Journal of Pediatric Orthopaedics - 2026-08-01 - Journal Article
Risk Factors and Surgical Sequelae of Physeal Arrest in Pediatric Salter-Harris III and IV Medial Malleolus Fractures.
Roth OS, Gupta A, Adebayo T, Tretiakov M
Topics
Key Takeaway
Physeal bar formation occurred in 30.4% of pediatric Salter-Harris III and IV medial malleolus fractures, with greater fracture displacement (5.4 vs. 3.3 mm) and coronal plane physeal involvement (23.6% vs. 17.8%) as significant predictors.
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Summary
This retrospective review evaluated predictors of physeal bar formation in 56 skeletally immature patients with SH III or IV medial malleolus fractures. Greater fracture displacement and coronal plane physeal involvement predicted both operative management and bar formation; 30.4% developed physeal bars. Of those, 47% required at least one secondary surgery including bar resection, epiphysiodesis, or osteotomy.
Key Limitation
Retrospective design with n=56 precludes multivariate analysis, making it impossible to determine whether fracture displacement and coronal physeal involvement are independent predictors or surrogates for the same injury severity.
Original Abstract
BACKGROUND
Pediatric medial malleolus fractures pose a risk for physeal bar formation and growth disturbances. This study aimed to determine the rate of physeal bar formation following Salter-Harris (SH) III or IV medial malleolus fractures and identify patient, fracture, and management factors predictive of bar formation. A secondary objective was to evaluate the rate of additional surgeries required in the event of physeal bar formation.
METHODS
A retrospective review was performed of 161 patients (age 16 y or younger) with isolated medial malleolus or bimalleolar fractures. Fifty-six skeletally immature patients (39% female) with SH III or IV medial malleolus fractures and ≥6 months of radiographic follow-up met the inclusion criteria. Demographics, injury mechanism, fracture management, and secondary surgeries were recorded. Radiographs were analyzed for fracture displacement, SH classification, coronal plane physeal involvement, anterior and lateral distal tibial angles, postreduction displacement, and physeal bar formation. Wilcoxon rank sum tests assessed statistical significance (α<0.05).
RESULTS
Thirty-five isolated medial malleolus and 21 bimalleolar ankle fractures were identified (SH III=40, SH IV=16). Initial treatment was operative in 34 patients (60.7%), with greater fracture displacement (4.9 vs. 2.4 mm) and coronal plane physeal involvement (21.5% vs. 16.4%) being significant predictors of surgical management. Physeal bars developed in 17 patients (30.4%), with a mean diagnosis time of 8.4 months. Patients with bar formation also presented with significantly greater fracture displacement (5.4 vs. 3.3 mm) and coronal plane physeal involvement (23.6% vs. 17.8%). No difference in bar formation rates was observed among other patient or fracture characteristics. Eight of 17 physeal bar patients (47%) required at least one secondary surgery, including bar resection (n=4), epiphysiodesis (n=7), and/or osteotomies (n=3).
CONCLUSIONS
Pediatric physeal medial malleolus fractures carry a high risk for bar formation. Greater fracture displacement and coronal plane physeal involvement were significant predictors of initial surgical management and bar formation. Close radiographic monitoring of these high-risk fractures for at least 1 year following injury and attentive patient counseling on the risk of secondary surgery is recommended for timely identification and intervention.
LEVEL OF EVIDENCE
Level IV-case series.