Physes close by late adolescence; SH type V fractures do not occur in adults
Equivalent injury in adults presents as intra-articular fracture or joint impaction
If an older adolescent with partially closed physes
Same management principles apply as in younger children
Medication considerations in adolescents with comorbidities
Dose NSAIDs conservatively if renal or hepatic compromise present
Bone density
Consider bone density evaluation if pathologic mechanism or metabolic disease suspected in older adolescent
Pediatrics
Age-specific management considerations
Younger age at injury correlates with higher risk of growth disturbance
More growth remaining means greater potential for clinically significant deformity
All clinically significant growth disturbances occur within 2 years of initial injury
Non-accidental trauma protocol
Physeal injuries in children under 3 years with axial mechanism require careful evaluation
Skeletal survey if any concern
Dosing in young children
Weight-based dosing for all analgesics
Ibuprofen 10 mg/kg every 6 to 8 hours
Acetaminophen 15 mg/kg every 4 to 6 hours
Cast considerations
Pediatric plaster or fiberglass cast sized appropriately for limb dimensions
Check cast fit and neurovascular status before discharge
Prognosis counseling
Inform parents that growth disturbance is possible even with appropriate treatment
Long-term follow-up minimum 1 to 2 years is mandatory
Distal femur injuries in young children
Peak age for clinically significant growth disturbance approximately 10.2 years in males and 9.1 years in females
Distal femur and proximal tibia most consequential anatomic sites
Background
Epidemiology
Incidence and prevalence
Physeal fractures account for 15 to 30% of all pediatric fractures
SH type V represents only 1 in 1,147 epiphyseal fractures in large series
True rarest SH subtype; exact incidence likely underestimated due to diagnostic difficulty
Sex distribution
Male-to-female ratio approximately 2:1 for physeal fractures overall
Age distribution
Peak age for distal femur and tibia physeal fractures approximately 10 to 14 years
Peak age for clinically significant growth disturbance approximately 10.2 years in males
Anatomic distribution
Most consequential locations: distal femur, proximal tibia, distal tibia
Distal radius most common overall physeal fracture site but lower growth consequence
Prognosis
SH type V carries worst prognosis for growth disturbance of all SH types
Only poor or fair outcomes reported in distal femoral series
Pathophysiology
Mechanism of injury
Axial compression or crush force applied to the physis
Unlike shear forces in SH types I and II or combined forces in SH types III and IV
Physeal anatomy and vulnerability
Growth plate composed of four zones: resting, proliferative, hypertrophic, calcification
Hypertrophic zone is weakest mechanically
Physis is weaker than surrounding ligaments before skeletal maturity
Compression injury effect
Compressive force disrupts chondrocyte columns without creating visible fracture line
Vascular supply to physeal chondrocytes may be compromised
Premature physeal closure mechanism
Physeal bar (bone bridge) forms across the damaged growth plate
Bar tethers one portion of the physis, causing asymmetric growth
Result is angular deformity, limb length discrepancy, or both
Consequences of location
Distal femur contributes 70% of femoral length and 40% of total lower limb length
Proximal tibia contributes approximately 60% of tibial length
Therapeutic Considerations
Evidence base for management
No prospective randomized trials exist for SH type V due to rarity
Management based on case series, retrospective cohorts, and expert consensus
Conservative immobilization evidence
Non-weight-bearing and casting remain standard first-line management
Duration 3 to 6 weeks based on clinical response and anatomic location
Physeal bar resection evidence
Resection with interposition material may restore growth when bar occupies less than 50% of physis
Success rates vary; best outcomes with early identification and small bar size
Serial imaging guidance
Follow-up radiographs every 3 to 6 months for at least 2 years recommended
MRI for suspected physeal bar formation or when plain films are equivocal
Emerging therapies
Mesenchymal stem cell-based therapy under investigation for growth plate cartilage repair
Preclinical studies show promise; clinical translation not yet established
Avoid repeated manipulation
Repetitive reduction attempts shown to increase risk of physeal arrest in case series
Surgical timing for bar resection
