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Salter-Harris I Fracture
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
Acute limb ischemia
Acute mesenteric ischemia
Aortic dissection
Aortic stenosis
Atrial fibrillation and flutter
Bradyarrhythmia and heart block
Cardiac arrest
Deep vein thrombosis
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Pericarditis
Pulmonary embolism
Stable angina
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Superior vena cava syndrome
Supraventricular tachycardia
Syncope (cardiogenic)
Unstable angina
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Respiratory Presentations
Acute bronchitis
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Aspiration pneumonia
Asthma exacerbation
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Community-acquired pneumonia
COVID-19 pneumonia
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Croup
Croup (laryngotracheobronchitis)
Epiglottitis
Hemothorax
Hospital-acquired pneumonia
Pleural effusion
Pneumothorax (traumatic)
Pulmonary contusion
Spontaneous pneumothorax
Neurological Presentations
Bell's palsy
Benign paroxysmal positional vertigo
Brain abscess
Cauda equina syndrome
Cervical radiculopathy
Concussion (mild traumatic brain injury)
Encephalitis
Guillain-Barré syndrome
Hemorrhagic stroke (intracerebral)
Ischemic stroke
Lumbar radiculopathy
Malignant spinal cord compression
Migraine
Peripheral neuropathy (acute)
Retropharyngeal abscess
Schizophrenia (acute exacerbation)
Seizure (breakthrough:known epilepsy)
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Spinal cord injury
Status epilepticus
Subarachnoid hemorrhage
Tension headache
Transient ischemic attack
Traumatic brain injury (moderate-severe)
Vestibular neuritis
Viral meningitis
Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
Peptic ulcer disease
Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
Fournier gangrene
Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
Impetigo
Infected diabetic foot ulcer
Infectious mononucleosis
Influenza
Necrotizing fasciitis
Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
Spontaneous bacterial peritonitis
Tick-borne illness (Lyme disease)
Tinea infection
Tuberculosis
Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Salter-Harris I Fracture
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Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
High-risk fracture recognition
▶
Distal femur or proximal tibia SH-I fracture
▶
36% risk of growth arrest at distal femur
Popliteal artery at risk with displacement
Peroneal nerve at risk at proximal fibula
Displaced fracture with deformity
▶
Neurovascular compromise until proven otherwise
Emergent orthopedic consultation
Open fracture
▶
Immediate orthopedic consultation
Antibiotics within 3 hours of contamination
Neurovascular assessment
Mandatory neurovascular exam
▶
Distal pulses
▶
Dorsalis pedis and posterior tibial at ankle
Radial and ulnar at wrist
Capillary refill
▶
Greater than 2 seconds as abnormal threshold
Compare bilateral
Sensation distal to injury
▶
Light touch and two-point discrimination
Peroneal nerve territory lateral foot and dorsum
Motor function distal to injury
▶
Active toe or finger flexion and extension
Weakness as compartment syndrome precursor
If neurovascular compromise, immediate orthopedic consultation
▶
Do not delay for imaging
Compartment pressure measurement if concern
Escalation triggers
Emergent escalation criteria
▶
Absent distal pulse after reduction
▶
Vascular surgery consultation
Emergent angiography or exploration
Suspected compartment syndrome
▶
Fasciotomy planning
Do not delay for pressure measurement if clinical signs present
Non-accidental trauma concern
▶
Child protection team activation
Social work and documentation
Displaced distal femoral SH-I fracture
▶
Operative fixation required in most cases
Cast alone has high failure rate
History
Mechanism and event
Mechanism of injury
▶
Inversion or twisting injury
▶
Most common at ankle distal fibula
Sports and play activities predominant
Hyperextension
▶
Knee physeal injuries
Dashboard and contact sport mechanisms
Fall on outstretched hand
▶
Distal radius physeal injury
Wrist pain and deformity
Direct trauma or axial loading
▶
Any physis can be involved
Crush mechanism raises SH-V concern
Temporal profile
▶
Acute onset with identifiable event
▶
Immediate pain localized over physis
Rapid swelling development
