What is the treatment for a Salter Harris fracture?

Treatment of Salter-Harris Fractures

Salter-Harris fractures require treatment based on fracture type, location, and degree of displacement, with most minimally displaced fractures managed conservatively with casting, while displaced fractures (≥3mm) require closed reduction and potentially surgical intervention if reduction fails or soft-tissue interposition is present.

Initial Management and Imaging

• Avoid manipulation prior to obtaining radiographs unless neurovascular compromise or critical skin injury is present, as premature manipulation may complicate subsequent management 1
• Standard three-view radiographs (anteroposterior, lateral, and mortise for ankle fractures) are the initial imaging study of choice 1
• MRI can help exclude Salter-Harris type I fractures in the pediatric population when radiographs are negative but clinical suspicion remains high 1

Treatment Algorithm by Displacement

Minimally Displaced Fractures (<2-3mm)

• Cast immobilization is the primary treatment for fractures with displacement less than 3mm 2
• Non-weight-bearing long-leg cast is appropriate for distal tibia Salter-Harris II fractures with minimal displacement 2, 3
• Rigid immobilization is preferred over removable splints for displaced fractures requiring nonsurgical treatment 1

Moderately Displaced Fractures (2-4mm)

• Initial closed reduction with conscious sedation in the emergency department is indicated for displacement ≥3mm 2
• If closed reduction achieves <2mm residual displacement, proceed with cast immobilization 2, 3
• Surgical management (open reduction and internal fixation) does NOT reduce the risk of premature physeal closure compared to casting for residual displacement of 2-4mm, but may be necessary for anatomic alignment 4

Severely Displaced Fractures (>4mm)

• Open reduction and internal fixation is indicated when closed reduction fails to achieve adequate alignment or when initial displacement exceeds 4mm 2, 4
• Surgical exploration should remove any interposed soft tissue, though this does not eliminate the risk of premature physeal closure 4

Special Considerations by Location

Distal Tibia Salter-Harris II Fractures

• Most (88%) are minimally displaced and do not require reduction 2
• High-grade injury mechanisms and initial displacement ≥4mm increase the odds of premature physeal closure by 12-14 fold, regardless of treatment method 3
• Overall complication rate is 2% for minimally displaced fractures but increases to 17% for displaced fractures 2
• Premature physeal closure occurs in 24-55% of cases depending on initial displacement, with higher rates in more severely displaced fractures 3, 4

Distal Phalanx Salter-Harris Fractures

• Any clinical finding suggestive of nail-bed laceration mandates surgical exploration, including subungual hematoma, nail plate subluxation, or eponychial fold laceration 5
• When explored, 82% have confirmed nail-bed laceration and 47% have soft-tissue interposition requiring removal 5
• Treatment consists of open reduction with nail-bed repair and either splinting or percutaneous pinning 5

Critical Pitfalls and Caveats

• Surgical fixation does not reduce premature physeal closure rates in Salter-Harris II distal tibia fractures and may actually increase the need for subsequent procedures (epiphysiodesis, osteotomy) 4
• The overall premature physeal closure rate for displaced distal tibia Salter-Harris II fractures is 43%, regardless of treatment method 4
• Patient age, sex, mechanism of injury, time to management, and number of reduction attempts do not significantly influence premature physeal closure risk 4
• Initial fracture displacement and high-energy mechanisms are the primary predictors of complications, not the treatment method chosen 3, 4
• Follow-up radiographs should be performed for a minimum of 6 months to assess for premature physeal closure, with CT imaging if clinical concern develops 4