Synopsis
Recognise growth-plate injury even when early radiographs are subtle, restore joint and physeal alignment gently and maintain site-specific surveillance for arrest, angular deformity and limb-length discrepancy.
- Salter-Harris I stays within the physis, II exits through metaphysis, III through epiphysis, IV crosses metaphysis to epiphysis and V is compression injury.
- First-line assessment includes mechanism, remaining growth, skin, deformity, adjacent joint and documented distal pulse, perfusion, motor and sensation before and after splintage.
- First-line imaging is orthogonal radiography including the adjacent joint; normal films do not exclude a type-I injury with focal physeal tenderness.
- CT is the reference structural study for complex intra-articular step and operative planning, while MRI detects occult physeal injury and maps a later growth bar without radiation.
- Restore alignment gently and early; avoid repeated reduction attempts because each pass can further damage the germinal physis.
- Salter-Harris III and IV fractures usually require anatomical joint reduction and stable fixation, placed to minimise additional physeal injury.
- Do not assume type predicts outcome alone: site, displacement, energy, age, reduction trauma and blood supply change arrest risk.
- Arrange growth surveillance for high-risk sites and injuries, comparing alignment, limb length and Harris growth-arrest lines until risk has passed.
Key red flags
Focal growth-plate tenderness after trauma can represent Salter-Harris I injury despite normal initial radiographs.
An intra-articular Salter-Harris III or IV fracture needs precise step and gap assessment because residual incongruity and physeal bar both matter.
Distal-femoral, proximal-tibial and distal-tibial physeal injuries carry substantial growth and neurovascular consequences and need careful follow-up.
Increasing pain, tense swelling, passive-stretch pain, paraesthesia or escalating analgesic requirement suggests compartment syndrome.
Late angular change, asymmetric growth-arrest lines or increasing limb-length difference can reveal an initially occult Salter-Harris V compression injury.
Injury inconsistent with developmental ability, multiple fractures or delayed presentation requires safeguarding assessment alongside fracture care.
Investigation priorities
Define physis, displacement, metaphyseal and epiphyseal extension, joint alignment and associated injury.
Management branches
Trauma produces focal physeal pain, deformity, open wound or neurovascular concern.
- Use trauma assessment, give analgesia and document skin, compartments and named distal neurovascular findings.
- Cover an open wound, give indicated antibiotics and tetanus care and splint without repeated manipulation.
- Obtain orthogonal radiographs, but reduce urgently under trained conditions if perfusion or skin is threatened.
- Repeat and document neurovascular and compartment examination after every splint or reduction.
Type I or II injury is stable and aligned within site- and age-specific limits.
- Immobilise in the appropriate cast or brace and provide written elevation, cast and return advice.
- Arrange early fracture-clinic imaging to detect loss of position.
- Progress motion and loading according to healing and site rather than pain alone.
- Select growth follow-up from physis, energy, displacement and age, not from Salter type alone.