Duration since injury
▶
Affects reduction feasibility
Greater than 7 days increases reduction difficulty
Symptom characterization
Pain localization
▶
Over the physis not over the ligament
▶
Distinguishes physeal from ligament injury
Point tenderness directly over growth plate
Weight-bearing status
▶
Inability or refusal to bear weight
Antalgic gait if partial weight-bearing
Associated symptoms
▶
Swelling and ecchymosis over physis
▶
Rapid onset after injury
Compare with contralateral limb
Numbness or tingling distal to injury
▶
Peroneal nerve territory at knee
Sural nerve territory at ankle
Absence of fever or night pain
▶
Helps exclude infection or malignancy
Systemic symptoms are red flags for alternative diagnosis
Risk factors and history
Patient-specific risk factors
▶
Age in rapid growth phase
▶
Peak incidence average 10 to 11 years
Physes mechanically weaker during rapid growth
Male sex
▶
Approximately 58% of physeal fractures in males
Higher sports participation rates
Sports participation
▶
Football, basketball, gymnastics, running
High-impact and twisting activities
Prior injury same site within 3 months
▶
Increased risk of growth disturbance with re-injury
Prior physeal injury as risk factor
Red flag history
▶
Mechanism inconsistent with injury severity
▶
Non-accidental trauma consideration
Pre-ambulatory child with physeal injury
Prior fractures or skeletal dysplasia
▶
Osteogenesis imperfecta
Metabolic bone disease
Constitutional symptoms
▶
Night pain, fever, weight loss
Raise concern for infection or malignancy
Physical Exam
Vitals and general assessment
Vital signs interpretation
▶
Heart rate
▶
Tachycardia from pain or occult vascular injury
Normalizes with adequate analgesia
Blood pressure
▶
Hypotension rare but signals major vascular injury
Bilateral comparison for limb ischemia
Temperature
▶
Fever suggests infection rather than fracture
Septic arthritis and osteomyelitis exclusion
Musculoskeletal exam
Inspection
▶
Swelling over physeal region
▶
Compare contralateral limb
Ecchymosis localizing to physis
Deformity
▶
Angular displacement of epiphysis
Limb length discrepancy for displaced fractures
Palpation
▶
Point tenderness directly over physis
▶
Hallmark finding distinguishing physeal from ligament injury
Specific location: distal fibula physis 1 cm proximal to tip of fibula
Absence of ligament tenderness
▶
Anterior talofibular ligament at ankle
Useful for differentiation from sprain
Squeeze test at ankle
▶
Calcaneal compression reproduces physeal pain
Supportive for distal fibula SH-I
Range of motion
▶
Pain with active and passive motion adjacent joint
▶
Guarding and muscle spasm
Compare with contralateral side
Joint effusion
▶
Ballottement and bulge sign at knee
Effusion with negative radiograph suggests occult SH-I distal femur
Neurovascular exam
Distal neurovascular status
▶
Pulses
▶
Dorsalis pedis and posterior tibial
Capillary refill bilateral comparison
Sensation
▶
Light touch in peripheral nerve territories
Peroneal nerve: lateral foot and web space first toe
Motor function
▶
Ankle dorsiflexion and plantarflexion
Toe extension and flexion
Compartment assessment
▶
Calf or forearm compartment firmness
▶
Tense compartment on palpation
Pain with passive stretch of compartment muscles
Pain out of proportion to injury
▶
Most sensitive early compartment syndrome indicator
Escalate immediately if present
PITFALLS
Diagnostic pitfalls
▶
Missing SH-I when radiograph is normal
▶
SH-I is often radiograph-negative as fracture runs through unossified cartilage
Clinical diagnosis in appropriate age with physeal tenderness
Treating as ligament sprain in a child with open physes
▶
Ligaments stronger than physis in children
Physeal tenderness over ligament tenderness is diagnostic key
Missing high-risk location injuries
▶
Distal femur SH-I carries 36% growth arrest rate
Do not dismiss knee injury as sprain in skeletally immature patient
Differential Diagnosis
Life threats and close mimics
Immediate threats requiring exclusion
▶
Septic arthritis
▶
ICD-10 M00.9
Fever, elevated inflammatory markers, effusion with refusal to bear weight
Osteomyelitis
▶
ICD-10 M86.9
Fever, localized bone tenderness, systemic illness
Non-accidental trauma
▶
ICD-10 T74.12XA
Mechanism inconsistent, pre-ambulatory child, multiple injuries
Vascular injury with fracture
▶
Absent pulses with displaced physeal fracture
Surgical emergency
Physeal fracture spectrum
