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. 2025 May 28;51(1):220. doi: 10.1007/s00068-025-02889-5

Ultrasound-guided closed reduction of distal radius Salter-Harris I and II fracture in children

Xing Wu 1,✉, Xijun Meng 1, Si Wang 1, Xiantao Shen 1,✉
PMCID: PMC12116895  PMID: 40425793

Abstract

Background

Distal radial physeal fractures are the most common type of physeal fracture. However, few studies have been dedicated to the role of ultrasound-guided closed reduction in these fractures. This study aimed to investigate the utility of ultrasound-guided closed reduction in paediatric distal radial physeal fractures.

Methods

Consecutive patients undergoing ultrasound-guided closed reduction of fractures in our department between November 2017 and October 2019 were included. The adequacy of realignment according to the ultrasound and radiography was recorded.

Results

A total of 51 patients were included in the study. Closed reduction was successfully achieved in all cases who underwent ultrasound-guided cases. The sensitivity for confirming successful anatomical manipulation with ultrasound was 95.3% (95% CI: 82.9 ~ 99.2%), while the specificity was 87.5% (95% CI: 46.7 ~ 99.3%). The positive predictive value (PPV) was 97.6% (95% CI: 85.9 ~ 99.9%), and the negative predictive value (NPV) was 77.8% (95% CI: 40.2 ~ 96.1%). The corresponding positive and negative likelihood ratios were 7.63 (95% CI: 1.22 ~ 47.77) and 0.05 (95% CI: 0.01 ~ 0.21). There was a high level of agreement between ultrasound and radiographs assessments of anatomical reduction [κ: 0.788 (± 0.117)]. Redisplacement occurred in three cases (5.9%) based on radiographic assessment with one case being a Salter-Harris type I injury and two cases being a Salter-Harris type II injury. At the final follow-up, all fractures had healed, resulting in excellent cosmesis without any other complications.

Conclusions

Our data suggest that ultrasound-guided closed reduction can be considered an excellent alternative method for the treatment of distal radial physeal fractures.

Keywords: Forearm fracture, Distal radial physeal fractures, Ultrasound, Closed reduction

Background

Distal radial physeal fractures represent approximately 18% of all physeal fractures in children [1]. Traditionally, these fractures are treated with closed reduction (CR). A blind-closed reduction is often performed in emergency or outpatient departments. However, the success of blind closed reduction is typically assessed using fluoroscopy or postreduction radiography, and failure may result in repeated attempts and potential medical epiphyseal injury, as well as additional radiation exposure for both the patient and medical staff [2–4].

Ultrasound has emerged as a widely accepted alternative for the management of musculoskeletal injuries. It offers a largely available, cost-effective, radiation-free, and non-invasive technique for the assessment of forearm fractures [5–7]. While several studies have reported the successful ultrasound-guided closed reduction of paediatric distal radial fractures [8, 9], limited data exists on the use of ultrasound to diagnose distal radial physeal fractures and guide CR in children [10–13]. However, previous studies have reported the successful ultrasound-guided reduction of other physeal fractures [14, 15]. Therefore, we hypothesized that ultrasound could be used as an alternative imaging tool for the treatment of distal radial physeal fractures. This study aims to explore the effectiveness of ultrasound in guiding CR for these fractures.

Materials and methods

This is a retrospective case-series study of consecutive children with distal radial physeal fractures from November 2017 to October 2019. The study protocol was approved by our institution's ethics board. Informed consent for the procedure was obtained from the parents or guardians of participating children. The inclusion criteria for patients were as follows: (1) Age ≤ 17 years; (2) Closed, physeal distal fractures. The exclusion criteria for patients were as follows: (1) Fractures presenting 7 days or more after the injury; (2) Pathological fractures; (3) Open fracture; (4) Patients with incomplete data or loss to follow-up. Initial anteroposterior and lateral wrist radiographs served to confirm the diagnosis and to perform ultrasound-guided closed reductions in these patients.

