01Approach to the Critical Patient/attcp49

Immediate priorities

›Neurovascular emergency recognition

›Absent or diminished distal pulses

›Popliteal artery at risk in distal femoral and proximal tibial fractures

›Immediate vascular surgery consultation if pulse deficit confirmed

›Signs of compartment syndrome

›Severe pain out of proportion to injury

›Pain with passive stretch of distal digits

›Tense, woody compartments on palpation

›Open fracture identification

›Skin breach overlying fracture site

›IV antibiotics within 1 hour of open fracture recognition

›Urgent orthopedic consultation

›Stabilization and analgesic priorities

›Splint in position of comfort before radiographs when deformity present

›Padding to bony prominences

›Neurovascular check before and after splinting

›Immediate analgesia

›Ibuprofen 10 mg/kg (max 600 mg) first-line

›Intranasal fentanyl 1.5–2 mcg/kg if IV access not yet established

›Elevation and ice application

›Reduces soft tissue swelling and pain

›Facilitates later radiographic interpretation

Escalation triggers

›Conditions requiring immediate orthopedic consultation

›Distal femoral physeal fracture

›Growth arrest risk 40–58%

›Highest risk site for premature physeal closure

02History/hx57

Mechanism and onset

›Mechanism of injury

›Fall on outstretched hand (FOOSH) — distal radius most common site

›Height of fall

›Surface fallen on

›Twisting or rotational injury — distal tibia most common mechanism

›Sports participation (43% of distal tibial SH-II)

›Direction of twist

›Hyperextension mechanism

›Associated with distal femoral physeal fractures

›Motor vehicle collision context

›Direct blow

›High-energy mechanism correlates with greater displacement

›Initial displacement ≥4 mm is a key prognostic factor for premature physeal closure

›Timing and functional status

›Time of injury

›Ability to bear weight or use extremity since injury

›Deformity noted at scene

›Any attempt at reduction or manipulation before arrival

Symptom characterization

›Primary symptoms

›Acute pain localized near a joint

›Physeal pain distinct from ligamentous pain

›Point tenderness at growth plate

›Swelling onset

›Rapid swelling suggests hemarthrosis or displaced fracture

›Inability to use limb

›Alarm symptoms

03Physical Exam/exam53

Vitals and general appearance

›Vital sign assessment

›Heart rate — tachycardia from pain or blood loss in high-energy injury

›Blood pressure — hypotension in polytrauma

›Respiratory rate — elevated in severe pain

›General appearance

›Distress level

›Ability to ambulate or bear weight

Musculoskeletal exam

›Inspection

›Swelling localization

›Periarticular swelling typical of physeal injury

›Deformity and angulation

›Angular deformity at joint

›Shortening

›Ecchymosis distribution

›Pattern inconsistent with mechanism raises NAT concern

›Skin integrity

›Open wound or puncture over fracture site

›Palpation

›Point tenderness over the physis — hallmark finding

›Distinguishes physeal from ligamentous injury

›Tenderness at growth plate rather than mid-ligament

›Comparison to contralateral limb

›Joint effusion

›Range of motion

›Limited by pain — do not force movement

›Assess as much as tolerated for intra-articular involvement

04Differential Diagnosis/ddx49

Physeal fracture spectrum

›Salter-Harris classification variants

›SH Type I — fracture through physis only

›ICD-10 S59.009A (distal radius, unspecified)

›Radiographically occult — diagnosed clinically by physeal tenderness

›Normal X-ray does not exclude SH-I

›SH Type II — fracture through physis and metaphysis

›ICD-10 S59.119A (distal radius, SH-II, unspecified)