▶
Salter-Harris Type II fracture
▶
ICD-10 S89.009A
Most common physeal fracture overall; Thurston-Holland metaphyseal fragment visible on X-ray
Salter-Harris Type III fracture
▶
Epiphyseal fragment involves articular surface
Requires articular surface restoration
Salter-Harris Type IV fracture
▶
Metaphysis, physis, and epiphysis all involved
Highest risk of growth arrest among fracture types
Common clinical mimics
Ligamentous injuries
▶
Ankle sprain lateral ligament complex
▶
ICD-10 S93.409A
MRI studies show up to 80% of clinically presumed SH-I distal fibula are actually ligament injuries
Tenderness over ATFL rather than distal fibula physis
Avulsion fracture distal fibula
▶
Radiograph may be negative
MRI detects avulsion at origin of ATFL
Bone contusion
▶
Radiograph negative bone bruise
▶
MRI most sensitive for detection
Common finding in pediatric ankle injuries
Apophysitis
▶
Sever disease calcaneal apophysitis
▶
Overuse not acute trauma
Bilateral involvement common
Osgood-Schlatter disease
▶
Tibial tubercle tenderness
Insidious onset not acute
Toddler fracture
▶
Spiral tibial fracture in young children
▶
ICD-10 S82.202A
Refusal to walk without clear mechanism
Distinct from physeal injury by age and location
Malignancy
▶
Leukemia and osteosarcoma
▶
Night pain, constitutional symptoms, rest pain
Radiograph may show periosteal reaction or lytic lesion
Laboratory Tests
Infection screen
Infection markers when clinically indicated
▶
Complete blood count
▶
Leukocytosis with left shift in septic arthritis
Normal CBC expected in isolated SH-I fracture
C-reactive protein
▶
Elevated in septic arthritis and osteomyelitis
Greater than 20 mg/L raises infection concern
Erythrocyte sedimentation rate
▶
Elevated in infection and inflammatory arthritis
Less specific than CRP; useful in combination
Blood cultures
▶
Prior to antibiotics when septic arthritis suspected
Two sets from separate sites
Metabolic evaluation
Metabolic bone disease when suspected
▶
Serum calcium and phosphorus
▶
Hypocalcemia in rickets
Hypophosphatemia in hypophosphatemic rickets
Alkaline phosphatase
▶
Elevated in metabolic bone disease and active growth
Interpret with age-specific reference ranges
25-hydroxyvitamin D
▶
Less than 50 nmol/l indicates deficiency
Supplementation if deficient
Parathyroid hormone
▶
Secondary hyperparathyroidism in renal disease
If metabolic workup otherwise abnormal
Malignancy exclusion
When malignancy suspected
▶
Complete blood count with differential
▶
Blasts on peripheral smear in leukemia
Pancytopenia pattern
Lactate dehydrogenase
▶
Elevated in osteosarcoma and lymphoma
Uric acid elevation in leukemia
Peripheral smear review
▶
Leukemic blasts or atypical lymphocytes
Abnormal platelet morphology
Diagnostic Tests
Scoring Systems
Salter-Harris classification system
▶
Type I: Straight through physis only
▶
ICD-10 S89.009A distal tibia example
Radiograph often normal
Prognosis generally good for nondisplaced
Type II: Above metaphysis and physis involved
▶
Most common physeal fracture overall
Thurston-Holland metaphyseal fragment on radiograph
Type III: Lower epiphysis and physis involved
▶
Articular surface disruption
Anatomic reduction required
Type IV: Through all three zones
▶
Highest growth arrest risk
Operative fixation usually required
Type V: Rammed crush injury of physis
▶
Radiograph normal at presentation
Diagnosis often retrospective after growth arrest
Ottawa Ankle Rules applicability
▶
Validated in children older than 5 years for ankle imaging decisions
▶
Bone tenderness at posterior edge or tip of lateral malleolus
Bone tenderness at posterior edge or tip of medial malleolus
Inability to bear weight immediately and in ED
Limitation in children with open physes
▶
Physeal tenderness generally warrants imaging regardless of Ottawa rules
Do not use to exclude imaging in child with physeal tenderness
Clinical diagnostic criteria for presumed SH-I distal fibula
▶
Criteria set used in RCT evidence
▶
Limited weight-bearing
Tenderness and swelling over distal fibular physis
Normal radiographs with open physes
All three criteria must be present for empirical treatment without MRI
MRI
MRI indications for physeal injuries
▶
Most sensitive modality for SH-I confirmation
▶
Detects physeal signal abnormality not visible on radiograph
Sensitivity superior to radiograph for physeal fracture
Indications for MRI
▶
Diagnostic uncertainty after radiograph and clinical exam
