What is the diagnosis?

With pain over the lateral ankle at an open physis and no findings on xray, this is classically considered a Salter Harris Type 1 Fracture.

• Pearl: Bones on radiograph may appear normal with only mild to moderate soft tissue swelling. Look for widening of the physis or displacement of the epiphysis, which may suggest a fracture [1].

What is the management in the ED?

Salter-Harris type 1 fractures can be treated with closed reduction (if there is displacement), splinting, or bracing. The reduction should be performed carefully to avoid damage to or grating of the physis on any metaphyseal bone fragments [2].

• Pearl: In children with low-risk ankle fractures such as this, a removable brace was found to be more effective than the cast with respect to an earlier recovery of physical function, is associated with greater patient/family satisfaction, and is less costly than the traditional casting [3].

What other diagnosis should you consider if xray is negative?

Ankle sprain. One study demonstrated that Salter-Harris 1 fractures occurred in only 3% of children with radiograph fracture–negative lateral ankle injuries; instead, these children most commonly have ligament injuries (sprains) [4]. For this case, however, your management would be the same.

When do you consult Orthopedics?

Salter Harris type 3, 4, or 5 fractures, concern for neurovascular compromise, and open fractures. Salter Harris type 1 and 2 fractures can be managed with outpatient Orthopedic follow-up in 1 week. For a more thorough review, click here.

What are complications of a missed Salter Harris or delayed treatment?

Growth arrest, which can lead to deformity and longitudinal growth arrest with possible limb length discrepancies.

• Pearl: If unsure of the diagnosis after x-ray, an outpatient MRI can be ordered. This may show widening or increased T2-weighted signal within the physis, adjacent bone marrow edema, associated metaphyseal (Salter-Harris II or IV) or epiphyseal (Salter-Harris III or IV) fracture lines, or periosteal disruption [5].