Injury 51 (2020) 636–641

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Injury
journal homepage: www.elsevier.com/locate/injury

Treatment and outcomes of distal tibia salter harris II fractures

Rachel A. Thomas∗, William L. Hennrikus
Department of Orthopaedics and Rehabilitation, Penn State College of Medicine Milton S. Hershey Medical Center, 500 University Drive, Mail Box 593,
Hershey, PA 17033 United States

a r t i c l e i n f o a b s t r a c t

Article history: Background: Distal Salter-Harris (SH) II fractures of the tibia are common injuries in the pediatric pop-
Accepted 28 January 2020 ulation. The purpose of this study is to evaluate our treatment and outcomes of SH II fractures of the
distal tibia.
Key words: Methods: The study was approved by the medical school’s institutional review board (IRB). Fifty-one dis-
Salter-harris fractures
tal tibia SH type II fractures were treated from 2003 to 2017. We performed a retrospective review of all
Tibial fractures
patients. Patients with displacement less than 3 mm, on x-ray, were treated with a cast. Patients with
Physeal Fractures
Ankle Pediatric displacement greater than or equal to 3 mm displacement were initially treated with closed reduction in
the emergency department with conscious sedation. Patients were also categorized based on the mecha-
nism of injury and complications were noted. Patients were followed for an average of 4 months (range,
4 weeks-28 months).
Results: Fifty-one patients, 28 females and 23 males, were included in the study, with a mean age of
9.4 years (range, 13 months-13 years) at presentation. The most common mechanism of injury was par-
ticipation in sports (43%). Out of the 51 patients, 45 were minimally displaced and treated with cast.
Six displaced fractures were treated with closed reduction. The mean displacement in the closed reduc-
tion group at presentation was 5.7 (range, 3- 8.8) mm. Five out of 6 patients had reduction to less than
3 mm. The overall complication rate was 1 out of 51 patients, 2%. When examining displaced fractures,
the complication rate was 1 out of 6 patients, 17%.
Conclusion: Most SH II fractures of the distal tibia are minimally displaced and do not need a reduction.
6/51 cases (12%) in the current study were displaced and were indicated for a reduction. Displacement
greater than or equal to 3 mm can be treated with closed reduction followed by a cast; if closed reduction
fails, open reduction is indicated. Displaced fractures have a small risk of growth arrest.
© 2020 Elsevier Ltd. All rights reserved.

Introduction requires reduction and the postreduction displacement that neces-

Distal Salter-Harris II fractures of the tibia are common injuries
in the pediatric population [1]. There are four main treatment op-
tions that exist for SH II fractures, which are casting, closed reduc-
tion with casting, closed reduction and percutaneous fixation, and
open reduction and internal fixation with casting [1–7]. The best
prognostic factor in regards to complication rates is the amount of
displacement remaining following fracture reduction [2,4,6]. Pub-
lications on the topic of distal tibia SH II fractures demonstrate
variability in the amount of displacement following the injury that
∗
Corresponding author.
E-mail addresses: rthomas8@pennstatehealth.psu.edu,
rachelannthomas@yahoo.com (R.A. Thomas).
sitates further intervention [2,4–6].
Over the past 15 years the approach to distal SH II fractures
has evolved. Due to an increased rate of premature physeal closure
(PPC) in patients with displacement greater than 3 mm following
closed reduction. In 2003, Barmada et al. stated a cutoff of 3 mm
postreduction displacement as an indication to perform open re-
duction. Seel (2011) found that good reduction is the most impor-
tant factor in reducing complications. Seel recommended a cutoff
of 2 mm or more to necessitate reduction. However, Seel found
no statistical significance linking a decrease in complications and a
residual displacement of 2 mm or more. In 2012, Mubarak found
up to 30% of patients with a displaced SH II fracture develop PPC,
independent of the degree of displacement. The purpose of this
study is to evaluate our treatment and outcomes of SH II fractures
of the distal tibia.

https://doi.org/10.1016/j.injury.2020.01.039
0020-1383/© 2020 Elsevier Ltd. All rights reserved.
 R.A. Thomas and W.L. Hennrikus / Injury 51 (2020) 636–641
Fig. 1. Anteroposterior radiograph of left ankle showing SH II distal tibia fracture and distal fibula metaphyseal fracture displaced greater than 3 mm.
Materials and Methods
A retrospective review of patients treated for a SH II fracture
of the distal tibia, with or without ipsilateral SH II fibula frac-
ture, at our institution between 2003 and 2017 was performed.
Inclusion criteria was as follows: less than 13 years old at time
of injury and SH II fracture confirmed with radiograph. Treatment
was based on the amount of displacement. There were six frac-
tures with greater than 3 mm displacement and 45 fractures with
less than 3 mm displacement, at time of presentation. Less than
3 mm displacement on x-ray were treated with a cast, short leg
cast (SLC) vs long leg cast (LLC); short versus long leg cast was
determined by physician preference. Patients with displacement
greater than or equal to 3 mm, as demonstrated by Figs. 1 and 2,
were treated with closed reduction followed by casting. Following
closed reduction, radiographs were used to determine postreduc-
tion fracture displacement. If greater than or equal to 3 mm of
displacement remained after closed reduction, open reduction is
indicated.
The medical records were reviewed for the following variables:
age, gender, side of injury, mechanism of injury, clinically signifi-
cant complications, and duration of follow-up. Radiographic eval-
uation included amount of initial displacement (measured in mil-
limeters) and if reduced the postreduction displacement (measured
in millimeters). AP and lateral radiographs were used to analyze
637
the distal tibia. Mechanism of injury was divided into three cate-
gories: sports, motor vehicle, and other. Any complications includ-
ing presence of a physeal bar, leg-length discrepancy, angular de-
formity, and pressure sores were documented.
Results
Fifty-one patients were included in the study, with a mean age
of 9.4 years at presentation, ranging from 13 months to 13 years.
Among the participants, there were 28 females and 23 males.
There were 21 left sided fractures and 30 right sided fractures.
Mechanism of injury was divided into three categories sports, mo-
tor vehicle accidents, and others as illustrated in Table 1. Faculty
preference dictated whether the patient was treated with a long
or short leg cast; 7 LLC and 38 SLC.
The average amount of initial displacement (measured in mil-
limeters) was 5.3 (range, 3- 8.8) mm, in patients requiring closed
reduction with sedation. The average postreduction displacement
(measured in millimeters) was less than 1 mm.
One patient experienced a complication due to treatment. Fol-
lowing closed reduction, a displacement greater than 3 mm re-
mained. The cast was wedged to correct the displacement. At 1
month, a partial thickness pressure sore developed at the heel.
Pressure sore was managed with wet to dry dressing changes and
a brief period of oral antibiotics. Later developed osseous bridg-
638 R.A. Thomas and W.L. Hennrikus / Injury 51 (2020) 636–641