High-risk location with normal radiograph
Failure to improve after empirical treatment
Suspected physeal bar formation on follow-up
Not routinely required for low-risk injuries
▶
Distal fibula nondisplaced SH-I treated empirically
Many orthopedists manage without MRI confirmation
MRI findings in SH-I fractures
▶
Physeal signal abnormality
▶
Increased T2 signal through physis
Periosteal disruption adjacent to physis
Associated soft tissue findings
▶
Bone marrow edema in adjacent metaphysis and epiphysis
Ligament integrity assessment simultaneously
Physeal bar detection
▶
Low T2 signal bridge across physis
Early growth arrest detection enables timely intervention
MRI protocol considerations
▶
Sedation requirement in young children
▶
Children under 6 to 8 years often require general anesthesia
Weigh diagnostic benefit against sedation risk
Preferred sequences
▶
Coronal T2 fat suppressed through physis
Axial T1 for anatomy
STIR sequence for bone marrow edema
CT
CT indications for physeal injuries
▶
Rarely indicated for SH-I specifically
▶
CT more useful for SH-III and SH-IV articular assessment
SH-I diagnosis is clinical and radiographic
CT indications in complex cases
▶
Articular surface displacement quantification for SH-III and SH-IV
Comminution assessment when mechanism severe
Pre-operative planning for complex physeal injuries
CT findings in physeal injuries
▶
Physeal widening quantification
▶
Greater than 3 mm physeal gap suggests periosteal entrapment
Epiphyseal displacement direction
Metaphyseal fragment assessment
▶
Size and displacement of Thurston-Holland fragment
Comminution pattern
Radiation considerations
▶
CT delivers higher radiation dose than radiograph
▶
Pediatric population is radiosensitive
Use only when MRI not available and clinical question cannot be answered otherwise
Low-dose pediatric protocols
▶
As low as reasonably achievable principle
Refer to institutional pediatric CT protocols
Ultrasound
Point-of-care ultrasound applications
▶
Subperiosteal hematoma detection
▶
Fluid collection adjacent to physis
Supports diagnosis of physeal injury when radiograph negative
Joint effusion assessment
▶
Hip effusion detection in limping child
Guides aspiration for septic arthritis exclusion
Soft tissue swelling localization
▶
Confirms swelling over physis versus ligament
Operator dependent but accessible in ED
Ultrasound-guided procedures
▶
Joint aspiration guidance
▶
Hip joint aspiration for septic arthritis exclusion
Knee effusion aspiration when diagnostic uncertainty
Hematoma block guidance
▶
Local anesthetic delivery adjacent to fracture
Improves patient comfort during reduction
Disposition
Discharge criteria
Copy
Low-risk nondisplaced SH-I discharge criteria
▶
Distal fibula SH-I
▶
Intact neurovascular exam
Adequate pain control achieved
Reliable family for follow-up
Removable brace applied
Weight-bearing as tolerated
Distal radius nondisplaced SH-I
▶
Short arm cast applied
Neurovascular exam intact
Follow-up arranged within 1 week
Follow-up timelines
▶
Distal fibula low-risk
▶
Primary care or orthopedics within 1 to 2 weeks
Orthopedic referral not routinely necessary
Moderate-risk locations distal tibia and distal radius
▶
Orthopedic follow-up within 1 week
Serial radiographs to monitor alignment
Long-term growth monitoring
▶
All physeal fractures monitored 6 to 12 months
Growth arrest and angular deformity surveillance
Orthopedic consultation indications
Emergent consultation
▶
Displaced fractures requiring reduction
▶
Any location with significant displacement
Neurovascular compromise
High-risk location fractures
▶
Distal femur SH-I
Proximal tibia SH-I
Suspected periosteal entrapment
▶
Physeal gap greater than 3 mm after reduction
Resistance to gentle closed reduction
Open fractures
▶
Surgical irrigation and debridement required
Antibiotics within 3 hours of contamination
Admission criteria
Admission indications
▶
Neurovascular compromise requiring monitoring
▶
Hourly neurovascular checks
Vascular surgery involvement if ischemia
Operative fixation planned
▶
Displaced distal femoral SH-I fractures
SH-III or SH-IV requiring articular restoration
Compartment syndrome concern
▶
ICU or step-down level monitoring
Compartment pressure measurement
Non-accidental trauma evaluation
▶
Child protective services involvement
Skeletal survey and social work
Treatment
Analgesia
Acute pain management
▶
Ibuprofen first-line NSAID