The CR of fractures was performed by an orthopaedic consultant by blind manual palpation under ultrasound guidance without anesthesia. Preoperatively, part of the patients received oral nonsteroidal anti-inflammatory medications for analgesia. All procedures were conducted within a pain threshold deemed tolerable by the patient population. The procedure was conducted with a 7.0–12.5 MHz linear array transducer (GE Healthcare, Tokyo). The transducer was positioned in a longitudinal orientation on the dorsal, lateral, and volar planes of the radius to visualize the fracture site, as illustrated in Fig. 1a, b, and c. The standardized sectional planes have already been introduced by Ackermann [16]. The ultrasound provided clear images of the fracture site and allowed for real-time monitoring of the reduction process. The fracture of the ultrasound image was visualized in three standardized longitudinal planes from a dorsal, lateral, and volar view. The ultrasound sign of fracture was defined as the presence of displacement between hyperechoic cortical and hypoechoic physeal cartilage in one view. In the realm of ultrasonographic diagnostics, a clear distinction is evident between the hypoechoic physeal region and the hyperechoic metaphyseal bone cortex, which is clinically defined as Salter-Harris type I injuries (Fig. 2). Simultaneously, the identification of a hyperechoic fracture fragment in continuity with the hypoechoic physis represents the diagnostic hallmark of Salter-Harris type II injuries (Fig. 3).

Fig. 1.

Fig. 1

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Clinical photographs demonstrating the patient and transducer positioning. a Dorsal view – the probe is placed on the dorsal side of the wrist, allowing evaluation of the anteroposterior displacement. b Lateral view – the probe is placed on the radial side of the wrist, allowing evaluation of the mediolateral displacement. c Volar view – the probe is placed on the volar side of the wrist, allowing evaluation of the anteroposterior displacement

Fig. 2.

Fig. 2

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A 10-year-old boy with Salter-Harris II injury of distal radial physeal fractures a, b Prereduction radiograph. Ultrasound estimation of closed reduction: c Dorsal section showed the posterior displacement of the epiphyseal. d Dorsal section after complete reduction. e The lateral section showed the lateral displacement of the epiphyseal. f Lateral section after complete reduction. g The volar section showed the anterior displacement of the epiphyseal. h The volar section after complete reduction. Asterisks: the epiphyseal core of ossification of the distal radial; arrowhead: alignment of the hypoechoic cartilaginous structures and hypoechoic cortex; double-headed arrows: the initial displacement distance of the fracture site; R: radial

Fig. 3.

Fig. 3

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An 8-year-old girl with Salter-Harris II injury of distal radial physeal fractures. a, b Pre-reduction radiograph. c, d Pre-reduction ultrasonography dorsal and volar views, and e, f ultrasonography dorsal and volar views after fracture reduction. g, h Post-reduction radiograph. Asterisks: the epiphyseal core of ossification of the distal radial; double-headed arrows: the initial displacement distance of the fracture site; R: radial

With axial traction the fracture may be reduced; otherwise, the fracture should be gently pressed with the thumb distal and dorsal to the fracture site and maintained in a flexed wrist position. Throughout the closed reduction process, ultrasound views were repeated as necessary until optimal alignment was achieved. Subsequently, the efficacy of the closed reduction was verified by ultrasound. Intraoperatively and postoperatively, there was noted to be a reduction of the gap within the borders of continuous lines was observed. The anatomic reduction was verified through ultrasound imaging, which demonstrated a continuous line between the hyperechoic proximal cortex and hypoechoic distal physeal cartilage. Before the application of casting, an assessment of the adequacy of realignment was conducted using ultrasound. The control radiographs were employed to assess the adequacy of the realignment. The radiographic findings were reported by a blinded trauma orthopedic specialist.

