What is the best way to diagnose a suspected Salter-Harris type 1 fracture of the distal fibula physis in a 14-year-old male with a right lateral ankle injury, presenting with tenderness to palpation (TTP) at the lateral malleoli and diffuse pain at the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL)?

From the Guidelines

The best way to diagnose a suspected Salter-Harris type 1 fracture of the distal fibula physis in a 14-year-old male with a right lateral ankle injury is to obtain plain radiographs (X-rays) of the ankle in multiple views, including anteroposterior, lateral, and mortise views, as recommended by the American College of Radiology 1. The initial imaging study should include these three standard views to provide a comprehensive assessment of the ankle, with a sensitivity of 92% to 99% for detecting ankle fractures 1. Key points to consider in the diagnosis include:

• The Ottawa Ankle Rules (OAR) criteria should be applied to determine the need for radiographs, which are validated in children over 5 years of age 1.
• Weight-bearing radiographs, if possible, can provide important information about the stability of the fracture, particularly in cases of uncertain stability 1.
• Special attention should be given to the lateral process of the talus, as snowboarder's fractures may be overlooked on routine radiographs between 40% and 50% of the time 1.
• If the initial X-rays are negative but clinical suspicion remains high, further imaging such as an MRI or CT scan may be necessary to detect physeal injuries or better visualize the bony architecture 1. The clinical examination should also include comparison with the uninjured ankle and stress testing (with caution in pediatric patients) to assess ligamentous involvement, as Salter-Harris I fractures often have normal-appearing X-rays with only tenderness at the growth plate 1.

From the Research

Diagnosis of Suspected Salter-Harris Type 1 Fracture

To diagnose a suspected Salter-Harris type 1 fracture of the distal fibula physis in a 14-year-old male, the following steps can be taken:

• Clinical examination: The patient presents with tenderness to palpation (TTP) at the lateral malleoli and diffuse pain at the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) 2.
• Imaging studies:
  • Radiographs: Initial radiographs may not show any evidence of a fracture, and the diagnosis may be suspected based on clinical examination alone 3, 4.
  • MRI: Magnetic resonance imaging (MRI) can be used to confirm the diagnosis of a Salter-Harris type 1 fracture, especially in cases where radiographs are negative 5, 4.
• Comparison of diagnostic approaches:
  • Emergency physicians may be more likely to diagnose Salter-Harris type 1 fractures than orthopedic physicians, but few fractures are missed 6.
  • MRI-confirmed Salter-Harris type 1 fractures are rare in children with radiograph-negative lateral ankle injuries, and most children have ligament injuries or sprains 4.

Treatment and Management

The treatment and management of suspected Salter-Harris type 1 fractures include:

• Immobilization: Patients with suspected Salter-Harris type 1 fractures should be immobilized and referred for orthopedic evaluation 6.
• Orthopedic follow-up: Patients should be followed up by an orthopedic physician to confirm the diagnosis and determine the best course of treatment 2, 6.
• Comparison of treatment outcomes:
  • Children with MRI-detected fibular fractures have a comparable recovery to those with sprains when treated with a removable ankle brace and self-regulated return to activities 4.
  • Most patients require ongoing immobilization by orthopedic physicians regardless of the final diagnosis 6.