▶
10 mg/kg PO every 6 to 8 hours
Maximum 400 mg per dose
Safe for short-term use in pediatric fractures
Acetaminophen adjunct or alternative
▶
15 mg/kg PO every 4 to 6 hours
Maximum 75 mg/kg per day
Alternate with ibuprofen for improved pain control
Opioids rarely required for nondisplaced SH-I fractures
▶
Reserve for displaced fractures or failed NSAID management
Oral oxycodone 0.1 mg/kg PO every 4 to 6 hours as rescue
Avoid aspirin in children
▶
Reye syndrome risk
No indication in pediatric fracture management
Immobilization by location and severity
Low-risk nondisplaced distal fibula SH-I
▶
Removable ankle brace or air-stirrup
▶
At least as effective as casting with faster functional recovery
RCT evidence supports removable splint over rigid cast
Weight-bearing as tolerated
Duration approximately 2 to 3 weeks
▶
Mobilize as symptoms allow after immobilization period
Return to sport when pain-free and full range of motion
Moderate-risk nondisplaced distal radius SH-I
▶
Short-arm cast
▶
3 to 4 weeks immobilization
Thumb spica if distal radius involvement significant
Nondisplaced distal tibia SH-I
▶
Short-leg cast
Non-weight-bearing or weight-bearing as tolerated
3 to 4 weeks duration
High-risk nondisplaced distal femur or proximal tibia SH-I
▶
Long-leg cast
▶
Non-weight-bearing
Close orthopedic follow-up mandatory
Orthopedic consultation in ED for all distal femur SH-I
▶
36% growth arrest rate necessitates specialist involvement
Some require percutaneous pin fixation even nondisplaced
Reduction of displaced fractures
Closed reduction technique
▶
Appropriate analgesia or procedural sedation required
▶
Hematoma block as alternative for peripheral fractures
Procedural sedation for high-risk or painful reductions
Gentle technique
▶
Avoid multiple reduction attempts
Each attempt risks further physeal damage
Post-reduction neurovascular check mandatory
▶
Immediate reassessment of pulses and sensation
Repeat radiograph in two planes to confirm reduction
Acceptable reduction criteria
▶
Alignment within acceptable limits by location
▶
Distal fibula: anatomic or near-anatomic preferred
Distal femur: anatomic reduction required
Physeal gap after reduction
▶
Greater than 3 mm raises suspicion for periosteal entrapment
Open reduction required if entrapment suspected
Surgical fixation indications
▶
Percutaneous pin fixation
▶
Distal femur fractures with cast alone having high failure rate
Unstable reductions at other high-risk locations
Open reduction
▶
Failed closed reduction
Periosteal entrapment suspected
SH-III and SH-IV with articular displacement
Evidence level
▶
Expert consensus for operative management of displaced distal femur SH fractures
Cochrane review supports functional rehabilitation for ankle physeal injuries
Procedural sedation for fracture reduction
Sedation indications
▶
Displaced fractures requiring closed reduction in ED
▶
Patient age and cooperation assessment
Failed or inadequate analgesia for reduction
Agents commonly used
▶
Intranasal dexmedetomidine plus ketamine combination
IV ketamine 1.5 mg/kg for procedural sedation
IV propofol with continuous monitoring for older children
Monitoring requirements
▶
Continuous pulse oximetry
Capnography during sedation
Resuscitation equipment at bedside
Special Populations
Pregnancy
Pregnancy considerations
▶
SH-I fractures are pediatric injuries; pregnancy co-occurs rarely in adolescent females
▶
Assess menstrual history and pregnancy status in adolescent females
Urine pregnancy test before procedural sedation or CT
Imaging approach in pregnant adolescent
▶
Plain radiographs with gonadal shielding for extremity imaging
Radiation dose to fetus from extremity radiograph is negligible
MRI preferred over CT if cross-sectional imaging required
Analgesia considerations in pregnancy
▶
Acetaminophen generally safe throughout pregnancy
NSAIDs: avoid after 20 weeks gestation due to premature ductus arteriosus closure
Opioids: use lowest effective dose and shortest duration
Procedural sedation in pregnant adolescent
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Obstetric consultation before sedation if viable gestation
Ketamine avoidance in first trimester if possible
Fetal monitoring during procedure if viable gestation
Geriatric
Geriatric considerations
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SH-I fractures are pediatric injuries by definition
