Children presenting to the ED after an ankle injury with isolated swelling and tenderness over the distal fibula but no radiographic evidence of fracture were often historically diagnosed with a Salter-Harris I (SH-I) fracture of the distal fibula because of presumed weakness of the growth plate relative to the adjacent ligaments.
MRI studies, however, have demonstrated that almost none of these patients has an SH-I fracture; they almost always have a ligamentous injury with an intact physis. (Pediatr Emerg Care. 2020;36:248; CMAJ. 2018;190:E367; https://bit.ly/2zCIMol; Foot Ankle Clin. 2015;20:705; https://bit.ly/2N0inUs; JAMA Pediatr. 2016;170:e154114; https://bit.ly/3e9e3hw; Injury. 2010;41:852.)
Physeal arrest after a nondisplaced fibula fracture has also not been reported in the literature. (Foot Ankle Clin. 2015;20:705; https://bit.ly/2N0inUs.)
Children with negative x-rays despite distal fibular physeal tenderness can be appropriately treated the same as those with a low ankle sprain, that is, immediate weightbearing as tolerated (e.g., removable ankle brace) and immobilization as needed for comfort. (Pediatr Emerg Care. 2020;36:248; CMAJ. 2018;190:E367; https://bit.ly/2zCIMol; Foot Ankle Clin. 2015;20:705; https://bit.ly/2N0inUs.)
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