What is the recommended acute management and follow‑up for a Salter‑Harris type III fracture of the right ankle in a child or adolescent?

Salter-Harris Type III Fracture of the Right Ankle: Management

Immediate Management

A Salter-Harris type III fracture of the ankle requires urgent orthopedic consultation for anatomical open reduction and internal fixation, ideally within 24 hours of injury, as any displacement ≥1 mm warrants surgical intervention to prevent growth arrest and angular deformity. 1, 2

Initial Imaging Protocol

• Obtain three-view ankle radiographs (anteroposterior, lateral, and mortise views) as the standard initial imaging study 3, 4
• Ensure imaging extends to include the base of the fifth metatarsal distal to the tuberosity 4
• Weight-bearing views should be obtained if tolerable to assess fracture stability 3, 4

Advanced Imaging When Fracture Confirmed

CT imaging is the first-line study after radiographs to determine exact displacement, intra-articular extension, and surgical planning for Salter-Harris III fractures 3

• CT provides critical information about cortical and subcortical involvement that guides operative approach 3
• MRI may be considered to exclude associated cartilage abnormalities and assess for concurrent ligamentous injuries, though this is typically not necessary for acute surgical planning 3

Surgical Indications and Timing

Critical Prognostic Factors

Two independent risk factors predict premature growth arrest 2:

1. Initial displacement: Any displacement ≥1 mm requires surgery
2. Operative delay: Surgery delayed beyond 24 hours significantly increases growth arrest risk

When both risk factors are present, 100% of patients develop premature growth arrest; when neither is present, 0% develop this complication 2

Surgical Technique

• Arthrotomy with direct visualization is recommended over closed reduction 1

  • Periosteal flaps frequently block closed reduction in displaced fractures 5
  • Direct visualization ensures anatomical reduction, which is difficult to confirm with fluoroscopy alone 1

• Internal fixation with screw fixation (46 of 48 cases in one series used screws vs. 2 with pins) 1

  • Anatomical reduction under direct view followed by stable fixation 1
  • Pin fixation is an alternative but less commonly used 1

Common Pitfalls to Avoid

• Do not attempt closed reduction for displaced fractures - periosteal interposition makes this unsuccessful 5
• Do not delay surgery beyond 24 hours - operative delay independently increases growth arrest risk 2
• Do not accept displacement >1 mm - even minimal displacement warrants surgical intervention 1, 2
• Avoid manipulation prior to radiographs unless neurovascular deficit or critical skin injury is present 3

Expected Outcomes with Optimal Management

When treated with early anatomical open reduction and internal fixation 1:

• 94% good long-term outcomes (45 of 48 patients)
• 4% fair outcomes (minor wound complications)
• 2% poor outcomes (angular deformity)
• No leg-length discrepancy or malunion at long-term follow-up
• Mean follow-up functional scores: AOFAS 98.3/100 2

Short-term Complications (3 months post-op) 1:

• Ankle stiffness: 13% (resolves by final follow-up)
• Ankle pain: 8% (resolves by final follow-up)
• Wound healing issues: 8%

Follow-up Protocol

• Serial radiographs to monitor for growth arrest during remaining skeletal growth 1, 2
• Mean follow-up should extend at least 3 years or until skeletal maturity 1
• Monitor for angular deformity development, particularly in cases with initial displacement or delayed surgery 2