What is the diagnosis?

Salter Harris type II distal radius fracture.

What is your management and disposition in the ED?

Closed reduction, if successful, can help prevent surgery. It is performed by recreating the fracture pattern (in this case, hyperextending the wrist) and applying longitudinal traction to allow the distal radial fragment to be brought over the proximal fragment and into position. The patient can then be placed in a sugar tong splint and discharged with orthopedic follow up in 1 week to evaluate stability of the reduction. Post-reduction x-rays and repeat neurovascular exam should be performed after splinting to assess adequate alignment prior to discharge.

How do you classify fractures through the growth plate?

The Salter-Harris classification system characterizes the relationship of the fracture line to the growth plate (physis, see Image 3) and the likelihood of impact on growth potential, from the least likely (type I) to most likely (type V). Type II is the most common (75%), with type V being the least and is rarely diagnosed on the first visit [1].

• Pearl: The physis is weaker than surrounding ligaments, so the impact of forces are more likely to cause fractures than tears in pediatric patients [1].

• Pearl: Although the SALTER mnemonic is generally used to help remember the types (Straight, Above, beLow, Through, and cRush), remembering that intra-articular fractures (type III) are worse than extra-articular (type II) can help keep the order straight (see Image 5).

Image 3. Case courtesy of Matt Skalski, Radiopaedia.org, labels by author

Image 4. Left to right, Salter Harris I (pain on exam at distal fibula physis), III and IV. Author’s images

When do you consult Orthopedics?

Salter Harris II fractures can be safely discharged with follow-up in 1-2 weeks. If there is concern for surgical management (unstable Salter Harris III or IV), consider discussing the case with the orthopedic team, but the surgery can likely be performed on an outpatient basis within the week. See Image 5 for more details. 

Image 5. Drawings courtesy of Matt Skalski, Radiopaedia.org, chart by author