What is the treatment for a Salter-Harris type 1 fracture?

Treatment of Salter-Harris Type 1 Fractures

The optimal treatment for a Salter-Harris type 1 fracture is immobilization with a rigid cast for non-displaced fractures, with surgical intervention reserved for completely displaced fractures that cannot be adequately reduced by closed methods.

Understanding Salter-Harris Type 1 Fractures

Salter-Harris type 1 fractures involve a fracture line that passes directly through the growth plate (physis) without affecting the metaphysis or epiphysis 1. These fractures are unique to the pediatric population and typically have a good prognosis when properly managed.

Treatment Algorithm

1. Initial Assessment

• Confirm diagnosis with appropriate radiographs
• Assess displacement (measure in millimeters)
• Evaluate integrity of the extensor mechanism
• Check neurovascular status

2. Non-Displaced Fractures (<2-3mm)

• Primary Treatment: Rigid immobilization with cast 2
  • Preferred over removable splints for displaced fractures
  • Removable splints may be considered only for minimally displaced fractures 2
• Duration: Typically 4-6 weeks depending on fracture location and healing progress
• Follow-up radiographs at 2-week intervals initially to ensure maintenance of reduction 3

3. Displaced Fractures

• Initial approach: Attempt closed reduction
• If reduction achieves <2mm displacement:
  • Immobilize with rigid cast 2
• If residual displacement remains >2mm or if closed reduction fails:
  • Consider surgical intervention with open reduction and internal fixation (ORIF) 4
  • Surgical approach is particularly important for completely displaced fractures where anatomic reduction cannot be achieved through closed methods 4

Important Considerations

Potential Complications

• Premature physeal closure (PPC): A significant risk regardless of treatment method 5
  • Studies show PPC rates of 29-55% across different treatment groups
  • Neither conservative nor surgical treatment has definitively shown to reduce PPC risk 5
• Growth disturbance: Monitor for angular deformity or limb length discrepancy
• Syndesmotic instability: Particularly relevant in ankle fractures 4

Rehabilitation Protocol

• Begin gentle passive range of motion exercises at approximately 4 weeks
• Progress to active-assisted range of motion as tolerated
• Advance to strengthening exercises after fracture healing is evident 3

Follow-up

• Regular clinical and radiographic follow-up for at least 6 months
• If clinical concern for premature physeal closure arises, consider advanced imaging (CT) 5
• Monitor for return to pre-injury function and mobility 3

Special Situations

• Completely displaced fibular fractures: May require ORIF if closed reduction fails, especially if syndesmotic ligaments are avulsed 4
• Patients with underlying conditions (e.g., sickle cell disease): May require more aggressive management due to increased risk of complications like osteomyelitis 6

Pitfalls to Avoid

• Failing to recognize completely displaced fractures that require surgical intervention
• Inadequate immobilization leading to loss of reduction
• Missing associated ligamentous injuries, particularly in ankle fractures
• Insufficient follow-up to detect premature physeal closure

While current evidence shows clinical equipoise between surgical and conservative management for some displaced Salter-Harris fractures 7, rigid immobilization remains the mainstay of treatment for most non-displaced Salter-Harris type 1 fractures, with surgery reserved for those that cannot be adequately reduced by closed methods.