›Thurston-Holland metaphyseal fragment characteristic finding

›Most common physeal fracture type — 75–85% of all physeal injuries

›SH Type III — fracture through physis and epiphysis

›Intra-articular extension

›Higher risk of joint incongruity and growth disturbance

›SH Type IV — fracture through metaphysis, physis, and epiphysis

›Highest risk of growth disturbance

›Requires anatomic reduction

›SH Type V — crush injury to physis

›Often retrospective diagnosis after growth arrest

›May appear normal on initial radiographs

Non-physeal pediatric fractures

›Metaphyseal fractures not involving physis

›Buckle (torus) fracture

›Cortical buckling without physeal involvement

›Lower energy mechanism

›Does not extend to growth plate

›Classic metaphyseal lesion (CML)

›Corner or bucket-handle fracture

›Highly specific for non-accidental trauma

05Laboratory Tests/lt33

Routine fracture assessment

›Standard isolated SH-II fracture

›Routine labs generally not indicated for isolated SH-II fractures

›Clinical and radiographic diagnosis

›Low diagnostic yield without systemic concern

Pre-operative and high-energy injury labs

›Operative management anticipated

›Complete blood count

›Hemoglobin baseline for high-energy injuries with blood loss

›Platelet count before procedural sedation

›Basic metabolic panel

›Renal function for anesthesia planning

›Electrolytes

›Coagulation studies

›PT and aPTT if clinical bleeding concern

›Known or suspected bleeding diathesis

›Type and screen

›High-energy injuries with anticipated surgical management

Metabolic bone disease workup

›Atypical mechanism or recurrent fractures

›Calcium and phosphorus

›Rickets or hyperparathyroidism

›Alkaline phosphatase

›Elevated in rickets and Paget-like conditions

›25-hydroxyvitamin D

›Deficiency increases fracture risk

›PTH

›Hyperparathyroidism evaluation

06Diagnostic Tests/dt77

Scoring Systems

›Salter-Harris classification (SALTR mnemonic)

›S — Straight across: Type I, physis only

›Lowest risk of growth disturbance

›Radiographically occult

›A — Above (metaphysis): Type II

›Most common type — 75–85% of physeal fractures

›Thurston-Holland fragment

›L — beLow (epiphysis): Type III

›Intra-articular

›Requires anatomic reduction

›T — Through (both): Type IV

›Highest malunion and growth arrest risk

›R — Rammed/cRush: Type V

›Axial compression of physis

›Often diagnosed in retrospect after growth arrest

›Ottawa Ankle Rules in children

›Validated for children >5 years

›Bone tenderness at posterior tip or distal 6 cm of fibula or tibia

›Inability to bear weight for 4 steps in ED

›Sensitivity approaches 100% for ankle fractures in children >5 years

›Specificity approximately 31–36%

›Negative rule reduces radiograph use without missing fractures

›Ottawa Knee Rules

›Age >55 years (less relevant for pediatric use but applicable to older adolescents)

›Isolated tenderness of patella

›Tenderness of fibular head

›Inability to flex knee to 90 degrees

›Inability to bear weight

MRI

›Indications for MRI

›Occult physeal injury — radiographically negative with high clinical suspicion

›Physeal tenderness with normal radiographs

›Effusion and inability to bear weight with normal plain films

›Most sensitive modality for physeal bar detection

›Early physeal bar formation during follow-up

›Superior to radiographs and CT for early growth disturbance

›Periosteal entrapment assessment

›Recent evidence suggests entrapment not an independent PPC risk factor

›MRI can identify interposed periosteum preoperatively

›Protocol considerations

›Short-tau inversion recovery (STIR) sequences

›Marrow edema and physeal signal abnormality

›Sedation requirement in young children

›Age-dependent — typically needed under 6–7 years

›Comparison views of contralateral physis helpful

›Normal physeal anatomy for reference

CT

›Indications for CT

›Surgical planning for displaced fractures

›Three-dimensional reconstruction for complex fractures

›Assessment of intra-articular extension (SH-III and IV overlap)

