8 year old male, Salter-Harris Type IV fracture of the Proximal Tibia
An 8-year-old male presented to Access Ortho a week after injuring their knee whilst jumping at a trampoline park.
The patient initially saw their GP and had an X-ray. The X-ray report did not note any fractures.
The pain in their knee continued with no improvement over the following week, so the GP ordered an MRI. The MRI showed a Salter-Harris Type IV fracture of the proximal tibia, and the GP referred them to Access Ortho for advice and care.
On presentation to Access Ortho, the child had tenderness over the anterior and posterior proximal tibia and decreased knee range of motion.
The child presented on crutches due to their inability to weight-bear.
The Access Ortho orthopaedic team determined that the patient had a hyperextension injury of the knee, which resulted in a Salter-Harris Type IV proximal tibia fracture. Due to the stability of the fracture, the orthopaedic team determined that surgery was not required, and the injury was immobilised with an above-knee fibreglass cast for 5 weeks from presentation (6 weeks from injury).
As specialists in Orthopaedic Care, the medical team considered the patient’s age and the fact that the fracture extended into the growth plate. The child’s family was advised of the risk of bone growth issues due to the growth plate being involved in the fracture. Specific long-term follow-up care is required to monitor the progress of these injuries.
Two weeks after the injury, a follow-up X-ray and appointment with the orthopaedic surgeon at Access Ortho was arranged to assess the status of the fracture and ensure no movement in the fracture position had occurred. The patient remained non-weight-bearing on crutches and in the cast. The X-ray showed excellent alignment of the fracture. Therefore, treatment was continued as per the original treatment plan.
Slowing down an 8-year-old boy can be difficult and frustrating. At this appointment, the Access Ortho team discussed the excellent progress the child was making and how, with a little more time, he would be getting back to normal activities. The child was back at school at this time, with the support of his teachers and classmates. His confidence on crutches was improving, which improved his independence around home.
Six weeks after the injury, the child returned to Access Ortho. The cast was removed, and follow-up radiology was arranged. This X-ray showed excellent healing of the fracture. Some muscle wasting was noted in the leg, which is to be expected after a period of immobilisation.
The Access Ortho medical team discussed the need to transition to weight bearing over time as the child felt comfortable. The child’s knee was stiff after the cast was removed, but due to their young age, this stiffness was expected to resolve without formal physiotherapy. Activities such as swimming were permitted at this time, but jumping and running were not advised.
A follow-up appointment one month later showed the child was making excellent progress. He now had a full range of motion in the knee, and there was no tenderness to the area of the fracture. The family was advised to continue the limitations to activities for another month to ensure no further injuries occurred.
A follow-up appointment six months later was arranged. At this time, an X-ray was taken to check the growth plate status. This X-ray showed no long-term damage to the growth plate had occurred. At this time, the child was back playing soccer and enjoying normal 8-year-old activities, although Mum did say she had not yet returned to a trampoline park!
A further appointment has been made in 6 months for an additional growth plate check.
What is a Salter-Harris Fracture?
A Salter-Harris Fracture is a fracture that extends into the growth plate in a child’s long bone. The growth plate is the area of new growth in a long bone; it is made up of a soft cartilage and is present during the growth phase.
Salter-Harris fractures are graded from 1 to 5, with 1 being the mildest. The classification system helps determine the prognosis and treatment. If left untreated Salter-Harris fractures can cause growth arrest.
How likely is bone growth arrest following a Type IV Salter-Harris Fracture of the proximal tibia?
With a Salter-Harris Type IV proximal tibia fracture, there is a 30% chance of growth arrest. The likelihood of growth arrest depends on several factors, including the type of fracture, the child’s skeletal maturity, and the amount of initial displacement. It is, therefore, essential to get specialist Orthopaedic advice rapidly with proximal Tibia fractures to minimise the risk of complications. In addition, long-term follow-up should be arranged to monitor progress.