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Adults have fused physes and cannot sustain true SH fractures
Physeal closure complete by late adolescence in most
Physeal closure timing reference
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Distal femur physis closes approximately age 16 to 18 years
Distal radius physis closes approximately age 14 to 17 years
Distal fibula physis closes approximately age 14 to 16 years
Adult analog injuries
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Ankle fractures after physeal closure follow adult classification
Distal radius fractures in adults not Salter-Harris
Triplane and Tillaux fractures occur during physeal closure in adolescents
Pediatrics
Pediatric-specific management
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Age-based epidemiology
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Peak incidence average 10 to 11 years of age
Males 58% of physeal fractures
Distal fibula most common site in ED
Weight-based dosing
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Ibuprofen 10 mg/kg PO every 6 to 8 hours maximum 400 mg per dose
Acetaminophen 15 mg/kg PO every 4 to 6 hours maximum 75 mg/kg per day
Procedural sedation dosing per institutional weight-based protocol
Immobilization compliance in children
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Removable braces require family and patient compliance education
Cast may be preferred when compliance questionable
Waterproof cast options improve quality of life
Non-accidental trauma recognition
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Indicators raising concern
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Mechanism inconsistent with injury severity
Pre-ambulatory child with physeal injury
Multiple injuries at different healing stages
Delay in presentation
Mandatory reporting requirements
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Report to child protective services per local statute
Document mechanism and caretaker accounts carefully
Skeletal survey for children under 2 years
Growth complication counseling
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Family education at discharge
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Risk of growth disturbance exists and requires follow-up
Growth arrest may present as leg length discrepancy or angular deformity
Follow-up appointments critical to detect early complications
Timing of growth complications
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Growth arrest may be apparent within 3 to 6 months
Angular deformity may develop over 1 to 2 years
MRI most sensitive for early physeal bar detection
Background
Epidemiology
Frequency and distribution
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Physeal fractures account for 15 to 30% of all pediatric fractures
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SH-I and SH-II are the most common types
SH-I most commonly clinically diagnosed in ED setting
Site distribution
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Distal fibula is the most common site in the ED
Distal radius is the most common site overall for physeal fractures
Distal femur SH-I uncommon but highest morbidity
Sex distribution
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Approximately 58% male in large case series
Higher male sports participation rates
Age distribution
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Peak incidence 10 to 11 years
Corresponds to period of rapid skeletal growth and greatest physeal vulnerability
Outcome data
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Most nondisplaced SH-I fractures heal without permanent deformity
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Excellent prognosis for distal fibula SH-I
Distal radius and tibia nondisplaced generally do well
Displaced fractures have significantly worse prognosis
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4-fold increased risk of growth arrest compared to nondisplaced
Distal femur SH-I carries 36% growth arrest rate
Pathophysiology
Physeal anatomy and vulnerability
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Growth plate structure
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Resting zone near epiphysis
Proliferative zone of active cell division
Hypertrophic zone weakest mechanically
Provisional calcification zone
Why physis fails before ligament
