01Approach to the Critical Patient/attcp38

Immediate threats

›Neurovascular emergency triggers

›Absent or diminished distal pulse

›Pallor, pulselessness, paresthesias, paralysis, pain out of proportion

›Distal femur and proximal tibia SH IV fractures at highest risk of popliteal artery injury

›Immediate vascular surgery consultation if pulse deficit confirmed

›Compartment syndrome signs

›Pain out of proportion to injury

›Pain with passive stretch of involved muscle groups

›Tense, woody compartment on palpation

›Immediate orthopedic and surgical consultation for fasciotomy planning

›Open fracture

›Visible bone or wound communicating with fracture site

›Sterile wound coverage and urgent OR consultation

›Perioperative antibiotics within 60 minutes

Stabilization priorities

›Initial stabilization bundle

›Splint in position of comfort — do not attempt reduction in field or without orthopedics present

›Long-leg posterior splint for lower extremity fractures

›Sugar-tong or coaptation splint for upper extremity fractures

›Ice and elevation above heart level

›Reduces swelling and pain

›Limits secondary neurovascular compromise from progressive edema

›Strict non-weight-bearing and immobilization

›IV access and analgesia

›Morphine 0.1 mg/kg IV for severe pain

›Ibuprofen 10 mg/kg PO/IV q6h for mild-to-moderate pain

›Acetaminophen 15 mg/kg PO/IV q4-6h as adjunct

02History/hx41

Mechanism and presentation

›Mechanism of injury

›Falls from height or sports collision

›Motor vehicle collision with pedestrian or passenger

›Direct trauma to an extremity

›Axial loading, rotational, hyperextension, or valgus/varus stress vector

›Timing and functional status

›Time since injury — delay greater than 72 hours increases complication risk

›Ability to bear weight or use the extremity after injury

›Progression of swelling or pain since injury

›Neurologic and vascular symptoms

›Numbness or tingling distal to injury

›Color change or coolness of fingers or toes

›Weakness distal to injury

Risk factors and context

›Skeletal maturity assessment

›Age of patient — peak incidence in adolescents

›Pubertal stage (Tanner staging)

›Remaining growth potential — more growth remaining means higher consequence of physeal arrest

›Prior injuries

›Previous fractures to the same extremity or growth plate

›Prior growth disturbance or documented leg length discrepancy

›Contralateral limb comparison history

›Bone health risk factors

›Chronic steroid use

›Known metabolic bone disease, rickets, or renal osteodystrophy

›Osteogenesis imperfecta history

›Non-accidental trauma screen (young children)

03Physical Exam/exam29

General and neurovascular

›Neurovascular examination — mandatory and must be documented

›Distal pulses — dorsalis pedis and posterior tibial for lower extremity

›Radial and ulnar pulses for upper extremity fractures

›Capillary refill time — abnormal if greater than 2 seconds

›Sensation in all major nerve distributions distal to fracture

›Motor function distal to fracture

›Compartment assessment

›Palpation of all compartments for tenseness

›Pain with passive stretch of muscles in each compartment

›Compartment pressure measurement if clinical concern

Local fracture examination

›Inspection

›Swelling and ecchymosis over the physis and joint

›Visible deformity or angulation

›Skin tenting or breach — rule out open fracture

›Even small puncture wounds must be recognized as potential open fractures

›Palpation

›Point tenderness directly over the physis

›Tenderness over the epiphysis and metaphysis distinguishing SH IV from sprain

›Intra-articular effusion or hemarthrosis on ballottement

›Range of motion

›Typically limited by pain — do not force through pain

›Document baseline active range of motion

›Contralateral comparison

›Symmetry of limb alignment

›Limb length discrepancy measurement

04Differential Diagnosis/ddx47

Other Salter-Harris fracture types

›Salter-Harris Type I

›ICD-10: S89.001A (distal tibia), S59.001A (distal radius)

