A 12-year-old female came to clinic because of pain in her distal great toe. Last evening she stubbed it on the floor as she was raising her leg for a kick in a martial arts class.
She had immediate pain and swelling. She has iced it several times, but it continues to swell, and has become ecchymotic and she is having some minor problems walking.
The pertinent physical exam reveals a pre-teen in no acute distress. She has significant swelling and ecchymosis of the great toe, with point tenderness at the distal phalyngeal joint. The rest of the examination was normal.
The radiologic evaluation confirmed the diagnosis of a Salter-Harris II fracture of the distal phalynx of the great toe.
The patient was treated by ‘buddy-taping’ the great toe to the second toe as a splint, and placed into a cast boot to aid support. She obtained some immediate relief with these measures. She was also instructed to rest, ice, and elevate her foot and use ibuprofen for pain control. The patient was to follow-up in approximately 1 week.
Figure 23 – AP (left) and lateral (right) radiographs demonstrate a subtle Salter-Harris Type II fracture of the distal phalanx of the first toe.
Toe and metatarsal fractures are common in children. For toe fractures that are non-displaced or minimally angulated, they can be adequately treated by buddy-taping the toe, and placement in a a hard-soled shoe using crutches. Sometimes a bulky splint can also be applied.
Fractures of the great toe and the metatarsals can have higher risks of complications. For example, intrarticular fractures of the proximal great toe may need surgical pinning and a 5th metatarsal fracture (Jones Fracture) has a high rate of non union.
Drs. Robert Salter and William Harris classified injuries inolving the epiphyseal plate in their article from the Journal of Bone and Joint Surgery in 1963. Because Salter-Harris fractures involve the physis (i.e. growth plate) they are unique to pediatrics.
The classification has 5 types with the risk of complications increasing with the level. This is because Type III and IV have intraarticular components and Type V crushes the physis (i.e. growth plate) itself.
The Salter-Harris Classification is:
- Type I – fracture through the physis (widened physis)
- Type II – fracture partway through the physis extending up into metaphysis
- Type III – fracture partway through the physis extending down into the epiphysis
- Type IV – fracture through the metaphysis, physis, and epiphysis — can lead to angulation deformities when healing
- Type V – crush injury to the physis
Figure 24 – Diagram showing the Salter-Harris Fracture Classification System. M = Metaphyseal involvement, E = Epiphyseal involvement, ME = Metaphyseal and Epiphyseal involvement.
Overall, only 30% of Salter-Harris fractures cause growth disturbance and 2% have significant functional problems. Generally plain radiographic examination is all that is needed to diagnose the fracture. Computed tomography can be used for surgical planning.
Questions for Further Discussion
1. What are the indications for an orthopaedics consultation for a fracture?
2. What does the acronym RICE stand for?
3. How long should ice be applied to a musculoskeletal soft tissue injury?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for these topics: Fractures and Dislocations and Casts and Splints.
To view current news articles on this topic check Google News.
Salter RB Harris WR. Injuries Involving the Epiphyseal Plate. J. Bone Joint Surg. 1963:45A:587-622.
Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:688.
Moore W, Smith TH. Salter-Harris Fractures. eMedicine.
Available from the Internet at http://www.emedicine.com/radio/topic613.htm (rev. 05/20/03, cited 8/11/05).
D’Alessandro MP. Fracture, Epiphyseal Plate (Salter Harris) Paediapaedia: Musculoskeletal Diseases. Available from the Internet at: http://www.vh.org/pediatric/provider/radiology/PAP/MSDiseases/FxEpiphyseal.html. (cited 8/11/05).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competency performed.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
October 3, 2005