Pediatric Distal Tibial Fracture Classification

 Salter-Harris Type I

• Approximately 15% of distal tibial physeal fractures.
• Low incidence of physeal arrest.
•  The physis is disrupted through the zone of hypertrophy.   
• Nondisplaced (step-off of <2 mm): long leg NWB cast for 3 weeks followed by short leg cast, WBAT for 3-4 weeks.  
• Displaced (step-off of >2 mm): Closed reduction under general anesthesia with muscle relaxation (decreased risk of iatrogenic physeal injury). Incomplete reduction suggests interposed peristeum which may lead to premature physeal closure required open reduction. (Barmada A, JPO 2003;23:733).  Open reduction indicated if 2 attempts at closed reduction are unsuccessful.  Internal fixation rarely needed.
• Residual physeal gap of ≥3 mm risks premature physeal closure.

Salter-Harris Type II

• Approximately 15% of distal tibial physeal fractures.
• Low incidence of physeal arrest. 
• The physis is disrupted through the zone of hypertrophy.   
• Nondisplaced (step-off of <2 mm): long leg NWB cast for 3 weeks followed by short leg cast, WBAT for 3-4 weeks.  
• Displaced (step-off of >2 mm): Closed reduction under general anesthesia with muscle relaxation (decreased risk of iatrogenic physeal injury). Incomplete reduction suggests interposed peristeum which may lead to premature physeal closure required open reduction. (Barmada A, JPO 2003;23:733).  Open reduction indicated if 2 attempts at closed reduction are unsuccessful.  Internal fixation rarely needed.
• Residual physeal gap of ≥3 mm risks premature physeal closure.

• Approximately 25% of distal tibial fractures. 
• Fracture extends through the physis and exits through the epiphysis. 
• Risk of joint incongruity and growth disturbance.  
• Non-displaced (<2mm) = long leg non–weight-bearing cast for 4 weeks, followed by boot for 4 weeks. 
• Displaced (>2mm) = ORIF.  Medial approach  medial malleolar fractures; anterolateral approach for Tillaux fractures.  Avoid fixation across the physis or use smooth pins that cross the physis.  Physeal pins removed  as soon as fracture is stable

• Appoximately 25% of distal tibial fractures. 
• Fracture traverses the metaphysis, physis, and epiphysis.  Triplane fractures and shearing injuries to the medial malleolus.
• Nondisplaced fractures= NWB long leg casts for 4 weeks, followed by NWB or SLC boot for 2 weeks. 
• Displaced (>2 mm) = ORIF to minimize articular incongruity and physeal bar formation. Consider metaphyseal and epiphyseal screw. 
• Associated fibular fractures typically are Salter-Harris type I/II injuries and are usually stable following reduction of the tibial fracture Consider ORIF of fibular fracture if unstable under fluoroscopy.

• Uncommon. 
• Compressive forces across the physis.
• Difficult to diagnose on initial radiographs. 
• May develop growth arrest.  Consider excision of the damaged portion of the physis and placement of fat graft. 
• May development limb-length discrepancy or angular deformity.