›Vascular injury suspected

›CT angiography if pulse deficit or expanding hematoma

›Doppler ultrasound as first-line if available and pulse present

›Complex peri-articular fracture anatomy

›Distal femoral physeal fractures with complex displacement

›Triplane or transitional fractures at the ankle

›Limitations

›Ionizing radiation exposure in pediatric population

›ALARA principle — justify each CT use

›Cartilaginous structures not directly visualized

›MRI superior for physeal soft tissue detail

Ultrasound

›Point-of-care ultrasound (POCUS) applications

›Cortical irregularity detection at the physis

›Periosteal elevation or step-off at growth plate

›Sensitivity for cortical disruption in pediatric fractures

›Joint effusion identification

›Hemarthrosis in intra-articular extension

›Guides aspiration if painful tense effusion

›Soft tissue swelling characterization

›Differentiates hematoma from soft tissue injury

›Doppler ultrasound for vascular assessment

›Diminished pulses with soft tissue swelling

›Vascular injury versus spasm assessment

›If Doppler negative with persistent clinical concern, proceed to CT angiography

›POCUS limitations

›Operator dependent

›Cannot exclude physeal injury definitively

›Adjunct to plain radiographs, not replacement

07Disposition/dispo41

Discharge criteria

›Suitable for outpatient management

›Nondisplaced or minimally displaced fracture

›<3 mm displacement on plain radiographs

›Acceptable angulation for age and site

›Successfully reduced fracture with adequate alignment

›Postreduction translation <3 mm

›Neurovascular status intact post-reduction

›Adequate pain control on oral analgesia

›Reliable follow-up arranged with orthopedics within 5–7 days

›Caregiver understanding of return precautions

Orthopedic consultation in the ED

›Situations requiring emergent orthopedic involvement

›Distal femoral physeal fractures

›Growth arrest rates 40–58%

›Displaced fractures have 4-fold increased odds of growth disturbance

›Proximal tibial physeal fractures

›Popliteal artery tethering risk

›Compartment syndrome risk

›Failed closed reduction

›Residual displacement >3 mm

›Coronal plane angulation

›Open fractures

›Neurovascular compromise

Admission criteria

›Inpatient management required

›Open fracture

›Operative washout and debridement

08Treatment/t99

Initial ED management

›Splinting and immobilization

›Splint in position of comfort initially

›Avoid circumferential cast in acute phase due to swelling

›Padding to bony prominences

›Upper extremity — sugar-tong or posterior splint

›Long-arm splint for elbow involvement

›Wrist splint in neutral to slight extension for distal radius

›Lower extremity — posterior long-leg splint

›Knee flexion 10–15 degrees for comfort

›Ankle in neutral for distal tibia and fibula

›Ice and elevation throughout stay

›Reduces edema and pain

›Elevate above the level of the heart

Analgesia

›First-line non-opioid analgesia

›Ibuprofen 10 mg/kg (max 600 mg) orally

›AAP-supported optimal first-line analgesic for pediatric musculoskeletal injuries

›Short-term NSAID use has not been shown to impair fracture healing

›Repeat every 6–8 hours as needed

›Acetaminophen 15 mg/kg (max 1000 mg) orally

›Adjunct — No OUCH RCTs showed no additional benefit of acetaminophen added to ibuprofen

›Can be alternated for ongoing pain management

›Intranasal analgesia for severe acute pain without IV access

›Fentanyl IN 1.5–2 mcg/kg

›Rapid onset within 5–10 minutes

›Avoids IV placement in distressed child

›Ketamine IN 1 mg/kg

›Analgesic dose (subanesthetic)

›Useful for procedural preparation

›Opioid use — restricted indications

›Ibuprofen equivalent efficacy for musculoskeletal pain with fewer adverse effects

