How should a nondisplaced Salter‑Harris type I fracture of the distal tibial growth plate in a child be managed?

Management of Nondisplaced Salter-Harris Type I Distal Tibia Fracture

A nondisplaced Salter-Harris type I fracture of the distal tibia should be treated with immobilization in a short leg cast or controlled ankle motion (CAM) boot for 3-4 weeks, followed by clinical reassessment without routine follow-up radiographs unless symptoms persist or new concerns arise. 1, 2

Initial Treatment Approach

• Immobilize immediately with either a short leg cast or CAM boot for 3-4 weeks 1, 2
• Provide short-course NSAIDs for analgesia 2
• Ensure the immobilization device is not overtightened to avoid compromising circulation, particularly critical in young children 3

Key Clinical Rationale

• Salter-Harris type I fractures involve only the growth plate (physis) without extension into the metaphysis or epiphysis, and have an excellent prognosis when nondisplaced 4
• Pediatric patients possess exceptional bone remodeling potential, which allows for rapid healing with minimal risk of residual deformity in nondisplaced fractures 1
• These fractures typically heal within 3-4 weeks in children due to their robust healing capacity 1, 2

Follow-Up Protocol

• Do NOT obtain routine serial radiographs for stable, nondisplaced fractures healing appropriately 1
• Clinical reassessment at 3-4 weeks to evaluate healing progress and ensure weight-bearing tolerance 3
• Only obtain repeat imaging if:
  • New trauma occurs 1
  • Increased pain develops 1
  • Loss of range of motion is noted 1
  • Neurovascular symptoms appear 1
  • Initial radiographs were equivocal but clinical suspicion remains high (repeat at 10-14 days) 1, 2

Important Distinction from Displaced Fractures

• This conservative approach applies only to nondisplaced fractures 5
• Displaced Salter-Harris I fractures (≥3mm displacement) require closed reduction and carry a higher complication risk of 17% versus 2% for nondisplaced fractures 5
• Salter-Harris type III and IV fractures of the distal tibia have much higher rates of growth disturbance and often require anatomic open reduction, but type I fractures when nondisplaced have minimal growth arrest risk 6, 7

Critical Pitfalls to Avoid

• Avoid prolonged immobilization beyond 4 weeks, which leads to unnecessary stiffness, muscle atrophy, and delayed return to activities 1
• Do not routinely obtain follow-up radiographs unless clinically indicated, as this increases healthcare contacts without changing management 1
• Never assume normal initial radiographs rule out fracture in a symptomatic child—approximately 10% of tibial fractures are only visible on follow-up films at 7-14 days 2
• Monitor for behavioral changes in young children (anxiety, agitation, increased analgesic requirements) as indicators of inadequate pain control or complications 1
• Watch for signs of vascular compromise, which would require immediate intervention 3

Special Pediatric Considerations

• At younger ages (toddlers through early adolescence), the growth plate is more vulnerable to injury but also heals more predictably when nondisplaced 1, 4
• The distal tibial physis contributes significantly to lower extremity growth, but nondisplaced type I fractures rarely cause growth disturbance 6, 7
• Educate families on maintaining immobilization despite the child's activity level and on recognizing signs of complications 3