›Slip through the physis only, no bony fragment

›Radiographs may appear normal — diagnosis by physeal tenderness

›Salter-Harris Type II

›ICD-10: S89.021A (distal tibia)

›Fracture through physis exiting through metaphysis

›Most common SH type — generally favorable prognosis

›Salter-Harris Type III

›ICD-10: S89.031A (distal tibia)

›Fracture through physis exiting through epiphysis into joint

›Requires anatomic reduction of articular surface

›Salter-Harris Type V

›ICD-10: S89.091A

›Compression/crush injury of physis

›Often diagnosed retrospectively when growth arrest develops

Distal tibia-specific variants

›Tillaux fracture

›ICD-10: S82.301A

›SH III variant of anterolateral distal tibial epiphysis in adolescents

›Occurs during transitional physeal closure (12-14 years)

›Avulsion of anterolateral epiphysis by anterior tibiofibular ligament

›Triplane fracture

›ICD-10: S82.301A

›Complex SH IV variant during physeal closure — fracture in all three planes

›Occurs in adolescents aged 10-16 years during closing of the distal tibial physis

›CT is essential for classification

05Laboratory Tests/lt20

Routine blood work

›Standard isolated SH IV fracture labs

›Routine labs generally not required for isolated closed SH IV fractures

›Pre-operative labs if ORIF planned

›Complete blood count

›Basic metabolic panel

›Type and screen per institutional protocol

›Coagulation studies if bleeding disorder suspected

Non-accidental trauma workup

›Metabolic bone disease and NAT panel

›Skeletal survey (radiologic, not a lab but ordered together)

›Serum vitamin D (25-OH vitamin D) level

›Deficiency defined as less than 50 nmol/l

›Serum calcium and phosphorus

›Alkaline phosphatase — elevated in metabolic bone disease

›Intact parathyroid hormone (PTH)

Infection-related labs

›Open fracture or delayed presentation with fever

›Complete blood count with differential

›Leukocytosis raises concern for developing infection

›Blood cultures if febrile

›C-reactive protein or ESR if osteomyelitis concern

›Wound culture at time of operative debridement

06Diagnostic Tests/dt63

Scoring Systems

›Salter-Harris classification (SALTR mnemonic)

›Type I — Slip through physis only (S)

›Type II — Above the physis, exits metaphysis (A)

›Type III — Lower/beLow physis, exits epiphysis (L)

›Type IV — Through all structures: epiphysis, physis, metaphysis (T)

›Type V — Rammed/cRush injury of physis (R)

›Risk stratification by displacement

›Nondisplaced SH IV — lower risk of physeal arrest but still requires close follow-up

›Displaced SH IV — 4-fold increased risk of growth arrest versus nondisplaced

›Physeal gapping greater than 3 mm after reduction suggests entrapped periosteum

›Coronal plane physeal involvement extent predicts physeal bar formation risk

›Ottawa Ankle Rules (pediatric application)

›Used by over 50% of practitioners for pediatric ankle injuries

›Sensitivity for physeal fractures is debated and may be lower than for adults

›Cannot be used to exclude physeal fracture in children with focal physeal tenderness

MRI

›MRI indications for SH IV fracture

›Acute setting — equivocal radiographs with clinical suspicion of physeal injury

›Detects cartilaginous injury not visible on plain films

›Useful when epiphysis is largely cartilaginous in young children

›Subacute and follow-up setting

›Most sensitive modality for detecting physeal bar formation

›Recommended if growth disturbance is suspected on serial radiographs

›Allows measurement of physeal bar size and percentage of physis involved

›MRI protocol considerations

›Coronal and sagittal T1 and STIR sequences across the physis

›Fat-suppressed sequences identify bone edema at fracture margins

›Physeal bar appears as low-signal bridging across the physis on T1

›Limitations

›Requires sedation in young or uncooperative children

›Not required in straightforward displaced SH IV with clear CT diagnosis

CT

›CT indications for SH IV fracture

›Recommended for displaced SH III and IV fractures at the distal tibia and distal femur

