From the Guidelines
The patient should be treated with immobilization and physical therapy, rather than surgical intervention, as the primary approach for a Salter-Harris type 1 fracture of the dorsal, fibular growth plate physis, with a positive Talar Tilt Test (TTP) and lateral instability of the Anterior Talofibular Ligament (ATFL) and Calcaneofibular Ligament (CFL), due to the excellent healing potential of this type of fracture and the risks associated with surgical treatment 1.
Diagnosis
The diagnosis of a Salter-Harris type 1 fracture is based on the history of trauma, physical examination findings, and radiographic studies. The presence of a positive Talar Tilt Test and lateral instability of the ATFL and CFL suggests ligamentous injury, but the primary concern is the growth plate fracture.
Treatment Approach
The treatment approach should focus on immobilization with a walking boot or cast for 3-4 weeks, followed by gradual return to activities. Weight-bearing as tolerated is typically allowed, and the patient should use crutches initially if pain limits walking. After immobilization, physical therapy focusing on ankle range of motion, proprioception, and strengthening exercises is recommended for 4-6 weeks.
Rationale
This approach is recommended because growth plate fractures in adolescents need protection to prevent growth disturbances, but Salter-Harris type 1 fractures have excellent healing potential as they are clean separations through the physis without displacement. The risks associated with surgical treatment, including longer recovery times, higher incidences of ankle stiffness, impaired ankle mobility, and complications, outweigh the benefits in this case 1. Additionally, referral to a pediatric orthopedic surgeon may be considered for further evaluation and management, especially if there are concerns about growth disturbances or ligamentous instability 1.
Follow-up
Follow-up imaging at 3-4 weeks should confirm healing before advancing activity. The patient should be monitored for any signs of complications, such as growth disturbances or recurrent instability, and referred to a pediatric orthopedic surgeon if necessary.
Key Considerations
- Immobilization and physical therapy are the primary treatment approaches for Salter-Harris type 1 fractures.
- Surgical intervention is typically reserved for cases with chronic instability or failed conservative treatment.
- Referral to a pediatric orthopedic surgeon may be considered for further evaluation and management.
- Follow-up imaging and monitoring for complications are crucial to ensure proper healing and prevent long-term sequelae.
From the Research
Diagnosis
- The patient has a Salter-Harris type 1 fracture of the dorsal, fibular growth plate physis, which is a type of fracture that occurs in the growth plate of the bone 2.
- The patient also has a positive Talar Tilt Test (TTP) and lateral instability of the Anterior Talofibular Ligament (ATFL) and Calcaneofibular Ligament (CFL), which indicates ankle instability.
Treatment
- Immobilization is a common treatment for severe limb trauma, including ankle fractures, to stabilize the bone and allow for healing 2.
- A removable orthosis or brace can be used for immobilization, which allows for early mobilization and can improve functional outcomes 3, 4.
- Immobilization with a removable walking brace can also be used to treat chronic foot and ankle pain, and can improve pain symptoms and physical examination findings 5.
- Manual physical therapy following immobilization can also be effective in treating patients with stable ankle fractures, and can improve functional outcomes and reduce pain 6.
- The choice of treatment between cast immobilization and removable braces depends on the individual patient and the specific fracture type, but removable braces may have better functional outcomes in the early and mid-term periods after ankle fractures 4.