For children aged 10 years or younger, acceptable alignment includes < 30° of sagittal angulation, < 15° of radius deviation, and < 50% displacement. For children aged 10 to 14 greater than 2 years of growth potential, acceptable alignment are < 20° of sagittal angulation, < 10° of radius deviation, and < 40% displacement [17–20]. Redisplacement is defined as displacement of more than 20% or dorsal angulation of 10° or more at one week after reduction [4]. Subsequently, participants were followed up at 1, 2, and 6 weeks post-treatment for clinical and radiological evaluations of fracture union progress. Once satisfactory healing had been confirmed during the follow-ups, the cast was removed in an outpatient department setting. The mean clinical follow-up for the cohort was 6 months (range, 3 to 28 months).

Statistical analysis

The demographic characteristics and clinical and radiologic findings during the assessment were recorded using a standard research form. All statistical analyses were done using Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp, Armonk, NY). Continuous data were presented as means (with ± SD), where appropriate, while categorical data were presented using percentages. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to determine the ability of ultrasound to identify the anatomic reductions as determined by radiograph. The agreement between ultrasound and radiographs was calculated by κ values. A p-value < 0.05 was considered statistically significant.

Result

Study population

A total of 79 children presented with distal radial physeal fractures to the pediatric emergency departments during the study period, and 28 of them were excluded from enrollment (Fig. 4). The mean age was 10.8 ± 2.6 years (range 2.0 to 16.9 years), including 38 male and 13 female patients. Injuries were observed on the right forearm in 15 (29%) patients and on the left forearm in 36 (71%) patients, with fracture types including 12 Salter-Harris type I injuries (23.5%), and 39 Salter-Harris type II injuries (76.5%). The mean percentage of displacement in the sagittal plane was 41.4% (range 15 ~ 105%), while the mean angulation in the sagittal plane was measured at an average of 22.8° (range 8 ~ 44°) (Table 1).

Fig. 4.

Fig. 4

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Diagram of study enrollment and analysis for prediction of anatomic CR by ultrasonography and radiographs

Table 1.

Fracture demographics and injury data (N = 51)

Demographics Result
Age (y): mean (range) 10.8(range, 2 ~ 16.9)
Male:n(%) 38(74.5)
Female:n(%) 13(25.5)
Side (right/left) 15/36
Salter-Harris classification
Type I 12(23.5)
Type II 39(76.5)
Displacement of the epiphysis
dorsally 48
volarly 3
The percentage of displacement(%):mean (range)
Sagittal plane 41.4(range, 15 ~ 105)
Frontal plane 17.1(range, 0 ~ 64)
the mean angulation(Degrees):mean (range)
Sagittal plane 22.8(range, 8 ~ 44)
Frontal plane 8.8(range, 0 ~ 25)
Ipsilateral Fractures of ulnar injury
Styloid process fracture 10
Buckle fracture 2
Greenstick fracture 8
Primary reduction
Anatomic 43 (82.4%)
Non-anatomic 9 (17.6%)
Redisplacement 3
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Ultrasound findings

Adequate fracture reduction was achieved in all fractures. For the forty-three (84.3%) patients for whom the CR was determined by radiograph as anatomic and eight (16.7%) as non-anatomic CR. However, ultrasound was identified as anatomic in forty-one cases (80.4%) and non-anatomic in ten cases (20.6%). There were four patients for whom the ultrasound and radiograph results did not agree. Ultrasound demonstrated a sensitivity of approximately 95.3% (95% CI: 82.9 ~ 99.2%) and specificity of around 87.5% (95% CI: 46.7 ~ 99.3%) in confirming successful anatomic manipulation, with a PPV was 97.6% (95% CI: 85.9 ~ 99.9%) and the NPV was 77.8% (95% CI: 40.2 ~ 96.1%) (Table 2). There was high agreement between ultrasound and radiographs for predicting the anatomic reduction of closed reduction [κ: 0.788 (± 0.117)].

Table 2.

