A 6 year-old boy presents with left wrist pain after he fell off the monkey bars onto an outstretched hand. You obtain wrist x-rays and see an abnormality. What is the most likely diagnosis, differential diagnosis, and management plan?
Figure 1. AP wrist radiograph. Courtesy of Mark Hopkins, MD.
Figure 2. Lateral wrist radiograph. Courtesy of Mark Hopkins, MD.
Displaced Type II Salter-Harris fracture of distal radius
Closed reduction is performed by recreating the fracture pattern (in this case, hyperextending the wrist) and with traction, the distal radial fragment can be brought over the proximal fragment and into position. This particular case can prove to be a more difficult reduction as only the radius is fractured. Commonly used splints are the volar or sugar tong (examples here).
If appropriate reduction is achieved, discharge home and follow up with orthopedics in 7-10 days [1]. Pediatric patients heal rapidly and full return of normal activity can be expected if treated properly, regardless of how dismal the initial fracture pattern looks (see discussion for more details).
- Neurovascular compromise
- Open fracture
- Unable to appropriately reduce
Figure 3. Normal growth plate. Courtesy of Dr Matt Skalski, Radiopaedia.org
The Salter-Harris classification system characterizes the relationship of the fracture line to the growth plate (physis) and the likelihood of impact on growth potential, from the least likely (type I) to most (type V). The physis is weaker than surrounding ligaments, so the impact of forces are more likely to cause fractures than tears in pediatric patients [1].
Always have a high index of suspicion while growth plates are open (girls 13-15, boys 15-17). Thankfully, Dr. Salter left his name as a perfect building block for remembering the types.
Figure 4. Chart depicting growth plate types. Images courtesy of Dr Matt Skalski, Radiopaedia.org. chart by Mark Hopkins, MD
Figure 5. Radiographs of various Salter-Harris fractures, arrows indicating fracture sites placed by Mark Hopkins, MD. Image of Type I courtesy of Dr Matt Skalski, Radiopaedia.org. Images of Type III and IV courtesy of Richard Hopkins, MD.
References:
- Black KJL, Duffy C, Hopkins-Mann C, Ogunnaiki-Joseph D, Moro-Sutherland D. Chapter 140: Musculoskeletal Disorders in Children. In: Tintanalli, J, ed. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: Mcgraw-Hill Education. 2015:916-917
- Levine RH, Foris LA, Nezwek TA, et al. Salter Harris Fractures. [Updated 2019 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430688/ PMID: 28613461
Mark Hopkins, MD
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William Denq, MD CAQ-SM
Department of Emergency Medicine
University of Arizona
@willdenq
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