Fig. 2. Lateral radiograph of left ankle showing SH II distal tibia fracture and distal fibula metaphyseal fracture displaced greater than 3 mm.

ing along the distal anteromedial tibia physis, measuring 16 by Follow up average 3.7 (range, 1–28) months. 12 patients have
12 mm, as demonstrated by Figs. 3 and 4. An epiphysiodesis was greater than 1 year follow up. Patients that required closed reduc-
performed 19 months post injury to decrease the risk of angular tion had an average follow-up time of 13 months compared to 3
deformity. months for patients who were treated only with a cast. As in many
 R.A. Thomas and W.L. Hennrikus / Injury 51 (2020) 636–641 639

Fig. 3. Anteroposterior radiograph of the left ankle showing osseous bridging along the distal anteromedial tibia physis.

retrospective studies, patients stop returning to clinic when they
feel better.
Discussion
The rate of complications following SH II fractures of the distal
tibia vary across the literature. There is also debate over the best
treatment option to prevent complications. Barmada et al. found
an incidence of complications of 32% of patients with fracture dis-
placement and Spiegel et al. reported that 17% of patients with lit-
tle or no displacement had complications, either angular deformi-
ties or leg length discrepancy.
The overall incidence of complications following distal tibia SH
II fractures in this study was 2.3%. For individuals with fracture dis-
placement, the rate of complication was 17%. We concluded that
the incidence of complications following SH II fracture of the distal
640 R.A. Thomas and W.L. Hennrikus / Injury 51 (2020) 636–641

Fig. 4. Lateral radiograph of the left ankle showing osseous bridging along the distal anteromedial tibia physis.

tibia is lower than recorded in the literature. Reduction to less than
3 mm of displacement prior to casting decreases the incidence of
complications. If more than 3 mm of displacement remains follow-
ing closed reduction, open reduction should be performed to al-
low for a better reduction [2,3,5,6,8–10], which may decrease the
prevalence of complications. Our patient who was treated with
cast wedging should have undergone ORIF to decrease displace-
ment to less than 3 mm; we do not recommend cast wedging.
Loss of angulation or incomplete correction following conser-
vative management can be treated with cast wedging to improve
alignment of diaphyseal fractures [11,12]. Cast wedging was re-
ported by Kattan et al. to obtain a satisfactory outcome in 96%
of patients with displaced fractures. Kattan et al. determined that
cast wedging was safe and effective for the treatment of diaphyseal
fractures, they did not discuss the use for treatment of metaphysis
or epiphysis fractures. We do not recommend wedging for growth
plate fractures due to our complication [11,12].
Seel et al. reported a lower rate of occurrence of SH II fractures
in girls than in boys, 5.1 in 10 0 0 and 17.1 in 10 0 0 respectively. In
our study, there were more girls than boys (28 females, 23 males).
In terms of mechanism of injury, there were more girls that sus-
tained injury during participation in sports (14 females, 8 males).
In recent years, there have been increasing opportunities for girls
to be involved in sports, and at a younger age [13]. The increased
involvement of girls in sports, could explain the higher number of
SH II fractures seen in girls than boys in our study.
The American Academy of Pediatrics (AAP) issued a policy
statement in 2012 discouraging the use of home trampolines [14].
 R.A. Thomas and W.L. Hennrikus / Injury 51 (2020) 636–641 641

Table 1 Conclusions
Patient Demographics. Mechanism of injury subdivided by gender and treatment
group.
Treatment of distal SH II fractures of the tibia related to the
Variables Cast only Closed reduction and cast All participants degree of fracture displacement. Based on study findings we rec-
Age 9.1 yrs 10.5 yrs 9.4 yrs ommend a protocol. Following the injury, if fracture displacement
Sex is less than 3 mm, the fracture can be treated with a cast. If the
Male 20 3 23 displacement is greater than or equal to 3 mm, the fracture should
Female 25 3 28
be treated with closed reduction and casted. Following closed re-
Injured side
Right 18 3 21 duction, if the displacement is still greater than or equal to 3 mm,
Left 27 3 30 open reduction is indicated. Either short or long leg cast can be
Mechanism of injury used to successfully immobilize the fracture for treatment. We do
Sports
not recommend cast wedging.
Males 7 1 8
Females 13 1 14
Motor vehicle Declaration of Competing Interest
Males 1 2 3
Females 1 0 1 This work is not from a prior or a duplication of a publication
Other
of the same or a very similar work. Authors did not receive grant
Males 12 0 12
Females 11 2 13 support or research funding and all authors have no conflicts of in-
Injury By Sport terest. The manuscript has been read and approved by all authors.
Trampoline 7 0 7
Gymnastics 2 0 2 References
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