From the Guidelines
For a 14-year-old male with a suspected displaced Salter-Harris type 1 fracture of the dorsal, fibular growth plate physis and suspected injury to the Anterior Talofibular Ligament (ATFL) and Calcaneofibular Ligament (CFL), I strongly recommend obtaining an MRI to definitively diagnose displacement and assess ligamentous injury. This recommendation is based on the highest quality evidence from the Journal of the American College of Radiology, which states that MRI is the reference standard for ligamentous injury and assessment of stability, particularly important in athletes 1. The study highlights that MRI can distinguish between tendinopathy, sprain, and partial or complete tears, and can also help exclude Salter 1 fractures in the pediatric population.
Key Points to Consider
- Initial X-rays may not clearly show the fracture due to the normal appearance of growth plates
- MRI can visualize both bone and soft tissue injuries, revealing growth plate disruption and any displacement
- The presence of bone bruise and adjacent soft-tissue edema have shown a higher association with acute ligamentous injuries, including those to the anterior talofibular ligament 1
- MRI can help assess the grade of syndesmotic ligament, anterior tibiofibular ligament, and deltoid injuries, critical for treatment planning and return to sport assessment
Management Recommendations
- Immobilize the ankle in a splint or boot, with weight-bearing restrictions until definitive diagnosis
- Implement RICE therapy (rest, ice, compression, elevation) to reduce pain and inflammation
- If the MRI confirms displacement greater than 2mm, orthopedic consultation for possible closed reduction or surgical intervention is necessary to prevent growth disturbances and potential long-term complications such as limb length discrepancies or angular deformities.
From the Research
Diagnosing Displaced Salter-Harris Type 1 Fracture
To diagnose a displaced Salter-Harris type 1 fracture of the dorsal, fibular growth plate physis in a 14-year-old male with a lateral ankle injury, the following steps can be taken:
- Initial assessment should include a thorough physical examination and medical history to identify any signs of physeal injury, such as pain, swelling, or limited mobility in the affected area 2.
- Differential diagnosis for a Salter-Harris fracture includes ligamentous sprain, acute osteomyelitis, or an extraphyseal fracture such as a Torus fracture 2.
- Imaging studies, such as X-rays, CT scans, or MRI, can be used to confirm the diagnosis and assess the extent of the injury 3, 4.
- In cases where initial X-rays are not visible due to the growth plate, further imaging studies or consultation with a specialist may be necessary to confirm the diagnosis 2.
Suspected Injury to ATFL and CFL
In cases where there is suspected injury to the Anterior Talofibular Ligament (ATFL) and Calcaneofibular Ligament (CFL), the following considerations can be taken:
- A high index of suspicion is important for diagnosis, as physeal injuries may not be initially obvious in children who present with periarticular trauma 2.
- Diagnostic ultrasonography or MRI may be useful in evaluating concomitant soft tissue injuries, such as ligament sprains 5.
- The patient's symptoms, such as pain and limited mobility, should be carefully evaluated to determine the extent of the injury and the appropriate treatment plan 2, 5.
Treatment and Management
The treatment and management of a displaced Salter-Harris type 1 fracture of the dorsal, fibular growth plate physis may include:
- Closed reduction and immobilization, which can be an effective treatment for Salter-Harris I and II fractures 2, 6.
- Open reduction and internal fixation, which may be necessary for more complex fractures or those with significant displacement 3, 4.
- Regular follow-up and monitoring to ensure proper healing and to prevent potential complications, such as malunion, bar formation, or growth arrest 2.