What is the treatment for a Salter-Harris fracture class IV of the 3rd proximal phalange of the foot?

Treatment for Salter-Harris Class IV Fracture of 3rd Proximal Phalange of Foot

Surgical intervention with open reduction and internal fixation (ORIF) is the recommended treatment for Salter-Harris type IV fractures of the proximal phalanx to prevent growth disturbances, deformity, and functional limitations.

Initial Management

• Immediate immobilization of the fracture
• Adequate pain management with:
  • Acetaminophen as first-line treatment
  • NSAIDs (if no contraindications)
  • Avoid opioids unless absolutely necessary 1
• Elevation of the extremity to reduce swelling
• Ice application (20 minutes on, 20 minutes off)

Diagnostic Imaging

• Standard radiographs: Anteroposterior, lateral, and oblique views
• MRI may be necessary if radiographs are inconclusive but clinical suspicion remains high 1
• CT scan may be helpful for preoperative planning in complex cases 1

Definitive Treatment

Surgical Approach

1. Open reduction and internal fixation (ORIF) is indicated for:

   • All Salter-Harris type IV fractures of the phalanges
   • Fractures with displacement >1mm 2
   • Intra-articular involvement

2. Surgical technique:

   • Careful exposure of the fracture site
   • Anatomic reduction under direct visualization
   • Fixation with K-wires or small screws appropriate for the phalanx size 3
   • Arthrotomy may be necessary to ensure perfect reduction of the articular surface 2

3. Timing of surgery:

   • Surgery should be performed within 48 hours of injury for optimal outcomes 4
   • Delay increases risk of growth disturbances and poor functional outcomes

Non-surgical Management

• Reserved only for completely non-displaced Salter-Harris type IV fractures (rare)
• Requires close monitoring with serial radiographs
• Immobilization with buddy taping and rigid-sole shoe 5

Postoperative Care

1. Immobilization:

   • Short-term immobilization (3-4 weeks) with appropriate splinting
   • Avoid prolonged immobilization to prevent stiffness 1

2. Follow-up:

   • Clinical and radiographic assessment at 2 weeks and 4-6 weeks 1
   • Regular monitoring until fracture healing and growth plate closure

3. Rehabilitation protocol:

   • Early mobilization after adequate healing (typically 4 weeks)
   • Progressive weight-bearing as tolerated
   • Range of motion exercises to prevent stiffness
   • Return to full activities at approximately 12-16 weeks based on healing 1

Complications and Monitoring

• Growth disturbance (most significant risk with type IV fractures)
• Malunion or nonunion
• Post-traumatic arthritis
• Joint stiffness
• Chronic pain (occurs in approximately 20% of patients) 1

Special Considerations

• Pediatric patients require close monitoring of growth plate activity
• Long-term follow-up until skeletal maturity is essential to detect and address growth disturbances early
• Even with optimal treatment, some patients may develop narrowing of the phalanx diaphysis as seen in long-term follow-up 3

Referral Criteria

Immediate orthopedic referral is indicated for:

• All Salter-Harris type IV fractures
• Displaced fractures
• Intra-articular involvement
• Open fractures
• Significant soft tissue injury 5

Proper surgical management of Salter-Harris type IV fractures of the proximal phalanx can lead to good long-term outcomes with minimal growth disturbances when anatomic reduction is achieved 3, 2.