Management of Salter-Harris Type IV Fractures
Salter-Harris Type IV fractures require open reduction and internal fixation (ORIF) to achieve anatomical reduction and prevent growth arrest and joint incongruity. 1, 2
Immediate Assessment and Imaging
- Obtain standard orthogonal radiographic views of the affected joint to confirm the fracture extends through the growth plate, epiphysis, and metaphysis 3, 4
- Document neurovascular status, point tenderness, deformity, and any open wounds 5
- Consider CT imaging if radiographs are inadequate to fully characterize the intra-articular component and displacement 6
- Any displacement ≥1 mm warrants surgical intervention 1
Surgical Management Algorithm
Perform open reduction with direct visualization of the fracture through arthrotomy, followed by rigid internal fixation 1, 2
- Open reduction is necessary because closed reduction cannot reliably achieve the anatomical alignment required to prevent growth disturbance 1, 2
- Direct visualization through arthrotomy ensures perfect reduction of both the articular surface and the growth plate 1
- Use screw fixation for rigid internal fixation in most cases 1
- Avoid crossing the growth plate with fixation when possible, but if necessary, use smooth pins rather than threaded screws 2
Rationale for Surgical Approach
The intra-articular nature of Type IV fractures creates two critical problems: joint incongruity leading to post-traumatic arthritis, and growth plate disruption causing angular deformity or limb length discrepancy 1, 4. Fluoroscopy alone is insufficient to evaluate if reduction is anatomical 1. Even 1-2 mm of displacement can result in growth arrest 1.
Post-Operative Management
- Immobilize in a cast or splint for 4-6 weeks depending on location 7
- Schedule follow-up at 3-4 weeks to assess healing and ensure no loss of reduction 7
- Avoid routine postoperative imaging unless clinically indicated (new pain, loss of motion, or concern for displacement) 5
- Remove hardware after fracture healing is complete 1
Long-Term Monitoring
Monitor for growth arrest until skeletal maturity is reached 1, 4
- Type IV fractures carry the highest risk of growth disturbance among Salter-Harris fractures due to disruption of both the germinal and reserve zones of the physis 4
- Serial radiographs every 3-6 months are necessary to detect early physeal bar formation 1
- Growth arrest occurs in a significant percentage despite anatomical reduction, though proper surgical management dramatically reduces this risk 1, 4
Critical Pitfalls to Avoid
- Never attempt closed reduction for displaced Type IV fractures - anatomical reduction cannot be reliably achieved or confirmed without direct visualization 1, 2
- Do not accept any residual displacement, as even minimal malalignment leads to growth arrest 1
- Avoid relying solely on fluoroscopy to judge reduction adequacy 1
- Do not delay surgical intervention, as acute management yields superior outcomes compared to delayed treatment 3
- In non-ambulatory children with Type IV fractures, perform skeletal survey to evaluate for non-accidental trauma 5, 8