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Hypertrophic zone is mechanically the weakest link
In skeletally immature children physis fails before ligament tears
Explains why ankle sprains are rare in children with open physes
Fracture mechanism by zone
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Shear and torsional forces
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SH-I and SH-II result from shear across physis
Twisting and inversion at ankle most common mechanism
Axial compression
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SH-V results from crush injury to physis
Diagnosis often missed acutely; apparent only after growth arrest
Growth arrest mechanism
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Physeal bar formation
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Bony bridge forming across physis after injury
Interrupts normal longitudinal growth
Location of bar determines deformity pattern
Peripheral bar causes angular deformity
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Valgus or varus deformity depending on location
Central bar causes symmetric growth arrest
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Leg length discrepancy without angular deformity
Risk factors for growth arrest
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Degree of displacement
Location: distal femur highest risk at 36%
Number of reduction attempts
Periosteal entrapment
Therapeutic Considerations
Evidence base for treatment decisions
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Cochrane systematic review on interventions for pediatric ankle fractures
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RCT evidence supports removable functional bracing over rigid cast for distal fibula SH-I
Faster functional recovery with removable brace
No difference in long-term outcomes between brace and cast
JAMA Pediatrics study on radiograph-negative lateral ankle injuries
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MRI showed 80% of clinically diagnosed SH-I distal fibula are actually ligament injuries or bone contusions
Empirical treatment with removable brace appropriate regardless of true diagnosis
Expert consensus for high-risk locations
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No RCT evidence for distal femur SH fracture management
Expert consensus supports operative fixation for displaced fractures
Monitoring for growth complications
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Serial radiographs at follow-up visits
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Every 3 to 6 months for high-risk location fractures
Growth line (Harris line) appearance may indicate arrest
MRI for physeal bar detection
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Most sensitive modality for early physeal bar formation
Enables timely physeal bar resection if small and peripherally located
Bar resection candidacy
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Less than 50% physeal involvement and sufficient growth remaining
Peripheral bars more amenable to resection than central bars
Antibiotic prophylaxis
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Open fractures require antibiotic prophylaxis
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First-generation cephalosporin for clean wounds
Add gram-negative coverage for highly contaminated wounds
Administer within 3 hours of contamination
Closed SH-I fractures do not require prophylactic antibiotics
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No evidence supporting prophylaxis for closed physeal fractures
Patient Discharge Instructions
copy discharge instructions
Copy
Salter-Harris growth plate fracture home care
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Keep the brace or cast on at all times unless instructed otherwise
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Remove removable brace only for bathing if instructed
Do not put anything inside the cast
Ice application for swelling
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Ice pack wrapped in cloth over injured area
20 minutes on then 20 minutes off for first 48 hours
Elevate the injured limb above heart level
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Reduces swelling and pain
Use pillows to prop limb while resting
Pain medications
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Ibuprofen every 6 to 8 hours as needed with food
