From the Guidelines
To diagnose displacement in a suspected Salter-Harris type 1 fracture of the dorsal, fibular growth plate physis in a 14-year-old male, I strongly recommend obtaining an MRI of the ankle. This is based on the most recent and 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 directly visualize the tendons and ligaments, allowing distinction between tendinopathy, sprain, and partial or complete tears, and can also help exclude Salter 1 fractures in the pediatric population 1.
Key Points to Consider
- Initial X-rays may not clearly show the fracture due to the normal appearance of growth plates in adolescents
- MRI can directly visualize the physis, surrounding soft tissues, and any displacement
- Comparison views of the uninjured ankle can also be helpful to detect subtle differences
- The tenderness over the lateral malleolus and potential ligament involvement (ATFL and CFL) suggests a significant injury that requires proper evaluation
Management Recommendations
- Immobilize the ankle in a removable boot or splint, with weight-bearing as tolerated if pain allows
- Implement RICE therapy (rest, ice, compression, elevation) to reduce pain and inflammation
- Use acetaminophen or NSAIDs for pain management if not contraindicated
- Consider a follow-up X-ray in 7-10 days if MRI is not immediately available to assess for periosteal new bone formation or callus that may not have been visible initially.
From the Research
Diagnosing Displacement in Suspected Salter-Harris Type 1 Fracture
To diagnose displacement in a suspected Salter-Harris type 1 fracture of the dorsal, fibular growth plate physis in a 14-year-old male, the following steps can be taken:
- Initial assessment: The patient presents with a lateral ankle injury, diffuse tenderness to palpation (TTP) laterally, involving the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) 2.
- Imaging: Initial X-rays may not be visible due to the growth plate, making it challenging to diagnose the fracture. However, radiographic images are essential for prompt diagnosis and to minimize negative health outcomes in these patients 3.
- Classification: The Salter-Harris classification of growth plate injuries aids in estimating both the prognosis and the potential for growth disturbance. A Salter-Harris type 1 fracture is a fracture through the growth plate 4.
- Treatment: Salter-Harris I & Salter-Harris II growth plate fractures are commonly managed by closed manipulation, reduction & immobilization. These are relatively stable injuries and can be retained by adequate plaster 2.
Key Considerations
- 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.
- Differential diagnosis for a Salter-Harris fracture includes a ligamentous sprain, acute osteomyelitis, or an extraphyseal fracture such as a Torus fracture 2.
- Physeal fractures can have many complications such as malunion, bar formation, acceleration of growth of physis, posttraumatic arthritis, ligament laxity and shortening of the bone 2.
- The key to well-healing fractures is successful anatomic reduction and patients must have regular follow-up for these injuries 2.
- Early treatment with closed reduction techniques can achieve excellent long-term results 5.