Immediate Management of Salter-Harris Type 1 Physeal Fractures
Immediate closed reduction under anesthesia followed by immobilization is the definitive treatment for Salter-Harris Type 1 fractures, with reduction performed as an emergency procedure preferably within the first 24 hours to minimize risk of premature physeal closure. 1, 2
Initial Assessment and Stabilization
- Perform immediate neurovascular examination to rule out vascular compromise or nerve injury, which would require urgent surgical evaluation 2
- Obtain plain radiographs in two planes (AP and lateral) to confirm the diagnosis and assess displacement 1, 2
- Provide adequate analgesia immediately upon presentation to facilitate examination and subsequent reduction 3
- Apply temporary splinting if reduction cannot be performed immediately to prevent further displacement 1
Reduction Technique and Timing
Closed reduction under general or spinal anesthesia should be performed emergently, ideally in the operating room setting rather than the emergency department to ensure adequate muscle relaxation and pain control 1, 2. The evidence strongly supports this approach:
- Apply longitudinal traction for several minutes to allow muscle spasm (particularly hamstrings in lower extremity fractures) to resolve before attempting reduction 2
- Confirm anatomic reduction with fluoroscopy in both AP and lateral planes, as anatomic reduction is the most important factor in preventing premature physeal closure 4
- Verification radiographs between days 7-14 post-reduction are mandatory to detect any loss of reduction that could lead to malunion 1
When Closed Reduction Fails
Open reduction with internal fixation is indicated if closed reduction cannot achieve or maintain anatomic alignment 1, 5. The surgical technique must avoid violating the growth cartilage:
- Use transepiphyseal wire fixation or intramedullary screw placement that does not cross the physis 1, 5
- In cases with associated syndesmotic injury (particularly distal fibula), address syndesmotic instability at the time of open reduction 5
Immobilization Protocol
- Immobilize in a plaster cast for 30-45 days depending on patient age and fracture location 1, 2
- Remove any internal fixation (K-wires) at 4 weeks if used, followed by transition to partial weight-bearing 2
- Initiate full weight-bearing at 6 weeks with concurrent range of motion rehabilitation 2
Critical Pitfalls to Avoid
The displacement following reduction—not the initial displacement—is the most important determinant of premature physeal closure, which occurs in approximately 40% of displaced Salter-Harris Type I fractures 4. Therefore:
- Never accept non-anatomic reduction, as this dramatically increases risk of growth disturbance 4
- Pronation-abduction mechanism injuries carry 54% risk of premature physeal closure versus 35% for supination-external rotation injuries, warranting more aggressive pursuit of anatomic reduction 4
- Neglected or delayed treatment leads to malunion requiring complex corrective osteotomy 1
Special Considerations
In patients with sickle cell disease, maintain high suspicion for osteomyelitis and consider surgical management even for Type I fractures if infection is present 6. These patients require:
- Early surgical intervention if osteomyelitis develops 6
- Aggressive monitoring for avascular necrosis 6
For proximal humeral physeal injuries ("Little League shoulder"), management differs: complete rest from throwing for minimum 6 weeks, followed by 6 additional weeks of strengthening before return to throwing (total 3 months rest) 7.