›Accurately assesses articular step-off

›Quantifies fragment displacement for surgical planning

›CT changed fracture classification in 30% of cases in published series

›CT significantly altered treatment decisions in multiple studies

›CT of distal humerus for lateral condyle fractures

›Determines displacement of articular fragment

›Guides decision between casting and ORIF

›CT protocol

›Thin-slice (1 mm) axial acquisition with coronal and sagittal reconstructions

›Low-dose pediatric protocol when available

›Limitations

›Not required for SH I or II fractures

›Cartilaginous components may not be fully visualized — MRI complements

›Radiation exposure — minimize with pediatric low-dose protocols

Ultrasound

›Point-of-care ultrasound in SH IV fracture

›Not standard for diagnosis of SH IV fractures

›May identify joint effusion or hemarthrosis

›Cortical irregularity at physeal zone visible in experienced hands

›Useful adjunct in resource-limited or prehospital settings

›Limitations

›Operator-dependent and does not replace plain radiographs or CT

›Cannot delineate cartilaginous structures adequately

›Cannot define degree of physeal displacement for surgical planning

›Plain radiographs — first-line imaging

›AP, lateral, and oblique views of the affected joint

›Oblique views are critical — metaphyseal fragment may only be visible on oblique projection

›Comparison views of the contralateral extremity in young children with largely cartilaginous epiphyses

›Radiographic signs of SH IV

›Fracture line visible through epiphysis, physis, and metaphysis

›Articular surface discontinuity on AP or oblique view

›Physeal widening or displacement

07Disposition/dispo31

Admission criteria

›Indications for admission

›Displaced SH IV fracture requiring ORIF

›Nearly all displaced SH IV fractures meet surgical criteria

›Admit to orthopedic or pediatric surgery service

›Neurovascular compromise at any time point

›Admitted for hourly neurovascular checks minimum

›Open fracture

›Admission for IV antibiotics and urgent OR

›Compartment syndrome confirmed or suspected

›ICU or high-dependency monitoring post-fasciotomy

›Polytrauma

›Trauma surgery or pediatric surgery service admission

Discharge criteria

›Criteria for ED discharge

›Truly nondisplaced SH IV fracture — rare

›Intact neurovascular exam confirmed

›Adequate splinting applied

›Reliable caregiver able to comply with non-weight-bearing instructions

›Orthopedic follow-up arranged within 5 to 7 days

›Orthopedic consultation obtained prior to discharge — mandatory for all SH IV

Transfer criteria

›Transfer indications

›No orthopedic surgeon available at treating facility

›Transfer to center with pediatric orthopedic coverage

›Vascular injury requiring vascular surgery

›Transfer to trauma center capable of combined orthopedic and vascular repair

›Polytrauma exceeding local resource capability

08Treatment/t67

Analgesia and sedation

›Pain management protocol

›Mild-to-moderate pain

›Ibuprofen 10 mg/kg PO/IV q6h — maximum 600 mg per dose

›Acetaminophen 15 mg/kg PO/IV q4-6h — maximum 1000 mg per dose

›Combination analgesia preferred for additive effect

›Severe pain

›Morphine 0.1 mg/kg IV — titrate to pain relief

›Fentanyl 1-2 mcg/kg IV as alternative

›Procedural sedation for reduction if needed

›Ketamine 1-2 mg/kg IV with midazolam 0.05 mg/kg IV

›Propofol 1-2 mg/kg IV per institutional protocol

›Continuous monitoring with resuscitation equipment at bedside

Immobilization and initial management

›Splinting protocol

›Lower extremity SH IV fractures

›Long-leg posterior splint with ankle at 90 degrees

›Plaster or fiberglass — 10 to 12 layers of plaster

›Splint from toes to proximal thigh for knee and femoral injuries

›Upper extremity SH IV fractures

›Sugar-tong splint for forearm and distal radius injuries

›Long-arm posterior splint for elbow and distal humerus injuries

›Strict non-weight-bearing and non-use instructions

›Ice packs applied 20 minutes on, 20 minutes off

›Elevation above heart level

Operative management

›Open reduction and internal fixation (ORIF)

