Salter-Harris II Ankle Fractures in Children: Does Fracture Pattern Matter?

SLR - December 2019 - Amar Chandra

Reference: Binkley A, Mehlman C.T, Freeh E. Salter-Harris II Ankle Fractures in Children: Does Fracture Pattern Matter? Journal of Orthopaedic Trauma. 2019 May; 33(5), 190-195.

Scientific Literature Review

Reviewed By: Amar Chandra, DPM
Residency Program: Grant Medical Center – Columbus, OH

Podiatric Relevance: Treatment of pediatric fractures continues to be of significant interest due to the complexity of the developing musculoskeletal system. The possibility of premature physeal closure (PPC) and resultant limb length loss and deformity make the diagnosis and appropriate treatment of utmost importance. While many studies have looked at the association of PPC with the type of Salter Harris fracture, few have delved into the relationship between the fracture pattern, such as pronation-external rotation, and rate of PPC. The main focus of this study was to determine whether an association exists between specific fracture patterns and premature physeal closure, in addition to the occurrence of future angular deformity, in Salter Harris type II fractures.

Methods: A retrospective review of 141 skeletally immature patients with Salter Harris type II ankle fractures was performed. After radiographic analysis, all were further subdivided according to the Dias-Tachdjian classification, resulting in the following: 52 pronation-external rotation (PER), 35 supination-external rotation (SER), and 54 supination-plantarflexion (SPF) injuries. Rates of premature physeal closure, initial and subsequent operative interventions, and final angular deformities were reported. A deformity was considered significant if there was more than 10 degrees of angulation in any plane as measured using the tibial shaft/joint angle. Furthermore, the initial displacement of the fracture and residual displacement following closed or open reduction were also recorded.

Results: The overall PPC rate was 22.7 percent among all patients, but the PER group had a significantly higher incidence of PPC compared to SER and SPF. In the PER group, 28.8 percent of the 52 patients had premature physeal closure. Six (11.5 percent) of the PER patients ended up with a significant angular deformity at the latest follow-up. 24.1 percent of the patients in the SPF group went on to PPC, but none had any resultant angular deformity at their last follow-up. Within the SER group, only 11.4 percent developed PPC, and like the SPF group, none resulted in any lasting angular deformity. No statistical differences were found between rates of PPC and initial displacement, residual displacement after reduction, initial operative intervention, or open vs closed reduction.

Conclusions: There was a significantly higher incidence of PPC in PER type fractures compared to SER and SPF types. Though a six month minimum follow-up was enforced, the authors noted that extending it to one year would be more ideal, as studies have shown that physeal bars tend to show up by 14 months. Another limitation of this study included a strict exclusion criteria, which predicated the angular deformity be greater than 10 degrees to be considered significant. This could possibly result in a higher than expected rate of angular deformity. The results of this study advocate for the close monitoring of patients with Salter Harris II fractures, specifically those with PER type patterns, to avoid significant angular deformity.