What reduction is required for a Salter-Harris type 2 (Salter-Harris II) fracture of the wrist?

From the Guidelines

For a Salter-Harris type 2 fracture of the wrist, anatomic reduction is required to ensure proper healing and prevent growth disturbances, with the goal of achieving less than 2mm of residual articular surface step-off to avoid long-term complications such as osteoarthritis 1. The reduction should be accomplished through closed manipulation under appropriate analgesia or sedation, with gentle longitudinal traction followed by correction of any angulation or displacement.

• Key considerations for reduction include:
  • Achieving less than 10 degrees of angulation
  • Minimizing displacement to less than 2mm
  • Restoring radial length, inclination, and tilt
  • Realignment of the articular fracture fragments After reduction, the wrist should be immobilized in a well-molded cast for 4-6 weeks, with the position of immobilization (slight flexion or extension) determined by the specific fracture pattern.
• Post-reduction care includes:
  • Post-reduction radiographs to confirm adequate alignment
  • Close follow-up at 1-2 weeks to ensure the reduction is maintained
  • Monitoring for potential complications such as growth arrest, deformity, or limb length discrepancy In cases where closed reduction fails to achieve acceptable alignment, surgical intervention with pins or screws may be necessary, as indicated by the presence of a coronally oriented fracture line, die-punch depression, or more than three articular fracture fragments 1.
• The most recent guidelines from the American Academy of Orthopaedic Surgeons/American Society for Surgery of the Hand do not provide specific recommendations for the reduction of Salter-Harris type 2 fractures, but emphasize the importance of proper reduction and stabilization in the treatment of distal radius fractures 1.

From the Research

Reduction Requirements for Salter Harris 2 Fracture of Wrist

• The amount of reduction required for a Salter Harris 2 fracture of the wrist is not explicitly stated in the provided studies.
• However, a study by 2 defines loss of reduction (LOR) as >5 degrees change of angulation on PA radiographs, >10 degrees change of angulation on lateral radiographs, and/or >25% translation on PA or lateral radiographs.
• Another study by 3 reports that angular deformity seems to correct to an acceptable alignment in patients less than 10 years of age, but these younger patients seem to be at higher risk for symptomatic shortening if a growth arrest occurs.
• A study by 4 mentions that the treatment for displaced Salter-Harris II distal tibia fractures remains controversial, and the rate of premature physeal closure (PPC) was 29.2% in their study.

Factors Affecting Reduction

• Age is a significant factor in the treatment of Salter Harris 2 fractures, with older patients being more likely to require surgical treatment 2.
• The degree of initial angulation is also a factor, with patients having initial angulation more than 5 degrees on the PA view being twice as likely to have LOR 2.
• The presence of concomitant fibula fracture is associated with PPC 4.

Treatment Options

• Closed reduction and casting is a common treatment option for Salter Harris 2 fractures, but LOR is seen in nearly 1/3 of these patients 2.
• Open reduction and internal fixation (ORIF) is an effective choice of treatment for displaced Salter-Harris II distal tibia fractures with displacement > 3mm 4.
• Percutaneous pinning with external fixation is another treatment option, but it may result in higher pain and disability scores compared to ORIF 5.