What is the management and treatment approach for a pediatric patient with a Salter-Harris type 2 fracture?

Salter-Harris Type 2 Fracture Management

Initial Treatment Approach

For minimally displaced Salter-Harris type 2 fractures (displacement <3 mm), immobilization with casting is the definitive treatment; for displaced fractures (≥3 mm), closed reduction under conscious sedation followed by casting is indicated, with open reduction reserved only for failed closed attempts. 1

Displacement-Based Treatment Algorithm

• Non-displaced or minimally displaced (<3 mm): Apply cast immobilization without reduction 1

  • This represents the majority of cases (88% in one series) 1
  • Healing occurs within 30-45 days depending on patient age 2

• Displaced fractures (≥3 mm): Perform closed reduction under conscious sedation in the emergency department or operating room under general anesthesia 1, 2

  • Success rate for achieving <3 mm displacement after closed reduction is 83% (5 of 6 patients) 1
  • If closed reduction fails, proceed to open reduction with internal fixation 1, 2

Location-Specific Considerations

Distal tibia: The most common site for SH type 2 fractures, with excellent outcomes when properly managed 1

• Complication rate is 2% overall for all distal tibia SH type 2 fractures 1
• For displaced fractures specifically, complication rate increases to 17% 1

Distal radius: Requires orthopedic reduction preferably in the operating room under general anesthesia 2

• Verification radiographs between days 7-14 are mandatory to detect early malunion 2
• Neglected or incorrectly treated fractures lead to malunion and radiocarpal subluxation requiring surgical correction 2

Distal femur: Carries significantly higher complication risk compared to other locations 3

• 70% complication rate at 4-year follow-up, including epiphysiodesis (60%), femoral over-lengthening (5%), and loss of knee motion (25%) 3
• Fractures with metaphyseal comminution (type 2B pattern) have particularly poor prognosis 3
• All completely displaced fractures without fragment contact resulted in complications 3

Phalanges: Can be successfully managed with closed reduction under local anesthesia in the emergency department 4

• Rotational deformities must be assessed clinically, as even 5 degrees of angulation causes evident rotational deformity 4
• Toe phalanx fractures in young children (age 3) can be managed conservatively with excellent outcomes 5

Critical Pitfalls to Avoid

• Do not miss rotational deformities: Clinical examination must include assessment for rotation, as radiographs may not reveal subtle rotational malalignment 4

• Do not skip follow-up radiographs at 7-14 days: This is essential to detect early malunion, particularly for distal radius fractures 2

• Do not underestimate distal femur fractures: These require heightened vigilance due to 70% complication rate, especially with metaphyseal comminution or complete displacement 3

• Do not delay reduction: Neglected fractures require complex surgical correction with transepiphyseal wire fixation and prolonged recovery (3-6 months for return of normal mobility) 2

Immobilization Duration and Follow-Up

• Standard immobilization period: 30-45 days depending on patient age 2
• Average follow-up duration: 4 months minimum 1
• For surgically corrected malunions: 30 days immobilization followed by 3-6 months of recovery treatment 2

Prognosis and Complications

• Overall risk of growth arrest: Small but present, particularly in displaced fractures 1
• Location-dependent outcomes: Distal tibia and phalanges have excellent prognosis (2% complication rate), while distal femur carries 70% complication risk 1, 3
• Age considerations: Younger patients have better remodeling potential and faster recovery 6, 2