01Approach to the Critical Patient/attcp29

Immediate priorities

›Initial assessment priorities

›Mechanism clarification

›High-energy axial loading or crush mechanism

›Motor vehicle accident, fall from height, direct compression

›Neurovascular status

›Distal pulses, capillary refill, motor and sensory function

›Popliteal artery at risk in distal femur or proximal tibia injuries

›Weight-bearing status

›Inability to bear weight despite normal-appearing radiographs is a key alarm

›If neurovascular compromise, emergent orthopedic and vascular surgery consultation

Alarm features

›High-suspicion triggers

›Pain and swelling directly over the physis with high-energy mechanism and normal radiographs

›Combination is pathognomonic clinical presentation of SH type V

›Progressive angular deformity or limb length discrepancy weeks to months post-injury

›Indicates premature physeal closure

›Open fracture with high-velocity mechanism

›Associated with universally poor outcomes

›Compartment syndrome signs

›Pain out of proportion, pain with passive stretch, paresthesias, pallor

Key decision points

›Branching decision logic

›If initial radiographs are normal but physis is tender and mechanism is axial

›Presumptive SH type V until proven otherwise

›MRI for definitive evaluation if available

›If neurovascular deficit present

›Emergent orthopedic consultation before further imaging

02History/hx51

Mechanism and onset

›Injury mechanism details

›Axial loading or compression force transmitted through the joint

›Fall from height landing on feet

›High-velocity motor vehicle accident

›Crush injury

›Distinction from shearing forces

›Shearing produces SH type I; axial compression produces SH type V

›Timing of injury and symptom onset

›Ability to bear weight immediately after injury

›Prior injuries to the same extremity

Symptom characterization

›Presenting complaints

›Pain localized over the physis

›Swelling without visible deformity acutely

›Inability to bear weight despite apparently normal radiographs

›Key negative findings

›No visible fracture line on X-ray

›No bony displacement

›This absence of radiographic findings is the hallmark diagnostic challenge

›Neurological symptoms

›Numbness or tingling in peroneal nerve distribution if knee or ankle involved

›Vascular symptoms

›Coolness or pallor of the foot

Risk factors

›Patient-level risk factors

›Skeletally immature children with open physes

›Physis is the weakest link in the musculoskeletal chain in this age group

03Physical Exam/exam33

Vital signs and general appearance

›Hemodynamic and general assessment

›Vital signs generally normal in isolated physeal injury

›Tachycardia if polytrauma or severe pain

›Deceptively benign appearance

›No gross deformity visible acutely in pure SH type V

Local extremity examination

›Systematic regional assessment

›Inspection

›Swelling over the physis

›Ecchymosis may be absent or minimal

›Subtle limb alignment assessment

›Palpation

›Point tenderness directly over the growth plate

›Single most important exam finding

›Range of motion

›Pain with active and passive motion of the adjacent joint

›Inability to bear weight

Neurovascular examination

›Mandatory neurovascular assessment

›Distal pulses

›Dorsalis pedis and posterior tibial if lower extremity

›Radial pulse if upper extremity

›Capillary refill

›Greater than 2 seconds is abnormal

›Sensation assessment

›Peroneal nerve distribution: dorsum of foot and first web space

›Motor function

04Differential Diagnosis/ddx33

Physeal and bony injuries

›Physeal injury mimics

›Salter-Harris type I fracture

›ICD-10: S89.001A (proximal tibia), S79.001A (proximal femur)

›Physeal separation without compression; shearing rather than axial mechanism

›Also may have normal radiographs; distinguished by mechanism

›Salter-Harris types II to IV

›Visible metaphyseal or epiphyseal fragment on radiograph

›Distinguishable from SH type V by imaging findings

›Bone contusion or occult fracture

›ICD-10: S80.011A (knee)