›Standard of care for displaced SH IV fractures

›Restores anatomic alignment of physis and articular surface

›Class I recommendation based on consensus and case series evidence

›Surgical timing

›Urgent ORIF within 6 to 12 hours if neurovascular compromise

›Semi-urgent ORIF within 24 to 48 hours for isolated displaced fractures

›Delay beyond 72 hours increases complication risk

›Reduction principles

›Anatomic reduction of physis is the most critical determinant of outcome

›Residual physeal displacement is the strongest predictor of premature physeal closure

›Maximum 2 reduction attempts — more than 2 attempts associated with 8.5x increased odds of premature physeal closure

›Hardware selection

›Smooth K-wires or cannulated screws

›Hardware should avoid crossing the physis when possible

›If physis must be crossed, use smooth pins perpendicular to the physis

›Partially threaded cannulated screws placed parallel to physis in epiphysis when possible

›Post-operative immobilization

›Long-leg or short-leg cast depending on fracture location

›Strict non-weight-bearing for 4 to 6 weeks post-operatively

Non-operative management

›Casting for nondisplaced SH IV

›Reserved for truly nondisplaced fractures — uncommon presentation

›Below-knee walking cast or non-weight-bearing long-leg cast

›Cast change at 2 weeks if swelling has resolved

›Total immobilization duration 6 to 8 weeks

›Mandatory orthopedic follow-up within 5 to 7 days

›Repeat radiographs at follow-up to confirm no displacement has occurred

Antibiotic prophylaxis

›Open fracture antibiotic protocol

›Gustilo Grade I and II

›Cefazolin 30 mg/kg IV (maximum 2 g) within 60 minutes of injury

›Continue for 24 hours post-operatively

›Gustilo Grade III

›Cefazolin 30 mg/kg IV plus gentamicin 2.5 mg/kg IV

›Add penicillin G or metronidazole for contaminated wounds

›Continue 48 to 72 hours post-operatively

Secondary procedures for growth complications

›Physeal bar resection

›Indicated if bar involves less than 50% of physis and patient has more than 2 years of growth remaining

›Fat or Cranioplast interposition to prevent bar reformation

›Contralateral epiphysiodesis

›Arrests growth of contralateral normal physis to equalize limb length

›Timed to skeletal maturity to achieve equalization at skeletal maturity

›Corrective osteotomy

›For established angular deformity from partial physeal arrest

›Deferred until physeal closure to prevent recurrence

09Special Populations/sp50

Pregnancy

›Pregnancy and SH IV fracture

›SH IV fractures are exclusively pediatric injuries occurring in skeletally immature patients

›Pregnancy combined with SH IV fracture is an extremely rare scenario (adolescent patient)

›Growth plate closes by late adolescence — SH fractures do not occur in adults

›Radiation considerations in pregnant adolescent patients

›Limit radiation exposure — use ultrasound where diagnostic

›MRI preferred over CT when possible in pregnant adolescents

›Shield pelvis for radiographs not involving the pelvis

›Medication safety in pregnant adolescents

›Avoid NSAIDs after 20 weeks gestation — risk of premature ductal closure

›Acetaminophen is first-line analgesic in pregnant patients

›Opioids only for severe pain with anesthesia or obstetric input

›Operative considerations

›Anesthesia team must plan for pregnant patient

›Left lateral tilt positioning after first trimester

›Obstetric consultation mandatory if general anesthesia planned

Geriatric

›Geriatric considerations for Salter-Harris fractures

›True SH fractures do not occur in adults with fused growth plates

›Adults may sustain epiphyseal or articular fractures but these are not classified SH

›Equivalent adult injury is an intra-articular fracture without physeal component

