What is the diagnosis for a 14-year-old male with a suspected Salter-Harris type 1 fracture of the dorsal, fibular growth plate physis, with tenderness to palpation (TTP) on the lateral aspect, and diffuse swelling of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL)?

From the Guidelines

The diagnosis for a 14-year-old male with a suspected Salter-Harris type 1 fracture of the dorsal, fibular growth plate physis, with tenderness to palpation (TTP) on the lateral aspect, and diffuse swelling of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) is likely a lateral ankle injury, and the recommended initial imaging study is radiography, including three standard views: anteroposterior, lateral, and mortise views, as indicated by the American College of Radiology (1).

The patient's symptoms, including tenderness to palpation over the lateral malleolus and diffuse swelling of the ATFL and CFL, are consistent with a lateral ankle injury. The Ottawa Ankle Rules (OAR) criteria, which are validated in children >5 years of age, suggest that radiographs are indicated in patients who meet these criteria as the initial imaging study (1).

The radiographic protocol should include three standard views: anteroposterior, lateral, and mortise views, to include the base of the fifth metatarsal bone distal to the tuberosity (1). Weight-bearing radiographs, if possible, provide important information, particularly with fractures of uncertain stability (1).

If the radiographs are negative for osseous injury, but physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation, further imaging options to evaluate ligamentous integrity include stress radiography, MRI, MR arthrography, CT arthrography, and US (1).

The patient should be immobilized with a removable walking boot or ankle brace for 3-4 weeks, with weight-bearing as tolerated, and follow RICE protocol (Rest, Ice, Compression, Elevation) for the first 48-72 hours, with ice applied for 15-20 minutes every 2-3 hours while awake (1).

Pain management can include acetaminophen (15mg/kg every 6 hours, not exceeding 3000mg daily) or ibuprofen (10mg/kg every 6-8 hours with food, not exceeding 40mg/kg daily) (1). An orthopedic referral is necessary within 1-2 weeks for follow-up imaging to confirm the diagnosis and ensure proper healing. Physical therapy should begin after the immobilization period to restore range of motion, strength, and proprioception (1).

Salter-Harris type 1 fractures involve separation of the growth plate without bone fracture, which is common in adolescents due to the relative weakness of the growth plate compared to surrounding ligaments (1). With proper treatment, these injuries typically heal well without growth disturbance, but follow-up is essential to monitor for complications (1).

Some key points to consider in the diagnosis and treatment of this patient include:

• The importance of radiography as the initial imaging study (1)
• The need for weight-bearing radiographs, if possible, to assess stability (1)
• The use of RICE protocol and pain management with acetaminophen or ibuprofen (1)
• The importance of orthopedic referral and follow-up imaging to confirm the diagnosis and ensure proper healing (1)
• The need for physical therapy to restore range of motion, strength, and proprioception after the immobilization period (1)

From the Research

Diagnosis of Suspected Salter-Harris Type 1 Fracture

• The diagnosis for a 14-year-old male with a suspected Salter-Harris type 1 fracture of the dorsal, fibular growth plate physis, with tenderness to palpation (TTP) on the lateral aspect, and diffuse swelling of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) is based on the classification of growth plate injuries 2.
• The Salter-Harris classification system categorizes growth plate fractures into five groups, with type 1 being a fracture through the growth plate 2.
• A high index of suspicion is important for diagnosis, as physeal injuries may not be initially obvious in children who present with periarticular trauma 3.
• Differential diagnosis for a Salter-Harris fracture includes a ligamentous sprain, acute osteomyelitis, or an extraphyseal fracture such as a Torus fracture 3.

Diagnostic Approach

• The diagnostic approach for suspected Salter-Harris type 1 fractures involves radiographic evaluation, including plain radiographs and possibly advanced imaging studies 4.
• Emergency physicians and orthopedic physicians may have different diagnoses and treatment approaches for patients with distal fibular physis pain without radiographic fracture 4.
• A study found that emergency physicians were more likely to diagnose Salter-Harris type 1 fractures, while orthopedic physicians were more likely to diagnose sprains or other fractures 4.

Treatment and Management

• The treatment for Salter-Harris type 1 fractures typically involves closed reduction and immobilization, with the goal of achieving anatomic reduction and maintaining joint congruity 3, 5.
• Immobilization is usually achieved with a splint, boot, or cast, and patients may require ongoing immobilization and referral for orthopedic evaluation 4.
• Neglected or incorrectly treated fractures can lead to malunion and radiocarpal subluxations, which may require surgical intervention 6.