What is the treatment for a Salter-Harris (S-H) type 1 fracture of the left ankle in a 14-year-old?

Treatment of Salter-Harris Type 1 Fracture of the Left Ankle in a 14-Year-Old

For a clinically diagnosed Salter-Harris type 1 fracture of the distal fibula in a 14-year-old, treat with an Aircast ankle brace for 5 days to 2 weeks, allowing immediate weight-bearing as tolerated, which provides superior functional recovery compared to rigid casting. 1

Initial Diagnostic Considerations

Important caveat: Most clinically diagnosed "low-risk" Salter-Harris type 1 fractures of the distal fibula are actually ankle sprains or bone bruises rather than true physeal fractures, as demonstrated by MRI studies. 1 However, this distinction does not change the treatment approach for undisplaced injuries.

• Confirm diagnosis with standard three-view ankle radiographs (anteroposterior, lateral, and mortise views) if Ottawa Ankle Rules are positive 2
• MRI can help exclude true Salter-Harris 1 fractures in the pediatric population if diagnosis is uncertain, though this is rarely necessary for treatment decisions 2

Primary Treatment Algorithm

For Undisplaced or Minimally Displaced Fractures (Most Common)

First-line treatment:

• Aircast Air-Stirrup ankle brace for 5 days to 2 weeks 1
• Allow immediate weight-bearing as tolerated 1
• Ensure protective sock is worn under the brace to prevent pressure-related complications 1
• Remove brace after 5 days if symptoms allow, or continue up to 2 weeks based on clinical improvement 1

Alternative acceptable option:

• Removable fiberglass posterior splint or walking boot for 2 weeks 3, 1
• Below-knee fiberglass walking cast for 2-3 weeks (less preferred due to slower functional recovery) 3, 1

Evidence Supporting Brace Over Cast

The brace approach provides:

• Clinically superior function at 4 weeks: Children treated with ankle braces scored 6% higher on modified Activities Scale for Kids-performance scores compared to walking casts (91.3% vs 85.3%), exceeding the 5% threshold for clinical significance 1
• Earlier return to pre-injury activity: Average 6 days faster return compared to rigid immobilization 1
• Higher patient satisfaction: Children strongly prefer 5 days in a brace over 3 weeks in a cast 1
• Similar pain control: No difference in pain outcomes at 4 weeks between brace and cast 1

Rehabilitation

• Physical therapy is generally not necessary for uncomplicated Salter-Harris type 1 distal fibular fractures 3
• If prescribed, focus on proprioception, strength, coordination, and functional exercises under supervision 2
• Gradual return to weight-bearing activities with supportive footwear after immobilization period 4

When Surgical Treatment is Required

Indications for operative management:

• Completely displaced fractures that fail closed reduction 5
• Fractures with syndesmotic injury or avulsion of syndesmotic ligaments 5
• Inability to achieve anatomic reduction with closed methods 5

Surgical approach for displaced fractures:

• Open reduction and internal fixation with transepiphyseal fixation, avoiding violation of the growth cartilage 6, 5
• Intramedullary screw fixation for appropriate fracture patterns 5
• Post-operative immobilization for 30 days followed by rehabilitation 6

Critical Pitfalls to Avoid

• Failure to use protective sock under ankle brace: This significantly increases pressure-related complications 1
• Premature return to high-impact activities: Ensure adequate healing before sports participation 4
• Neglected or inadequately treated fractures: Verify reduction between days 7-14 to avoid malunion, which would require surgical correction 6
• Unnecessary prolonged immobilization: Rigid casting beyond 3 weeks delays functional recovery without improving outcomes 1

Follow-Up Protocol

• Clinical reassessment at 7-14 days to verify maintained alignment 6
• Return to normal activities typically occurs within 2-3 weeks with brace treatment 1
• Full recovery of joint mobility expected within 30-45 days for properly treated fractures 6

Special Consideration for This 14-Year-Old

At age 14, the distal tibial physis is nearing closure. If this fracture represents a completely displaced injury, consider that it may be a variant of adolescent transitional ankle fracture, with energy propagating through the distal fibular physis. 5 Such cases warrant careful assessment for syndesmotic instability and may require operative management even for what appears to be an isolated Salter-Harris type 1 fracture. 5