›Codeine and tramadol contraindicated in children <12 years

›FDA black box warning for respiratory depression

›If opioid required — morphine IV 0.05–0.1 mg/kg or oxycodone 0.1 mg/kg orally

Closed reduction

›Indications for closed reduction

›Displacement ≥3 mm

›Unacceptable angulation for age and site

›Procedural sedation for reduction

›Ketamine IV 1–2 mg/kg for dissociative sedation

›Pre-treatment with glycopyrrolate 0.005 mg/kg to reduce secretions

›Ondansetron 0.1 mg/kg IV for antiemetic prophylaxis

›Propofol IV 1–2 mg/kg titrated for rapid offset sedation

›Continuous monitoring required

›Midazolam IV 0.05–0.1 mg/kg plus fentanyl IV 1–2 mcg/kg as alternative

›Reduction technique principles

›Traction-countertraction to disengage fracture fragments

›Gentle maneuver to avoid additional physeal damage

›Limit reduction attempts to 2 maximum

›Each attempt beyond 2 increases premature physeal closure risk 8.5-fold

›Post-reduction neurovascular exam mandatory

›Post-reduction radiographs to confirm alignment

›Target: residual displacement <3 mm, minimal angulation

Definitive immobilization

›Cast application after reduction or for nondisplaced fractures

›Upper extremity

›Long-arm cast for proximal and mid-radius/ulna SH-II

›Short-arm cast acceptable for distal radius SH-II in select cases

›4–6 weeks immobilization typical

›Lower extremity

›Long-leg walking cast with knee flexion

›Non-weight-bearing for distal femoral and proximal tibial fractures

›Weight-bearing as tolerated for distal tibia and fibula after confirmation of alignment

›Cast duration

›Distal radius 4–6 weeks

›Distal tibia 6 weeks

›Distal femur 6–8 weeks in most cases

›Orthopedic follow-up

›Repeat radiographs within 5–7 days

›Check for displacement during early healing

›Cast change at 1–2 weeks if significant swelling subsides

Operative management

›Indications for surgical fixation

›Failed closed reduction

›Residual displacement >3 mm

›Periosteal interposition preventing anatomic alignment

›Intra-articular extension with displacement (SH-III/IV overlap)

›Open fractures

›Vascular injury requiring exploration

›Surgical options

›Closed reduction and percutaneous pinning (CRPP)

›Minimally invasive

›Appropriate for most displaced fractures amenable to closed reduction

›Open reduction internal fixation (ORIF)

›Irreducible fractures or failed CRPP

›Smooth K-wires preferred over crossing physis with threaded hardware

›Evidence note on operative vs nonoperative

›Operative treatment has not been shown to reduce premature physeal closure rates compared to nonoperative management in distal tibial SH-II fractures

›Clinical equipoise exists — Russo et al 2013, Peterson and Perry 2023

›Anatomic reduction goal regardless of method

Open fracture management

›Antibiotic prophylaxis

›Cefazolin IV 30 mg/kg (max 2 g) within 1 hour of open fracture

›Grade I and II open fractures

›Continue 24 hours post-operatively

›Add gentamicin for Grade III open fractures

›Gentamicin 2.5 mg/kg IV

›Tetanus prophylaxis

›Verify immunization status

›Tetanus immunoglobulin if unimmunized

›Wound management

›Saline-moistened dressing to wound

›Do not attempt wound closure in ED

›Urgent operative washout

09Special Populations/sp59

Pregnancy

›Pregnant adolescent with SH-II fracture

›Analgesic selection

›Acetaminophen first-line — safest analgesic in pregnancy

›Ibuprofen and NSAIDs: avoid in third trimester

›Risk of premature closure of ductus arteriosus

›Reduced amniotic fluid

›Ibuprofen may be used with caution in first and second trimester for short course

›Imaging considerations

›Plain radiographs acceptable with lead shielding

›Radiation dose to fetus minimal for extremity radiographs

›MRI preferred over CT if advanced imaging needed

›No ionizing radiation

›Gadolinium contrast avoided in pregnancy

›Procedural sedation in pregnancy

›Obstetric consultation for third-trimester patients

›Fetal monitoring during and after sedation

›Propofol and ketamine used with caution — limited safety data

Geriatric

›Older adolescents approaching skeletal maturity

›Physeal closure timeline

›Distal radius physis closes at approximately 16–17 years in females, 17–18 years in males

