An 11-year-old male presented to the emergency department after being kicked by a cow, unable to bear weight on his right leg and experiencing excruciating pain. Examination revealed swelling and bruising around the right ankle with pain on movement. X-rays showed a fracture extending from the metaphysis through the epiphysis, classified as a Salter-Harris Type IV injury. This type of injury crosses the physis and involves both the epiphysis and metaphysis, is associated with a worse prognosis than other types, and may affect growth even with perfect reduction. Orthopedic consultation was recommended for possible open reduction and internal fixation if any displacement was present.

2.  11 yo male presents to ED
after sustaining an injury to
his right leg after being
kicked by a cow. Per the
pt’s mother, he has not
been able to bear weight on
the extremity since the
accident and he is c/o
excruciating pain. No other
injuries to report.
 T: 98.3 P: 96 BP: 110/74
R:20 O2: 100%
 Gen: NAD
 HENT: no traumatic abn
 CV/Resp: RRR, CTA
 MSK: swelling /
ecchymosis involving
medial portion of R ankle.
 Ext: 2+ DP/PT pulse, pain
with dorsi/plantar flexion
 Mild swelling noted to
medial malleolus (R).

4. M
P
E
Fracture noted
to extend from
metaphysis
though
epiphysis

5.  Good neurovascular exam
 Reduce significant angulation or obvious deformity in
combination with good analgesia or sedation +/-
hematoma block.
 For displaced fractures, get ortho involved as will likely
need ORIF
 For non-displaced fractures, splint and ortho follow
up.
 Repeat neurovascular exam after splinting

6.  Crosses physis as fracture involves both epiphysis and
metaphysis
 Associated with a worse outcome than type I-III.
 If any displacement, involve ortho as ORIF is required
 Even with perfect reduction growth may still be
affected.

8.  http://www.feinberg.northwestern.edu/emergencyme
d/residency/ortho-
teaching/pediatrics/case23/case23diagnosis.html
 http://www.parkhurstexchange.com/challenge/analyz
e/may08/salter-harris
 http://www.wheelessonline.com/ortho/salter_harris_t
ype_iv
 Menkes, J.S. Orthopedic Injuries. Tintinalli’s
Emergency Medicine: A Comprehensive Study Guide
Chapter 267