Salter-Harris III Fracture

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:

• 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

• 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]

• 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

• 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

• 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

• 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

• 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]

• 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

• 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

• 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

• 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

• 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

• 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

• Not routinely indicated for isolated SH III fractures
• Consider if procedural sedation is planned (per institutional sedation protocols)
• Obtain if polytrauma or hemodynamic instability

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]

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

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]

• 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

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.