›If evaluating a young elderly patient with an unusual fracture pattern

›Consider delayed skeletal maturity as a rare cause of persistent physeal vulnerability

›Bone density screening if osteoporosis-pattern fracture

›DEXA scan if low-energy mechanism raises metabolic bone disease concern

Pediatrics

›Pediatric-specific considerations for SH IV fractures

10Background/b61

Epidemiology

›Incidence and distribution

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

›Salter-Harris Type II is the most common — approximately 75% of physeal fractures

›Salter-Harris Type IV accounts for approximately 10% to 12% of physeal fractures

›Age and sex distribution

›Peak incidence in adolescent males

›Male to female ratio approximately 2:1

›Physeal fractures are rare in children under 5 years of age

›Most common fracture sites for SH IV

›Distal radius and phalanges (most frequent overall for all SH types)

›Distal humerus — lateral condyle is a classic SH IV location in young children

›Distal tibia — medial malleolus SH IV is well-characterized

›Distal femur — less common but highest risk of growth disturbance

›Risk of growth disturbance by location

›Distal femur SH IV — growth disturbance in up to 64% of cases

›Distal tibia SH IV — growth disturbance in approximately 20% of cases

›Physeal bar formation reported in 30% of SH III/IV medial malleolus fractures

›47% of those with physeal bar required secondary surgical procedures

Pathophysiology

›Anatomy of the growth plate

›The physis (growth plate) is a cartilaginous structure at the ends of long bones

›Composed of four zones: reserve zone, proliferative zone, hypertrophic zone, calcification zone

›Weakest mechanical zone is the hypertrophic zone — where most SH I and II fractures occur

›SH IV fracture traverses all four zones plus epiphysis and metaphysis

›SH IV fracture pattern

›Fracture line begins in epiphysis, crosses the physis, exits through the metaphysis

›Results in an intra-articular fracture with physeal disruption

›Two fragments: one containing epiphysis, physis, and metaphysis; one the main bone segment

›Mechanism of physeal arrest

›Disruption of blood supply to physeal chondrocytes from fracture

›Formation of bony bridge (physeal bar) bridging across the fractured physis

›Physeal bar tethers growth — causes angular deformity if peripheral, limb shortening if central

›Articular congruity requirement

›Because SH IV is intra-articular, articular step-off greater than 2 mm leads to posttraumatic arthritis

›Anatomic reduction restores joint surface and reduces posttraumatic arthritis risk

›Factors predicting physeal arrest

›Degree of initial displacement — strongest predictor

›Coronal plane physeal involvement extent

›Number of reduction attempts — more than 2 attempts associated with 8.5x increased odds

Therapeutic Considerations

›Evidence base for ORIF

›Near-universal consensus for ORIF in displaced SH IV fractures

›Class I recommendation based on observational evidence and expert consensus

›Anatomic reduction reduces posttraumatic arthritis and physeal arrest risk

›Nondisplaced fractures

›Limited evidence supports casting for truly nondisplaced SH IV

›Must confirm nondisplacement with CT — plain radiographs may underestimate displacement

›Hardware considerations

›Smooth K-wires cause less physeal damage than threaded screws crossing the physis

›Cannulated screws parallel to physis in epiphysis do not cross physis and are preferred when anatomy allows

›Physeal bar management

›Bar resection (Langenskiold procedure) for bars involving less than 50% of physis

›Best outcomes when more than 2 years of growth remaining

›Success rate approximately 50% to 70% — physeal growth may not fully recover

›Monitoring frequency drives early detection

›Serial radiographs every 3 to 4 months for at least 12 months

›Park-Harris growth arrest lines on radiograph indicate interval growth

›MRI for early bar detection before angular deformity develops

›Complications and natural history

›Displaced fractures have 4-fold increased risk of growth arrest versus nondisplaced

›Posttraumatic arthritis risk from articular incongruity — significant with step-off greater than 2 mm

