Management of Salter-Harris Type I Fracture of the Capitellar Growth Plate
For a Salter-Harris Type I fracture of the capitellar growth plate in an 8-year-old, immediate immobilization with a posterior splint or cast is the primary treatment if nondisplaced, with close radiographic follow-up at 7-14 days to detect any displacement that would require surgical intervention.
Initial Assessment and Classification
- Salter-Harris Type I fractures involve separation through the growth plate (physis) without extension into the metaphysis or epiphysis 1
- These fractures in the capitellum are rare but require careful evaluation, as capitellar injuries in children can lead to significant complications including osteonecrosis, loss of motion, and growth disturbances 2
- The capitellum is particularly vulnerable to avascular necrosis due to its tenuous blood supply 2
Treatment Algorithm
For Nondisplaced Fractures:
- Immobilize immediately with a posterior splint or long arm cast in 90 degrees of elbow flexion 3, 4
- The posterior splint provides superior pain relief compared to collar and cuff immobilization during the first 2 weeks 3
- Duration of immobilization: 4-6 weeks depending on healing progression 4
For Displaced Fractures:
- Open reduction and internal fixation is indicated for any displacement 2
- Displaced capitellar fractures treated nonoperatively have poor outcomes with loss of elbow motion and mechanical symptoms 2
- Surgical fixation should avoid violating the growth cartilage; use transepiphyseal wires if internal fixation is required 4
Critical Follow-Up Protocol
Radiographic surveillance is mandatory to prevent malunion:
- Obtain repeat radiographs at 7-14 days post-injury to detect any displacement 4
- Continue radiographic evaluation during the first 3 weeks of treatment 3
- Obtain final radiographs at cessation of immobilization to confirm healing 3
- Failure to detect early displacement can result in malunion requiring corrective osteotomy 4
Common Pitfalls and Complications
High-Risk Complications Specific to Capitellar Fractures:
- Secondary surgical procedures are required in approximately 29% of displaced anterior capitellar fractures due to soft-tissue contracture, osteonecrosis, implant prominence, or intra-articular loose bodies 2
- Growth arrest can occur if the fracture is inadequately reduced or if repeated forceful manipulation damages the physis 5
- Avascular necrosis of the capitellum is a significant risk given the precarious blood supply 2
Critical Management Errors to Avoid:
- Never perform repeated forceful closed reduction attempts, as this increases risk of growth arrest, compartment syndrome, and avascular necrosis 5
- Do not accept displacement in capitellar fractures—unlike other pediatric fractures with high remodeling potential, the capitellum has limited capacity for remodeling and displacement leads to poor functional outcomes 2
- Avoid delayed diagnosis: if initial radiographs are equivocal, obtain advanced imaging (MRI or CT) as capitellar fractures can be subtle 2
Rehabilitation Phase
- After cast removal (typically 4-6 weeks), initiate range-of-motion exercises 4
- Full restoration of motion may take 3-6 months depending on patient age and severity of initial injury 4
- Monitor for development of elbow stiffness, which may require secondary procedures 2
Long-Term Monitoring
- Continue follow-up until skeletal maturity to monitor for growth disturbances 4
- Salter-Harris Type I fractures generally have good prognosis if properly treated, but the capitellum's unique anatomy makes this location higher risk 1, 2
- Watch for late complications including premature physeal closure, angular deformity, or post-traumatic arthritis 2