›Distal femur physis closes at approximately 16–17 years

›Near-closed physis may behave more like adult fracture pattern

›Ligamentous injury more common as physis closes

›Adult-pattern sprains and avulsion fractures become more common

›Growth disturbance risk diminishes as physis approaches closure

›True geriatric population (rare context)

10Background/b85

Epidemiology

›Incidence and prevalence

›Physeal fractures account for approximately 15–30% of all pediatric fractures

›Most common long bone injury in skeletally immature children

›SH-II is the most common physeal fracture type

›75–85% of all physeal fractures — Deng et al 2023 (n=1124 children)

›Peak incidence in adolescents aged 10–16 years

›Boys affected approximately 2:1 over girls

›Growth spurts associated with increased vulnerability

›Site distribution

›Distal radius — most common overall site

›Fall on outstretched hand (FOOSH) mechanism

›Lowest complication rate — physeal bridge ~1.3%

›Distal tibia — second most common lower extremity site

›Premature physeal closure rate 12–43% depending on displacement

›Distal femur — rarest but highest complication risk

›Growth arrest 40–58%

›Mechanism distribution

›Falls — most common overall cause

›Sports injuries — 43% of distal tibial SH-II fractures

›Motor vehicle collisions — associated with high energy and greater displacement

›Premature physeal closure (PPC) risk factors

›Initial displacement ≥4 mm

›High-energy mechanism

›Younger age at injury

›More than 2 reduction attempts — 8.5-fold increased PPC risk

Pathophysiology

›Growth plate anatomy and vulnerability

›Physis — cartilaginous growth plate at ends of long bones

›Four zones: reserve, proliferative, hypertrophic, provisional calcification

›Hypertrophic zone is weakest — fracture propagates through this layer

›Periosteum — stronger on tension side of fracture

›Intact periosteum on compression side aids reduction stability

›Physis has lower tensile strength than surrounding ligaments in skeletally immature children

›Point of failure before ligament rupture in children

›Ligament injuries more common as physis closes in late adolescence

›SH-II fracture mechanics

›Fracture begins in hypertrophic zone of physis

›Propagates transversely through physis

›Exits through the metaphysis rather than epiphysis

›Thurston-Holland fragment

›Triangular metaphyseal fragment attached to epiphysis

›Pathognomonic for SH-II on radiograph

›Periosteum often intact on metaphyseal fragment side

›Epiphysis remains intact

›Cartilaginous blood supply to epiphysis generally preserved

›Growth disturbance lower risk than SH-III and IV

›Premature physeal closure mechanism

›Bony bridge formation across physis (physeal bar)

›Interrupts longitudinal growth

›Central bars cause angular deformity

›Peripheral bars cause limb length discrepancy

›Risk increased by vascular disruption of germinal cell layer

›Greater displacement — more vascular disruption

›High-energy injury — more germinal cell damage

›Periosteal entrapment

›Recent evidence suggests it is not an independent risk factor for growth disturbance

›Zhang et al 2026 — routine periosteal stripping may be unnecessary

Therapeutic Considerations

›Fracture healing timeline

›Most SH-II fractures heal within 4–6 weeks

›Distal radius — 4–6 weeks cast immobilization

›Distal tibia — 6 weeks

›Distal femur — 6–8 weeks

›Return to sports typically 6–12 weeks

›Depends on site, sport, and healing trajectory

›Growth monitoring protocol

›SH fractures monitored 6–12 months for growth arrest

›Clinical and radiographic follow-up

›Standing limb length assessment at intervals

›MRI most sensitive for early physeal bar detection

›Bridge as small as 10–12% of physeal area may be visible

›Early detection allows bar resection before significant deformity

›Evidence base for reduction thresholds

›Nonoperative management supported if postreduction displacement <3 mm

›Margalit et al 2020 (STROBE study — distal tibia SH-II)