›Neurovascular injury particularly at distal femur and proximal tibia where popliteal artery is at risk

›Outcome is generally better with anatomic reduction and rigid fixation — delays do not improve outcome

11Patient Discharge Instructions/pdi31

copy discharge instructions

›Discharge instructions for Salter-Harris IV Fracture

›Your child has a growth plate fracture called a Salter-Harris Type IV fracture

›This fracture goes through the joint surface and the growth plate

›Most of these fractures need surgery to heal properly

›It is very important to follow all instructions carefully

›Activity restrictions

›No weight bearing on the injured leg — use crutches as instructed by the doctor

›No use of the injured arm — keep it elevated and in the splint

›Do not remove or get the splint or cast wet

›Pain management at home

›Ibuprofen 10 mg/kg every 6 hours as needed for pain (if no allergy)

›Acetaminophen 15 mg/kg every 4 to 6 hours as needed if ibuprofen is not enough

›Do not give both at the same time — space them out

›Swelling control

›Keep the injured limb elevated above heart level as much as possible for the first 48 hours

›Ice pack wrapped in a cloth — 20 minutes on, 20 minutes off

›Follow-up appointment

›Orthopedic appointment is scheduled within 5 to 7 days — do not miss this

›Growth plate fractures require repeated X-rays over many months to check for growth problems

›Bring your child back for all follow-up appointments even if feeling better

›Return to the emergency department immediately if

›Increasing pain that is not controlled with medication

›Numbness, tingling, or color change (pale, blue, or very red) in the fingers or toes

›Swelling or tightness inside the splint or cast that feels like squeezing

›Inability to move fingers or toes

›Fever above 38.5 degrees Celsius (101.3 degrees Fahrenheit)

›Drainage or bad smell from the cast or wound

12References/r33

Guidelines and key sources

›MacDonald J, Rodenberg R, Sweeney E — Acute Knee Injuries in Children and Adolescents

›JAMA Pediatrics 2021

›Primary source for neurovascular risk, growth disturbance rates, and management algorithm

›Brown JH, DeLuca SA — Growth Plate Injuries: Salter-Harris Classification

›American Family Physician 1992

›Foundational classification reference including SALTR mnemonic and epidemiology

›Podeszwa DA, Mubarak SJ — Physeal Fractures of the Distal Tibia and Fibula

›Journal of Pediatric Orthopedics 2012

›Source for distal tibia physeal bar rates, reduction principles, and follow-up recommendations

›Wall EJ, May MM — Growth Plate Fractures of the Distal Femur

›Journal of Pediatric Orthopedics 2012

›Source for distal femur growth disturbance rates up to 64% and CT classification changes

›Deng H, Zhao Z, Xiong Z et al — Clinical Characteristics of 1124 Children With Epiphyseal Fractures

›BMC Musculoskeletal Disorders 2023

›Large series data on SH fracture distribution and epidemiology

Supporting references

›Cass JR, Peterson HA — Salter-Harris Type IV Injuries of the Distal Tibial Epiphyseal Growth Plate

›Journal of Bone and Joint Surgery 1983

›Classic reference on medial malleolus SH IV outcomes and physeal arrest rates

›Wuerz TH, Gurd DP — Pediatric Physeal Ankle Fracture

›Journal of the American Academy of Orthopaedic Surgeons 2013

›Physeal bar formation rates (30%), secondary surgery rates (47%), and Ottawa Ankle Rules applicability

›Roth OS, Gupta A, Adebayo T, Tretiakov M — Risk Factors and Surgical Sequelae of Physeal Arrest in Pediatric SH III and IV Medial Malleolus Fractures

›Journal of Pediatric Orthopedics 2025

›Most recent data on coronal plane involvement and multiple reduction attempts

›Nguyen JC, Markhardt BK, Merrow AC, Dwek JR — Imaging of Pediatric Growth Plate Disturbances

›Radiographics 2017

Evidence & Review

Evidence & Review