Salter Harris I Fibula Fractures: Fact vs Fiction

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When I did my training, the standard party line was that if a skeletally immature patient has an ankle injury, is tender over the distal fibular physis and did not really have significant tenderness over the lateral ankle ligaments, the injury should be assumed to be a Salter Harris I fracture. If you aren’t familiar with the Salter Harris classification system for fractures affecting the growth plate, a Salter Harris I fracture goes straight through the physis, so an x-ray usually won’t help diagnose it; a Salter Harris II fracture goes through the physis into the metaphysis (or towards the shaft of the bone); a Salter Harris III fracture goes through the physis and into the epiphysis (or towards the joint side of the bone); a Salter Harris IV fracture involves the metaphysis, the physis and the epiphysis (so think of a combo Salter Harris II and III) and a Salter Harris V fracture is a crush injury of the physis.

However, the Salter Harris I fibular fracture makes a clinical assumption the way we talk about it. But what does the research say about this injury? Today on the podcast, my guest may change your approach entirely to this diagnosis and our preconceived notions.

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— Boutis K, Narayanan UG, Dong FF, Mackenzie H, Yan H, Chew D, Babyn P. Magnetic resonance imaging of clinically suspected Salter-Harris I fracture of the distal fibula. Injury. 2010 Aug;41(8):852-6. doi: 10.1016/j.injury.2010.04.015. Epub 2010 May 21. PMID: 20494352. https://pubmed.ncbi.nlm.nih.gov/20494352/

— Boutis K, Plint A, Stimec J, Miller E, Babyn P, Schuh S, Brison R, Lawton L, Narayanan UG. Radiograph-Negative Lateral Ankle Injuries in Children: Occult Growth Plate Fracture or Sprain? JAMA Pediatr. 2016 Jan;170(1):e154114. doi: 10.1001/jamapediatrics.2015.4114. Epub 2016 Jan 4. PMID: 26747077. https://pubmed.ncbi.nlm.nih.gov/26747077/

— Dion V, Sabhaney V, Ahn JS, Erdelyi S, Kim DJ. The physical examination is unreliable in determining the location of the distal fibular physis. Am J Emerg Med. 2021 Dec;50:97-101. doi: 10.1016/j.ajem.2021.07.040. Epub 2021 Jul 22. PMID: 34325216. https://pubmed.ncbi.nlm.nih.gov/34325216/

— Hofsli M, Torfing T, Al-Aubaidi Z. The proportion of distal fibula Salter-Harris type I epiphyseal fracture in the paediatric population with acute ankle injury: a prospective MRI study. J Pediatr Orthop B. 2016 Mar;25(2):126-32. doi: 10.1097/BPB.0000000000000248. PMID: 26569428. https://pubmed.ncbi.nlm.nih.gov/26569428/

— Perry DC, Achten J, Knight R, Appelbe D, Dutton SJ, Dritsaki M, Mason JM, Roland DT, Messahel S, Widnall J, Costa ML; FORCE Collaborators in collaboration with PERUKI. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet. 2022 Jul 2;400(10345):39-47. doi: 10.1016/S0140-6736(22)01015-7. Erratum in: Lancet. 2022 Jul 23;400(10348):272. Erratum in: Lancet. 2022 Oct 1;400(10358):1102. PMID: 35780790. https://pubmed.ncbi.nlm.nih.gov/35780790/

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The Host of this Program:

Mark Halstead:

Dr. Mark Halstead received his medical degree from the University of Wisconsin Medical School. He stayed at the University of Wisconsin for his pediatric residency, followed by a year as the chief resident. Following residency, he completed a pediatric and adult sports medicine fellowship at Vanderbilt University. He has been an elected member to the American Academy of Pediatrics (AAP) Council on Sports Medicine and Fitness and the Board of Directors of the American Medical Society for Sports Medicine (AMSSM). He has served as a team physician or medical consultant to numerous high schools, Vanderbilt University, Belmont University, Washington University, St. Louis Cardinals, St. Louis Blues, St. Louis Athletica, and St. Louis Rams. He serves and has served on many local, regional and national committees as an advisor for sports medicine and concussions. Dr. Halstead is a national recognized expert in sport-related concussions and pediatric sports medicine.

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The Guest Featured Inside this Program:

Kathy Boutis:

Dr. Kathy Boutis is a graduate of the University of Toronto medical school followed by a pediatrics residency and pediatric emergency medicine fellowship at Children’s Hospital in Boston. She also completed a Masters degree in Heatlh Research Methodology at McMaster University. Currently she is a staff physician in the emergency department at the Hospital for Sick Children and a Professor of Pediatrics at the University of Toronto. She has also acted as the Research Director in Pediatric Emergency Medicine and is currently the Vice-Chair of the Research Ethics Board. She also gets the distinction as my first international guest on the podcast.

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