Sensitivity, specificity, PPV, NPV, and positive and negative LRs to determine the accuracy of ultrasound in identifying anatomic reduction of fractures

Characteristics Outcome (95%CI)
Sensitivity 93.0(79.9 ~ 98.2)
Specificity 87.5 (46.7 ~ 99.3)
PPV 97.6 (85.6 ~ 99.9)
NPV 70.0 (35.4 ~ 91.9)
Positive LR 7.44 (1.19 ~ 46.63)
Negative LR 0.08 (0.03 ~ 0.25)
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CI Confidence interval; PPV Positive predictive value; NPV Negative predictive value; LR Likelihood ratio

Redisplacement occurred in three cases (5.9%) following radiographic assessment. Of these, one case (33%) involved a Salter-Harris type I injury while two involved Salter-Harris type II injuries case (67%). All redisplacement happened within the first 1 week. No patient required more than two attempts at reduction.

At the final follow-up, the cosmetic results and joint function were excellent, and there were no additional complications associated with the reduction.

Discussion

The present study introduced the application of ultrasound-guided closed reduction in distal radius physeal fracture management. Given the anatomical features of the physeal cartilage, ultrasound is particularly suitable for this purpose due to its ability to display direct signs of physeal fracture more effectively than radiography. With the real-time guidance of the ultrasound, we were able to achieve an anatomic or nearly anatomic reduction in this study. Furthermore, ultrasound-guided closed reduction can be performed in the emergency room or the outpatient clinic rapidly and easily where fluoroscopy is unavailable in these departments of most hospitals in China.

Although previous studies have provided support for the use of ultrasound in the treatment of paediatric forearm fractures [8, 10, 21], there is limited evidence demonstrating the reduction of physeal fractures under ultrasound guidance. This study presents a novel technique for ultrasound-guided closed reduction of distal radial physeal fractures, with an initial anatomic reduction success rate of 84.3%. This is comparable to those reported in previous studies [4]. Besides, our study performed blind closed reduction without sedation. It is postulated that the successful anatomic reduction rate was increased under sedation. Furthermore, our findings indicated good agreement between ultrasound and radiography assessments post-reduction, with ultrasound confirming anatomical reduction success at a sensitivity of 95.3% and specificity of 87.5%. The use of ultrasound in multiple planes provides sufficient visualization information to determine the status of fracture reduction. However, the role of ultrasound in improving fracture reduction success remains uncertain. Nevertheless, our results support the utility of ultrasound as a tool for assessing adequate reduction of distal radial physeal fractures.

Ossification of the distal radius epiphysis typically begins between 8 and 18 months, with complete closure at the approximate age of 17 years [22]. Ultrasound is advantageous for detecting epiphyseal cartilage, although its application in diagnosing distal radial fractures in children primarily focuses on the metaphysis [23, 24]. The diagnosis of periarticular epiphyseal fracture by ultrasound is rare [11, 12], but ultrasound has been utilized for diagnosing other types of epiphyseal fractures such as distal humeral epiphyseal fracture [25], lateral humeral condyle fracture [26], and radial neck fracture [14]. Additionally, Chen[10]reports three cases of Salter-Harris type I injury of distal radius epiphyseal fracture diagnosed by ultrasound. Snelling [27] suggests using the"Point-of-care ultrasound (POCUS) 1-cm rule"to aid in diagnosing Salter-Harris type II distal radius fractures. Our study directly shows that epiphyseal cortical impedance appears high and reveals a hyperechoic image on ultrasound, whereas epiphyseal cartilage exhibits low impedance and reveals a hypoechoic image on ultrasound. High-quality ultrasound images can be obtained to diagnose displacement between hypoechoic epiphyseal cartilage and hyperechoic cortex in cases of distal radius epiphyseals fractures. Therefore, ultrasound could be used for diagnosing these fractures. The ability of ultrasound to assess the physeal cartilage is better than radiography.