›MRI shows marrow edema without physeal disruption

Soft tissue injuries

›Non-osseous injury consideration

›Ligamentous sprain

›More common in older adolescents near skeletal maturity

›Ligaments fail before physis in skeletally mature patients

›Osteochondral fracture

›Intra-articular injury with possible loose body

›MRI or arthroscopy differentiates

›Stress fracture

›Repetitive microtrauma rather than acute compression

›Imaging changes may be delayed

Serious considerations

›Must-not-miss diagnoses

›Non-accidental trauma

›Consider in young children with physeal injury and inconsistent mechanism

›Skeletal survey required

05Laboratory Tests/lt29

Routine evaluation

›Standard laboratory assessment

›Routine labs generally not indicated for isolated physeal fractures

›Clinical and imaging diagnosis in most cases

›Exceptions based on clinical concern

›Infection workup if fever, warmth, systemic symptoms

›Metabolic bone disease workup if pathologic mechanism suspected

Infection screen

›Inflammatory markers if infection considered

›Complete blood count

›Leukocytosis with left shift suggests infection

›Elevated white cell count greater than 12 x 10^9/L raises concern

›Erythrocyte sedimentation rate

›Greater than 40 mm/hr supportive of infection

›C-reactive protein

›Greater than 20 mg/L significantly raises infection probability

›Blood cultures if bacteremia suspected

Metabolic bone disease evaluation

›Bone metabolism laboratory panel when indicated

›Serum calcium and phosphorus

›Low phosphorus or calcium suggests rickets or metabolic disorder

›Alkaline phosphatase

›Elevated in active bone disease or rickets

›25-OH vitamin D

›Deficiency below 50 nmol/L common in physeal fractures with metabolic cause

›Parathyroid hormone

›Elevated in secondary hyperparathyroidism

06Diagnostic Tests/dt78

Scoring Systems

›Salter-Harris classification system

›Type I: Fracture through physis only; normal radiographs

›Prognosis excellent; growth arrest rare

›Type II: Fracture through physis and metaphysis; Thurston-Holland fragment

›Most common SH type; approximately 75% of all physeal fractures

›Good prognosis

›Type III: Fracture through physis and epiphysis; intra-articular

›Fair prognosis; anatomic reduction important

›Type IV: Fracture through metaphysis, physis, and epiphysis

›Risk of growth arrest; surgical reduction often required

›Type V: Crush or compression injury of the physis; no fracture line

›ICD-10: S89.001A applies across physeal fracture codes by site

›Rarest type representing approximately 1 in 1,147 epiphyseal fractures in large series

›Worst prognosis for growth disturbance of all SH types

›Diagnosis is almost always retrospective

›Mnemonic SALTR

›S: Same (I - physis only)

›A: Above (II - metaphysis)

›L: Lower (III - epiphysis)

›T: Through (IV - all three zones)

›R: Rammed/crush (V - compression)

MRI

›MRI indications and protocol

›Preferred modality for suspected SH type V when radiographs are negative

›Most sensitive modality for physeal injury detection

›Detects bone marrow edema adjacent to the physis

›MRI performance in physeal injury

›Changed SH classification or staging in 2 of 9 patients in one series

›Detected radiographically occult fractures in 5 of 14 patients in another series

›Key MRI findings in SH type V

›Physeal edema or hemorrhage without fracture line

›T2 signal increase within the physis

›Adjacent metaphyseal and epiphyseal marrow edema

›Late MRI findings indicating growth arrest

›Physeal bar or bone bridge formation across the growth plate

›3D MRI reconstruction maps configuration of physeal bars for surgical planning

›MRI sequences

›STIR and fat-suppressed T2 most sensitive for marrow edema

›Coronal plane optimal for growth plate visualization

›Emerging technique

›Diffusion tensor imaging tractography can quantify growth plate activity

CT

›CT indications in physeal fracture

›Not first-line for acute SH type V diagnosis

›Radiograph and MRI preferred

›Utility in surgical planning

›Suspected intra-articular extension of physeal injury

›Defining fracture geometry before operative fixation

›CT findings relevant to SH type V

›May show subtle physeal narrowing on axial or coronal reconstruction

›Physeal bar visible on CT in established growth arrest

›Radiation consideration

›Avoid routine CT in children; MRI preferred for soft tissue and physeal detail

›CT arthrography

›Can delineate intra-articular pathology if MRI contraindicated

Ultrasound

›Ultrasound role in physeal injury

›Limited primary diagnostic role for SH type V specifically

›Cannot visualize physis directly in most locations

›Utility contexts

›Soft tissue swelling and effusion characterization

›Joint effusion aspiration guidance

›Vascular Doppler assessment for suspected popliteal artery injury

›Comparison to contralateral physis

›Real-time comparison may reveal physeal widening in SH type I

›Less reliable for SH type V pure compression

Plain Radiography

›Radiographic assessment protocol

›First-line imaging modality

›AP and lateral views of the affected joint

›Classic finding in SH type V

›Normal-appearing radiographs acutely

›Subtle physeal narrowing compared to contralateral side

›Comparison views

›Contralateral limb radiographs essential for subtle physeal narrowing detection

›Late radiographic findings

›Premature physeal closure with sclerotic physeal line

›Physeal bar formation

›Angular deformity (valgus, varus, procurvatum, recurvatum)

