Long-term management
- Serial clinical and radiographic follow-up for at least 6–12 months, and ideally 2 years to detect growth disturbance [6-7]
- MRI if growth arrest or physeal bar formation is suspected [6][11]
- If a physeal bar forms and occupies <50% of the physis with significant growth remaining → physeal bar resection with interposition material (fat, polymeric silicone) may be considered [15]
- If bar occupies >50% or near skeletal maturity → epiphysiodesis of the contralateral physis or corrective osteotomy for angular deformity [2]
- Limb lengthening procedures for significant leg length discrepancy
17. Disposition
- Admission criteria: Polytrauma, neurovascular compromise, need for surgical intervention, concern for non-accidental trauma, inability to ensure non-weight-bearing at home
- Discharge criteria: Isolated injury, adequate immobilization, reliable family, confirmed orthopedic follow-up within 1 week
- Observation indications: Uncertain diagnosis with high clinical suspicion and pending MRI
- Specialist consultation triggers:
- All suspected SH type V injuries warrant orthopedic consultation [13]
- Neurovascular compromise → emergent orthopedic/vascular surgery consultation
- Developing growth disturbance → pediatric orthopedic surgery referral
18. Follow Up / Return Precautions
- Follow-up timing: Orthopedic follow-up within 5–7 days; serial radiographs at 4–6 weeks, 3 months, 6 months, 12 months, and 24 months [6-7]
- Symptoms requiring immediate reassessment:
- Increasing pain, swelling, or inability to move digits
- Signs of compartment syndrome (pain out of proportion, pain with passive stretch, paresthesias)
- Neurovascular changes (numbness, pallor, pulselessness)
- Cast-related concerns (tightness, skin breakdown)
- Patient/family counseling points:
- This injury may not be visible on initial X-rays and is often diagnosed over time
- The growth plate has been damaged, and there is a high risk of growth disturbance including limb shortening and angular deformity
- Long-term follow-up (minimum 1–2 years) is essential even if the child feels better
- Activity restriction until cleared by orthopedics
- Expected recovery course: Unlike other SH fractures, the prognosis for SH type V is guarded to poor — the majority of patients develop some degree of growth disturbance, and many require subsequent surgical intervention [4][15]
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. Fractures Involving the Distal Epiphyseal Plate of the Femur. — Czitrom AA, Salter RB, Willis RB. International Orthopaedics. 1981.
5. 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.
6. Acute Knee Injuries in Children and Adolescents: A Review. — MacDonald J, Rodenberg R, Sweeney E. JAMA Pediatrics. 2021.
7. Epidemiology of Physeal Fractures and Clinically Significant Growth Disturbances Affecting the Distal Tibia, Proximal Tibia, and Distal Femur: A Retrospective Cohort Study. — Yamamura MK, Carry PM, Gibly RF, et al. The Journal of the American Academy of Orthopaedic Surgeons. 2023.
8. MRI for Occult Physeal Fracture Detection in Children and Adolescents. — Gufler H, Schulze CG, Wagner S, Baumbach L. Acta Radiologica. 2013.
9. Pediatric Physeal Ankle Fracture. — Wuerz TH, Gurd DP. The Journal of the American Academy of Orthopaedic Surgeons. 2013.
10. MRI of Pediatric Growth Plate Injury: Correlation With Plain Film Radiographs and Clinical Outcome. — Carey J, Spence L, Blickman H, Eustace S. Skeletal Radiology. 1998.
11. Premature Partial Closure and Other Deformities of the Growth Plate: MR Imaging and Three-Dimensional Modeling. — Craig JG, Cramer KE, Cody DD, et al. Radiology. 1999.
12. Evaluation of Physeal Abnormalities of the Knee With MRI. — Jaramillo D, Perdomo-Luna C, Kvist O. Skeletal Radiology. 2026.
13. The Adolescent Athlete and the Team Physician: A Consensus Statement. 2025 Update. — Putukian M, Leclere LE, Herring SA, et al. Medicine and Science in Sports and Exercise. 2026.
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. Preclinical Studies on Mesenchymal Stem Cell‐Based Therapy for Growth Plate Cartilage Injury Repair. — Chung R, Foster BK, Xian CJ. Stem Cells International. 2011.