What is the treatment for a Salter 2 fracture of the foot in a pediatric patient?

Treatment of Salter-Harris Type II Fracture of the Foot in an 8-Year-Old

For a Salter-Harris type II fracture of the foot in an 8-year-old child, treat with closed reduction if displacement is ≥3 mm, followed by immobilization in a short leg cast for 4-6 weeks; if displacement is <3 mm, immobilize without reduction. 1

Initial Assessment and Displacement Criteria

• Measure displacement carefully on radiographs - the critical threshold is 3 mm of displacement, which determines whether closed reduction is needed 1
• Fractures with displacement <3 mm can be treated with cast immobilization alone without reduction 1
• Fractures with displacement ≥3 mm require closed reduction under conscious sedation in the emergency department 1

Treatment Algorithm

For Minimally Displaced Fractures (<3 mm):

• Apply a short leg cast without attempting reduction 1
• This represents the majority of cases (approximately 88% of Salter-Harris II fractures are minimally displaced) 1
• A posterior splint (back-slab) provides better pain relief during the first two weeks compared to other immobilization methods 2

For Displaced Fractures (≥3 mm):

• Perform closed reduction under conscious sedation in the emergency department 1
• The goal is to reduce displacement to <3 mm 1
• After successful closed reduction, apply a short leg cast 1, 3
• If closed reduction fails to achieve adequate alignment, open reduction is indicated 1

Immobilization Specifics

• Use a short leg cast for foot fractures - this provides adequate immobilization for lower leg and foot fractures 3
• Duration of immobilization is typically 4-6 weeks, though specific evidence for optimal duration is limited 2
• Consider using a controlled ankle motion boot or short leg back slab as alternatives, as these can be removed by family and are associated with fewer complications 4

Follow-Up and Monitoring

• Follow patients for an average of 4 months to monitor for complications 1
• Take any complaint of increased pain seriously - this could indicate complications such as compartment syndrome, burns, or pressure sores 3
• Imaging should only be performed if it will change management, minimizing unnecessary radiation exposure 5

Expected Outcomes and Complications

• Overall complication rate is low at 2% for all Salter-Harris II fractures of the distal tibia 1
• For displaced fractures requiring reduction, the complication rate increases to 17% 1
• The primary complication is growth arrest, which carries a small risk even with appropriate treatment 1
• Pediatric patients have high remodeling potential, which mitigates the risk of residual deformity even if some initial deformity is accepted 5

Key Clinical Pitfalls to Avoid

• Do not accept >3 mm of displacement - this is the evidence-based threshold for requiring reduction 1
• Do not dismiss patient complaints of pain after casting - serious complications can occur despite casting being less invasive than surgery 3
• Avoid unnecessary follow-up imaging that won't change management 5
• Most patients do not require orthopedic specialist follow-up if the fracture is appropriately managed and healing progresses normally 4