Early intervention (within first year of identified bar) associated with better outcomes
Greater than 50% bar involvement or near skeletal maturity favors ablative rather than resective approach
Patient Discharge Instructions
copy discharge instructions
Diagnosis and explanation
Your child has been diagnosed with a suspected growth plate compression injury (Salter-Harris type V fracture)
This type of injury is caused by a crushing or compressive force on the growth plate
The growth plate is the area where bones grow in children; it can be injured without a visible fracture on X-ray
What to expect
This injury may not show clearly on initial X-rays and is often confirmed over time
There is a significant risk that the growth plate has been damaged, which can affect bone growth
Your child may develop a difference in limb length or a bend in the bone over the coming months
Cast or splint care
Cast and weight-bearing instructions
Keep the cast or splint clean and dry at all times
Do not bear weight on the injured limb until cleared by orthopedics
Use crutches as instructed; do not put any weight through the foot
Do not insert objects into the cast to scratch the skin
Elevate the limb above heart level for the first 48 to 72 hours to reduce swelling
Medications at home
Pain management plan
Ibuprofen (Advil or Motrin) every 6 to 8 hours with food as needed for pain
Acetaminophen (Tylenol or Tempra) every 4 to 6 hours as needed if ibuprofen is insufficient
Do not exceed recommended doses; contact us if pain is not controlled
Follow-up instructions
Follow-up schedule
Orthopedic appointment within 5 to 7 days from today is mandatory
Serial X-rays will be needed at 4 to 6 weeks, 3 months, 6 months, 12 months, and 24 months
Long-term follow-up for at least 1 to 2 years is essential even if your child feels completely better
Activity restriction until cleared by your orthopedic surgeon
Return to emergency department immediately if
Red flag symptoms requiring immediate return
Increasing pain that is not controlled by medications
Numbness, tingling, or weakness in the foot or toes
Foot becomes pale, blue, or cold
Cast becomes too tight, cracks, or breaks
Fever above 38.5 degrees Celsius
Signs of compartment syndrome: severe pain with movement of the toes, tight swollen limb
References
Guidelines and key sources
Primary literature and guidelines
Brown JH, DeLuca SA. Growth Plate Injuries: Salter-Harris Classification. American Family Physician. 1992. PMID: 1414883
Foundational classification reference
Deng H, Zhao Z, Xiong Z, et al. Clinical Characteristics of 1124 Children With Epiphyseal Fractures. BMC Musculoskeletal Disorders. 2023. PMID: 37479999
Large series; epidemiologic data on physeal fracture types and growth disturbance
Yamamura MK, Carry PM, Gibly RF, et al. Epidemiology of Physeal Fractures and Clinically Significant Growth Disturbances Affecting the Distal Tibia, Proximal Tibia, and Distal Femur. JAAOS. 2023. PMID: 37054395
Key epidemiologic data on growth disturbance rates and age at injury
Nguyen JC, Markhardt BK, Merrow AC, Dwek JR. Imaging of Pediatric Growth Plate Disturbances. Radiographics. 2017. PMID: 29019753
MRI protocols and imaging findings in physeal injury
Czitrom AA, Salter RB, Willis RB. Fractures Involving the Distal Epiphyseal Plate of the Femur. International Orthopaedics. 1981. PMID: 7228463
Classic distal femur SH fracture series with outcome data
Yeung DE, Jia X, Miller CA, Barker SL. Interventions for Treating Ankle Fractures in Children. Cochrane Database of Systematic Reviews. 2016
Systematic review; conservative versus operative management evidence
Carey J, Spence L, Blickman H, Eustace S. MRI of Pediatric Growth Plate Injury: Correlation With Plain Film Radiographs and Clinical Outcome. Skeletal Radiology. 1998. PMID: 9638834
MRI sensitivity for occult physeal injury
MacDonald J, Rodenberg R, Sweeney E. Acute Knee Injuries in Children and Adolescents: A Review. JAMA Pediatrics. 2021
Includes orthopedic consultation recommendations and management framework
Jaramillo D, Perdomo-Luna C, Kvist O. Evaluation of Physeal Abnormalities of the Knee With MRI. Skeletal Radiology. 2026. PMID: 41699098
Latest MRI techniques for physeal evaluation
Putukian M, Leclere LE, Herring SA, et al. The Adolescent Athlete and the Team Physician: A Consensus Statement. 2025 Update. Medicine and Science in Sports and Exercise. 2026
Return-to-sport guidance and physeal injury management in athletes
Emerging regenerative approaches for physeal injury
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.