01Approach to the Critical Patient/attcp40

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

02History/hx60

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

03Physical Exam/exam61

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

04Differential Diagnosis/ddx51

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

05Laboratory Tests/lt36

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

06Diagnostic Tests/dt100

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

07Disposition/dispo47

Discharge criteria

›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

08Treatment/t78

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

09Special Populations/sp60

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

›Obstetric consultation before sedation if viable gestation

›Ketamine avoidance in first trimester if possible

›Fetal monitoring during procedure if viable gestation

Geriatric

›Geriatric considerations

›SH-I fractures are pediatric injuries by definition

›Adults have fused physes and cannot sustain true SH fractures

›Physeal closure complete by late adolescence in most

›Physeal closure timing reference

›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

›Ankle fractures after physeal closure follow adult classification

10Background/b80

Epidemiology

›Frequency and distribution

›Physeal fractures account for 15 to 30% of all pediatric fractures

›SH-I and SH-II are the most common types

›SH-I most commonly clinically diagnosed in ED setting

›Site distribution

›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

›Approximately 58% male in large case series

›Higher male sports participation rates

›Age distribution

›Peak incidence 10 to 11 years

›Corresponds to period of rapid skeletal growth and greatest physeal vulnerability

›Outcome data

›Most nondisplaced SH-I fractures heal without permanent deformity

›Excellent prognosis for distal fibula SH-I

›Distal radius and tibia nondisplaced generally do well

›Displaced fractures have significantly worse prognosis

›4-fold increased risk of growth arrest compared to nondisplaced

›Distal femur SH-I carries 36% growth arrest rate

Pathophysiology

›Physeal anatomy and vulnerability

›Growth plate structure

›Resting zone near epiphysis

›Proliferative zone of active cell division

›Hypertrophic zone weakest mechanically

›Provisional calcification zone

›Why physis fails before ligament

›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

›Shear and torsional forces

›SH-I and SH-II result from shear across physis

›Twisting and inversion at ankle most common mechanism

›Axial compression

›SH-V results from crush injury to physis

›Diagnosis often missed acutely; apparent only after growth arrest

›Growth arrest mechanism

›Physeal bar formation

›Bony bridge forming across physis after injury

›Interrupts normal longitudinal growth

›Location of bar determines deformity pattern

›Peripheral bar causes angular deformity

›Valgus or varus deformity depending on location

›Central bar causes symmetric growth arrest

›Leg length discrepancy without angular deformity

›Risk factors for growth arrest

›Degree of displacement

›Location: distal femur highest risk at 36%

›Number of reduction attempts

›Periosteal entrapment

Therapeutic Considerations

›Evidence base for treatment decisions

›Cochrane systematic review on interventions for pediatric ankle fractures

›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

›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

›No RCT evidence for distal femur SH fracture management

›Expert consensus supports operative fixation for displaced fractures

›Monitoring for growth complications

›Serial radiographs at follow-up visits

›Every 3 to 6 months for high-risk location fractures

›Growth line (Harris line) appearance may indicate arrest

›MRI for physeal bar detection

›Most sensitive modality for early physeal bar formation

›Enables timely physeal bar resection if small and peripherally located

›Bar resection candidacy

›Less than 50% physeal involvement and sufficient growth remaining

›Peripheral bars more amenable to resection than central bars

›Antibiotic prophylaxis

›Open fractures require antibiotic prophylaxis

›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

›No evidence supporting prophylaxis for closed physeal fractures

11Patient Discharge Instructions/pdi44

copy discharge instructions

›Salter-Harris growth plate fracture home care

›Keep the brace or cast on at all times unless instructed otherwise

›Remove removable brace only for bathing if instructed

›Do not put anything inside the cast

›Ice application for swelling

›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

›Reduces swelling and pain

›Use pillows to prop limb while resting

›Pain medications

›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

›No return to sports or physical education until cleared by doctor

›Return to sport typically 4 to 6 weeks for low-risk injuries

›Longer recovery expected for high-risk location fractures

›Weight-bearing instructions

›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

›Fingers or toes turning blue white or very pale

›Sign of circulation problem

›Numbness or tingling that is new or worsening below the injury

›Sign of nerve pressure

12References/r30

Guidelines and key sources

›Primary evidence sources

›Boutis K et al. JAMA Pediatrics 2016

›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

›Interventions for treating ankle fractures in children

›RCT evidence supporting removable functional bracing

›Wall EJ and May MM. Journal of Pediatric Orthopedics 2012

›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

›Physeal fractures of the distal tibia and fibula

›Management recommendations by fracture type

›Nguyen JC et al. Radiographics 2017

›Imaging of pediatric growth plate disturbances

›MRI protocols and physeal bar detection

›Deng H et al. BMC Musculoskeletal Disorders 2023

›Clinical characteristics of 1124 children with epiphyseal fractures

›Epidemiologic data on physeal fractures

›Boutis K et al. Pediatric Emergency Care 2014

›Evidence into practice: emergency physician management of common pediatric fractures

›Coding references

›ICD-10 coding for physeal fractures

›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

Evidence & Review

Evidence & Review