›Operative versus nonoperative for PPC prevention

›No reduction in PPC with surgery versus closed management — clinical equipoise

›Russo et al 2013, Jalkanen et al 2021 (systematic review and meta-analysis)

›Follow-up radiograph utility

›Routine delayed follow-up radiographs in asymptomatic distal radius SH-II fractures have low yield

›Physeal bridge detection rate 1.3% — Brahee and Smith 2021

›Analgesia evidence

›Ibuprofen 10 mg/kg equivalent to opioids for pediatric musculoskeletal pain

›Ali et al 2021 (observational cohort — ibuprofen vs oxycodone for fractures)

›No additional benefit of acetaminophen or opioid added to ibuprofen

›No OUCH trials — Ali et al 2026 (JAMA)

›Utsumi et al 2024 systematic review and network meta-analysis — ibuprofen remains optimal first-line

11Patient Discharge Instructions/pdi50

copy discharge instructions

›Diagnosis and what it means

›Your child has a Salter-Harris Type II fracture

›A break through the growth plate (physis) and the bone just above it

›The most common type of growth plate injury in children

›The growth plate is the area of developing tissue near the ends of long bones

›Most of these fractures heal well with proper immobilization

›Expected healing time is 4–6 weeks in a cast or splint

›Regular orthopedic follow-up is essential to monitor healing

›Cast and splint care

›Keep the cast or splint dry at all times

›Use a waterproof sleeve or bag for bathing

›Wet casts must be replaced

›Do not put anything inside the cast

›No sticks, pencils, or objects to scratch under cast

›Risk of skin breakdown and infection

›Elevate the injured limb above heart level for the first 48–72 hours

›Reduces swelling and pain

›Ice packs around the outside of the cast for the first 48 hours

›20 minutes on, 40 minutes off

›Pain management at home

›Ibuprofen for pain as directed

›Dose: 10 mg/kg by mouth (maximum 600 mg per dose)

›Every 6–8 hours with food

›Do not give if allergy to NSAIDs

›Acetaminophen can be alternated with ibuprofen

›Dose: 15 mg/kg by mouth (maximum 1000 mg per dose)

›Every 4–6 hours as needed

12References/r47

Guidelines and key sources

›Deng H, Zhao Z, Xiong Z, et al

›Clinical Characteristics of 1124 Children With Epiphyseal Fractures

›BMC Musculoskeletal Disorders 2023

›PMID 37479999

›Brown JH, DeLuca SA

›Growth Plate Injuries: Salter-Harris Classification

›American Family Physician 1992

›PMID 1414883

›Margalit A, Peddada KV, Dunham AM, Remenapp CM, Lee RJ

›Salter-Harris Type II Fractures of the Distal Tibia: Residual Postreduction Displacement and Outcomes

›Medicine 2020 — STROBE compliant study

›PMID 32118764

›Russo F, Moor MA, Mubarak SJ, Pennock AT

›Salter-Harris II Fractures of the Distal Tibia: Does Surgical Management Reduce the Risk of Premature Physeal Closure?

›Journal of Pediatric Orthopedics 2013

›PMID 23752150

›Jalkanen J, Sinikumpu JJ, Puhakka J, et al

›Physeal Fractures of Distal Tibia: A Systematic Review and Meta-Analysis

›Journal of Pediatric Orthopedics 2021

›PMID 33843787

›Ali S, Klassen TP, Candelaria P, et al

›Acetaminophen or Opioid Analgesia Added to Ibuprofen for Children's Musculoskeletal Injury (No OUCH trials)

›JAMA 2026

›PMID via jamanetwork.com

›Utsumi S, Amagasa S, Moriwaki T, Uematsu S

›Oral Analgesic for Musculoskeletal Injuries in Children: Systematic Review and Network Meta-Analysis

›Academic Emergency Medicine 2024

Evidence & Review

Evidence & Review