Salter-Harris fractures: Difference between revisions
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===Mnemonic=== | ===Mnemonic=== | ||
*S 1 - Slipped ( | *S 1 - Slipped (through physis/growth plate) | ||
*A 2 - Above ( | *A 2 - Above (physis with metaphysis fracture) | ||
*L 3 - Lower ( | *L 3 - Lower (physis with epiphysis fracture) | ||
*T 4 - Through ( | *T 4 - Through (physis, metaphysis and epiphysis fracture) | ||
*R 5 - Rammed (growth plate crushed) | *R 5 - Rammed (growth plate crushed) | ||
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| align="center" style="background:#f0f0f0;"|'''V (Crush)''' | | align="center" style="background:#f0f0f0;"|'''V (Crush)''' | ||
|- | |- | ||
| Fracture Location||hypertrophic zone of physis (epiphysis separates from metaphysis)||Through physis and out through piece of metaphyseal bone||Intra-articular||Starts at articular surface and extends through epiphysis, physis, | | Fracture Location||hypertrophic zone of physis (epiphysis separates from metaphysis)||Through physis and out through piece of metaphyseal bone||Intra-articular||Starts at articular surface and extends through epiphysis, physis, metaphysis||Physis compression | ||
|- | |- | ||
| Pathophysiology||Growing cells remain on the epiphysis in continuity with blood supply||Growing cells remain on the epiphysis in continuity with blood supply||fracture extends from epiphysis through physis|||| | | Pathophysiology||Growing cells remain on the epiphysis in continuity with blood supply||Growing cells remain on the epiphysis in continuity with blood supply||fracture extends from epiphysis through physis|||| | ||
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*Suspect if point tenderness over a physis | *Suspect if point tenderness over a physis | ||
*X-ray findings are subtle (epiphyseal displacement) or absent (clinical diagnosis) | *X-ray findings are subtle (epiphyseal displacement) or absent (clinical diagnosis) | ||
*Often radiograph negative | |||
===Type 2 (Above)=== | ===Type 2 (Above)=== | ||
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===Type 4 (Both)=== | ===Type 4 (Both)=== | ||
*fracture starts at articular surface and extends through epiphysis, physis, | *fracture starts at articular surface and extends through epiphysis, physis, metaphysis | ||
===Type 5 (Crush)=== | ===Type 5 (Crush)=== | ||
[[File: Salter_harris.JPG|thumb|Salter-Harris IV fracture of the distal tibia with associated distal fibular fracture that does not involve the physis]] | [[File: Salter_harris.JPG|thumb|Salter-Harris IV fracture of the distal tibia with associated distal fibular fracture that does not involve the physis]] | ||
*X-ray shows physis compression fracture | *X-ray shows physis compression fracture | ||
**May confuse for Type 1 injury | **May confuse for Type 1 injury: differentiation based on clinical presentation, history, and exam. | ||
**X-ray findings may be minimal | **X-ray findings may be minimal | ||
==Management== | ==Management== | ||
{{General Fracture Management}} | |||
===Type I=== | ===Type I=== | ||
Radiograph-negative ankle injury (peds) | |||
Low risk mechanism | |||
* | *Most: Removable brace <ref name="removable"/><ref> Ilene Claudius MD, David Newman MD. (Sept. 2015). EMRAP. https://www.emrap.org/episode/september/pediatricpearls</ref><ref>Yeung DE, Jia X, Miller CA, Barker SL. Interventions for treating ankle fractures in children. Cochrane Database Syst Rev. 2016 Apr 1;4(4):CD010836. doi: 10.1002/14651858.CD010836.pub2. PMID: 27033333; PMCID: PMC7111433.</ref><ref>Yeung DE, Jia X, Miller CA, Barker SL. Interventions for treating ankle fractures in children. Cochrane Database Syst Rev. 2016 Apr 1;4(4):CD010836. doi: 10.1002/14651858.CD010836.pub2. PMID: 27033333; PMCID: PMC7111433.</ref> | ||
**Return to activities as tolerated by pain | **Return to activities as tolerated by pain | ||
** | **Follow up with pediatrician | ||
===Type II=== | ===Type II=== | ||
*Most: Splint, ortho follow up | *Most: Splint, ortho follow up | ||
*Ankle | *Ankle injury - Consider removable ankle brace<ref name="removable"> Boutis K, Willan AR, Babyn P, Narayanan UG, Alman B, Schuh S. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007;119(6): e1256-e1263.</ref> | ||
===Type III-V=== | ===Type III-V=== | ||
