Non-surgical interventions for isolated Salter-Harris type I distal fibula fractures: A systematic review

Abstract

Background: Salter-Harris Type I (SH1) fractures of the distal fibula are inherently stable and can be managed conservatively with immobilisation. Numerous immobilisation techniques are used in clinical practice, with no gold standard currently established. This systematic review aims to evaluate the functional and patient-reported outcomes of traditional, rigid immobilisation techniques compared to less restrictive ones that allow earlier mobilisation. Methods: The PubMed, MEDLINE Ovid, Embase and Cochrane Library databases were searched systematically for studies on skeletally immature children and adolescents with isolated distal fibula SH1 fractures. Those with polytrauma or pre-existing musculoskeletal or developmental conditions were excluded. Quality assessment was conducted using Cochrane risk-of-bias and JBI tools. Narrative analysis was employed in conjunction with Synthesis Without Meta-analysis (SWiM). Results: Six studies involving 349 participants were included, of which four were randomised controlled trials (RCTs) and two were observational studies. Within the RCT group, three compared casting to bracing, tubular bandaging or controlled ankle motion (CAM) boot wearing, while one compared posterior splinting to bracing. Both observational studies only reported outcomes of one immobilisation technique – one on casting and the other on bracing. Nine outcomes were reported, with less restrictive immobilisation having more favourable results in six – time to return to normal levels of activity, functional scores, satisfaction, complications, cost-effectiveness and hours of school missed. The remaining three outcomes – pain, duration of analgesia and weight-bearing – were comparable in both immobilisation groups. Discussion: Collectively, the findings underscore the adequacy and benefits of using less restrictive immobilisation for SH1 distal fibula fractures, which is in keeping with the current trend towards less rigid immobilisation techniques in clinical practice. Limitations of this review include reporting biases and lack of certainty of evidence from small sample sizes. Level of evidence: II.