›Limb length discrepancy on scanogram

›Serial follow-up radiographs

›At 4 to 6 weeks, 3 months, 6 months, 12 months, and 24 months post-injury

07Disposition/dispo32

Admission criteria

›Indications for hospital admission

›Polytrauma with concomitant injuries

›Tertiary survey for missed injuries

›Neurovascular compromise

›Emergent operative or vascular intervention required

›Planned operative intervention

›Reduction, fixation, or physeal bar resection

›Concern for non-accidental trauma

›Safe discharge planning required

›Inability to ensure non-weight-bearing compliance at home

›Social circumstance assessment

Discharge criteria

›Criteria for safe emergency department discharge

›Isolated physeal injury without neurovascular compromise

›Adequate immobilization applied

›Reliable caregiver and home situation

›Able to maintain non-weight-bearing

›Confirmed orthopedic follow-up arranged within 5 to 7 days

›Not acceptable to discharge without follow-up plan

›Caregiver education completed

›Return-to-ED criteria reviewed

Observation indications

›Criteria for short-stay observation

›Uncertain diagnosis with high clinical suspicion

›Pending MRI to confirm or exclude SH type V

›Pain management requirement beyond acute treatment

›Social work evaluation in progress

08Treatment/t56

Immediate management

›Acute stabilization measures

›Immobilization

›Splint or circumferential cast depending on swelling

›Long leg posterior splint for knee and distal femur injuries

›Short leg posterior splint for ankle and distal tibia injuries

›Non-weight-bearing status

›Strict non-weight-bearing for 3 to 6 weeks depending on location

›Crutches with supervised gait training

›RICE protocol

›Ice application for 20 minutes every 2 to 4 hours in acute phase

›Elevation above the level of the heart

›Compression wrapping under the splint

Analgesia

›Pain management protocol

›First-line analgesia

›Ibuprofen 10 mg/kg orally every 6 to 8 hours (maximum 600 mg per dose)

›With food to reduce gastrointestinal irritation

›Avoid if renal impairment or bleeding concern

›Acetaminophen 15 mg/kg orally every 4 to 6 hours (maximum 1000 mg per dose)

›Can be alternated with ibuprofen every 3 hours

›Opioid analgesia for severe acute pain

›Morphine 0.1 mg/kg IV every 4 hours as needed

›Maximum 4 mg per dose in children under 12

›Oxycodone 0.1 to 0.2 mg/kg orally every 4 to 6 hours

›Short course only; reassess at 24 to 48 hours

›Procedural sedation if manipulation required

›Ketamine 1 to 2 mg/kg IV or 4 to 5 mg/kg IM

09Special Populations/sp43

Pregnancy

›Physeal fractures in pregnant adolescents

›Relevant for older adolescent females with incomplete physeal closure

›Physis may still be partially open in females up to approximately 16 to 17 years

›Imaging considerations

›MRI preferred over CT and radiography to avoid fetal radiation exposure

›Non-urgent imaging should be deferred to second trimester where possible

›Medication safety

›Avoid NSAIDs after 20 weeks gestation

›Risk of premature closure of ductus arteriosus

›Acetaminophen is safe throughout pregnancy

›Opioids: short course acceptable with monitoring for neonatal effects

›Orthopedic management

›Conservative immobilization preferred

›Surgical intervention deferred unless neurovascular compromise present

Geriatric

›Physeal considerations in older patients

›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

10Background/b52

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

11Patient Discharge Instructions/pdi34

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

12References/r23

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

›Chung R, Foster BK, Xian CJ. Preclinical Studies on Mesenchymal Stem Cell-Based Therapy for Growth Plate Cartilage Injury Repair. Stem Cells International. 2011

›Emerging regenerative approaches for physeal injury

Evidence & Review

Evidence & Review