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==See Also== | ==See Also== | ||
*[[Fractures]] | *[[Fractures]] | ||
*[[Radiograph-negative ankle injury (peds)]] | |||
*[[Triplane fracture]] (type IV fracture of distal tibia) | |||
==External Links== | ==External Links== | ||
Latest revision as of 04:49, 13 September 2022
Background
- The higher the classification, the higher the likelihood of growth abnormalities
- If physis fracture missed may lead to premature closure and bone growth arrest
- It was previously taught that ligaments are stronger than bones in kids (and fractures were more likely than sprains), however newer studies (to date in ankles) contradict that assumption[1]
Mnemonic
- S 1 - Slipped (through physis/growth plate)
- A 2 - Above (physis with metaphysis fracture)
- L 3 - Lower (physis with epiphysis fracture)
- T 4 - Through (physis, metaphysis and epiphysis fracture)
- R 5 - Rammed (growth plate crushed)
Fracture Chart
| Type | I (Slip) | II (Above) | III (Below) | IV (Through) | V (Crush) |
| Fracture Location | hypertrophic zone of physis (epiphysis separates from metaphysis) | Through physis and out through piece of metaphyseal bone | Intra-articular | Starts at articular surface and extends through epiphysis, physis, metaphysis | Physis compression |
| Pathophysiology | Growing cells remain on the epiphysis in continuity with blood supply | Growing cells remain on the epiphysis in continuity with blood supply | fracture extends from epiphysis through physis | ||
| Epidemiology | Occurs mostly in infants and todlers | Most common type of fracture | Typically occurs at knee or ankle | ||
| Prognosis | Good | Good | Moderate | Moderate | Highest chance of growth arrest |
Clinical Features
- Trauma with point tenderness over a non-closed (pediatric) physis
Differential Diagnosis
- Sprain
- Contusion
- Other fracture
Evaluation
Type 1 (Slip)
- Suspect if point tenderness over a physis
- X-ray findings are subtle (epiphyseal displacement) or absent (clinical diagnosis)
- Often radiograph negative
Type 2 (Above)
- X-ray shows triangular fragment of metaphysis with out injury to epiphysis
Type 3 (Below)
- X-ray shows epiphyseal fragment not associated with etaphyseal fracture
- Greater the displacement greater chance of vascular supply compromise
Type 4 (Both)
- fracture starts at articular surface and extends through epiphysis, physis, metaphysis
Type 5 (Crush)
- X-ray shows physis compression fracture
- May confuse for Type 1 injury: differentiation based on clinical presentation, history, and exam.
- X-ray findings may be minimal
Management
General Fracture Management
- Acute pain management
- Open fractures require immediate IV antibiotics and urgent surgical washout
- Neurovascular compromise from fracture requires emergent reduction and/or orthopedic intervention
- Consider risk for compartment syndrome
Type I
Radiograph-negative ankle injury (peds) Low risk mechanism
- Most: Removable brace [2][3][4][5]
- Return to activities as tolerated by pain
- Follow up with pediatrician
Type II
- Most: Splint, ortho follow up
- Ankle injury - Consider removable ankle brace[2]
Type III-V
- Splint, ortho consult
Disposition
- Outpatient
See Also
- Fractures
- Radiograph-negative ankle injury (peds)
- Triplane fracture (type IV fracture of distal tibia)
External Links
- POSNA (Pediatric Orthopaedic Society of North America) - http://orthoinfo.aaos.org/topic.cfm?topic=A00040
References
- ↑ Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Joint Surg Am. 2012; 94(13):1234-1244.
- ↑ 2.0 2.1 Boutis K, Willan AR, Babyn P, Narayanan UG, Alman B, Schuh S. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007;119(6): e1256-e1263.
- ↑ Ilene Claudius MD, David Newman MD. (Sept. 2015). EMRAP. https://www.emrap.org/episode/september/pediatricpearls
- ↑ Yeung DE, Jia X, Miller CA, Barker SL. Interventions for treating ankle fractures in children. Cochrane Database Syst Rev. 2016 Apr 1;4(4):CD010836. doi: 10.1002/14651858.CD010836.pub2. PMID: 27033333; PMCID: PMC7111433.
- ↑ Yeung DE, Jia X, Miller CA, Barker SL. Interventions for treating ankle fractures in children. Cochrane Database Syst Rev. 2016 Apr 1;4(4):CD010836. doi: 10.1002/14651858.CD010836.pub2. PMID: 27033333; PMCID: PMC7111433.