The current study showed that closed reduction under ultrasound guidance can achieve near-anatomical and anatomical reduction. The potential for bone remodeling after residual angulation of distal radius epiphysis injury and its impact on function is controversial. Regardless of the great potential for remodeling at the physis, displaced physeal fracture may not allow for complete correction of displacement and angulation [2]. Previous studies have shown that approximately 80% of epiphyseal injuries occur at ages older than 10 years [18, 28]. Larsen [2] considers that children over 10 years old may not be able to obtain completely remodeled angular deformity. Achieving anatomical reduction is valuable in children with little remaining growth potential and a high risk of residual angulation. Moreover, non-anatomic reduction may increase the risk of redisplacement [4]. It could be essential to undergo repeated reduction to achieve anatomical realignment. However, multiple reduction attempts may elevate the risk of growth arrest [28], highlighting the significant benefit our study provides by assisting physicians in determining when a closed reduction procedure is complete. After each reduction attempt, ultrasonography can be effective in assessing the quality of the reduction. Several studies support these results of a decrease in the number of reduction attempts in distal radial fracture [29, 30]. Therefore, our study suggests that ultrasound guidance can accurately facilitate the process of reducing epiphyseal fractures, and avoid invalid reattempts.

Portable fluoroscopy may be utilized for guidance and assessment of reduction before casting, however, its availability is limited in some emergency departments. Radiographs are commonly employed to confirm the effectiveness of fracture reduction in most hospitals, but this process is time-consuming and not available in real-time. Ultrasound serves as a readily easily acquired, easy-to-use, and economical alternative that has been widely utilized as a diagnostic tool and an aid in emergency room settings. It is very noteworthy that ultrasound can rapidly and accurately visualize fracture reduction in a resource-limited setting lacking fluoroscopy and sedation. Similar to previous studies [8, 9, 21], ultrasound assists in reducing the need for further radiography and shortening hospital stays. Furthermore, adhering to the ALARA (“as low as reasonably achievable”) radiation safety principle emphasizes the use of ultrasound guidance over fluoroscopy [31]. Ultrasound-guided CR of fracture is ideally suited for applications in outpatient or emergency room settings without radiation exposure.

Our study has some limitations. First, a brief yet essential learning phase is required for this technique. Before the examination, the operator underwent accredited training on the basic ultrasonic structure of the distal radius physeal fracture. However, physicians without any prior experience in ultrasound and limited training can still accurately diagnose pediatric distal radial fractures [32]. Additionally, assessment of the contralateral side's ultrasonic structure is crucial for accurately evaluating epiphyseal injuries. Secondly, the study involved a relatively small sample size and utilized a retrospective design. Without a control group, there is no data available on the advantages of ultrasound-guided reduction compared to fluoroscopy or postreduction radiography. An ideal study would be prospective to compare ultrasound with other techniques to address whether ultrasound-guided reduction offers superior results. Nevertheless, based on these findings, we believe that our technique is effective and safe when compared to other techniques [18, 28, 33–35]. Thirdly, while ultrasound imaging shows good alignment and may even replace postreduction radiography in some cases, it cannot detect issues after cast application; therefore radiography remains superior during follow-up.

Conclusion

In conclusion, this study presents a case series focusing on the management and outcomes of distal radial physeal fractures. It introduces a safe, real-time visualization and radiation-free alternative that can be swiftly and easily implemented, even in settings without access to fluoroscopy. The study illustrated that ultrasound-guided closed reduction was a safe and effective alternative in managing distal radial physeal fractures despite its limitations; however, further comparative controlled trials are necessary to validate its efficacy.

Author contribution

XW and XTS wrote the main manuscript text; XW, XTS, XJM and SW contributed to the conception and design of the research; XW, XJM and SW contributed to the data collection. All authors reviewed the manuscript.

Funding

This study was supported by the Natural Science Foundation of Hubei Province (2022 CFB460); Science and Technology Program of Hubei Province (2021BCA140).

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Conflict of interest

The authors declare no competing interests.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Xing Wu, Email: wx2001091@163.com.

Xiantao Shen, Email: XTshenWH@aliyun.com.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

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