Acetaminophen every 4 to 6 hours as needed
Alternate the two for better pain control
Activity restrictions
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No return to sports or physical education until cleared by doctor
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Return to sport typically 4 to 6 weeks for low-risk injuries
Longer recovery expected for high-risk location fractures
Weight-bearing instructions
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Follow specific instructions given at discharge
Non-weight-bearing: use crutches as instructed
Weight-bearing as tolerated: comfortable amount of weight on limb
Warning signs return to emergency room immediately
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Fingers or toes turning blue white or very pale
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Sign of circulation problem
Numbness or tingling that is new or worsening below the injury
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Sign of nerve pressure
Severe increasing pain especially in a cast
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Sign of compartment syndrome
If cast feels too tight or pain worsening remove if removable brace and go to ER
Cast or brace becoming loose after swelling decreases
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Return to clinic for re-application
Fever above 38.3 degrees Celsius with pain at injury site
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Sign of possible infection
Child refusing to use limb after expected improvement
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May indicate missed injury or complication
Follow-up appointments
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Attend all scheduled follow-up appointments
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Growth plate injuries need monitoring for months
Doctor will check that the bone is healing correctly
Follow-up timeline
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Low-risk ankle fracture: 1 to 2 weeks with primary care or orthopedics
Wrist or leg fracture: 1 week with orthopedics
Knee area fracture: within 1 week and ongoing monitoring 6 to 12 months
References
Guidelines and key sources
Primary evidence sources
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Boutis K et al. JAMA Pediatrics 2016
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Radiograph-negative lateral ankle injuries in children: occult growth plate fracture or sprain
MRI showed 80% are ligament injuries or bone contusions rather than SH-I fractures
Yeung DE et al. Cochrane Database of Systematic Reviews 2016
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Interventions for treating ankle fractures in children
RCT evidence supporting removable functional bracing
Wall EJ and May MM. Journal of Pediatric Orthopedics 2012
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Growth plate fractures of the distal femur
36% growth arrest rate for SH-I distal femur
Podeszwa DA and Mubarak SJ. Journal of Pediatric Orthopedics 2012
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Physeal fractures of the distal tibia and fibula
Management recommendations by fracture type
Nguyen JC et al. Radiographics 2017
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Imaging of pediatric growth plate disturbances
MRI protocols and physeal bar detection
Deng H et al. BMC Musculoskeletal Disorders 2023
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Clinical characteristics of 1124 children with epiphyseal fractures
Epidemiologic data on physeal fractures
Boutis K et al. Pediatric Emergency Care 2014
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Evidence into practice: emergency physician management of common pediatric fractures
Coding references
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ICD-10 coding for physeal fractures
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S89.009A physeal fracture distal tibia initial encounter
S49.009A physeal fracture distal radius initial encounter
S79.009A physeal fracture distal femur initial encounter
S93.409A ankle sprain for clinical mimics
SNOMED CT concepts
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Salter-Harris type I epiphyseal fracture
Growth plate fracture disorder
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
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Management Protocols
Salter-Harris I Fracture