Salter-Harris fractures: Difference between revisions

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

Salter Harris Types

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)

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
- 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

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.

Authors:

[1] Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Joint Surg Am. 2012; 94(13):1234-1244.

[removable-2] 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.

[3] Ilene Claudius MD, David Newman MD. (Sept. 2015). EMRAP. https://www.emrap.org/episode/september/pediatricpearls

[4] 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.

[5] 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.

[1]

[2]

[3]

[4]

[5]

@@ Line 1: / Line 1: @@
 ==Background==
-* is composed of proliferating cartilage cells and lacks inherent strength and therfore easily damaged.
+*The higher the classification, the higher the likelihood of growth abnormalities
-* injury can happen at any age but most common during period of rapid growth
+*If physis fracture missed may lead to premature closure and bone growth arrest
-* if missed- prematume 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 ([[Radiograph-negative ankle injury (peds)|to date in ankles]]) contradict that assumption<ref>Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Joint Surg Am. 2012; 94(13):1234-1244.</ref>
-* most common after age 10
-* more in boys- more active and later skeletal maturity than girls
-* funtion of physis is for rapid longitudinal bone growth
-* distal radius most common site
-* ligaments stronger than bones in kids- more likely to fx than sprain
-* repetitive stress injury can also cause it
-* suspect if point tenderness over physis and neg xray
-==Types==
+===Mnemonic===
-===Type 1- slip===
+*S 1 - Slipped (through physis/growth plate)
-* slip through epiphysis
+*A 2 - Above (physis with metaphysis fracture)
-* mostly in infants and todlers
+*L 3 - Lower (physis  with epiphysis fracture)
-* by shearing torsion avulsion
+*T 4 - Through (physis, metaphysis and epiphysis fracture)
-* fx thru hypertrophic zone with growing cells remaining on the epiphysis in continuity with blood supply
+*R 5 - Rammed (growth plate crushed)
-* no osseous fx
-* good prognosis
-===Type 2- above===
+===Fracture Chart===
-* fx thru\above metaphysis. fx thru hypertrophic zone of physis and then above thru metaphysis.
+{| {{table}}
-* most common type of fx
+| align="center" style="background:#f0f0f0;"|'''Type'''
-* segment of metaphyseal bone called Thurston Holland fragment
+| align="center" style="background:#f0f0f0;"|'''I (Slip)'''
+| align="center" style="background:#f0f0f0;"|'''II (Above)'''
+| align="center" style="background:#f0f0f0;"|'''III (Below)'''
+| align="center" style="background:#f0f0f0;"|'''IV (Through)'''
+| 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, 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
+|-
+|}
-===Type 3- below===
+==Clinical Features==
-* intraarticular fx
+*Trauma with point tenderness over a non-closed (pediatric) physis
-* relatively rare
-* the greater displacement, greater chance of vasc supply compromise and greater chance of growth disturbance
-===Type 4- both===
+==Differential Diagnosis==
-* starts at articular surface thru epiphysis thru physisi thru metaphys
+*Sprain
-* mostly at distal humerus
+*Contusion
+*Other fracture
-===Type 5- crush===
+==Evaluation==
-* most rare type
+[[File:Salter_Harris.jpg|thumb|Salter Harris Types]]
-* highest chance of growth arrest
+===Type 1 (Slip)===
-* compression crushes cells of zone of reserve and proliferation
+*Suspect if point tenderness over a physis
-* minimal or no displacement of epiphysis
+*X-ray findings are subtle (epiphyseal displacement) or absent (clinical diagnosis)
-* usually at knee or ankle by severe adduction abductn
+*Often radiograph negative
-* usually dx in retrospect once bone growth abnormality already seen
-==Mneumonic==
+===Type 2 (Above)===
-S 1- Slipped (thru epiphysis)
+*X-ray shows triangular fragment of metaphysis with out injury to epiphysis
-A 2- Above (epiphysis c metaphysis fx)
+===Type 3 (Below)===
+*X-ray shows epiphyseal fragment not associated with etaphyseal fracture
+*Greater the displacement greater chance of vascular supply compromise
-L 3- Lower (thru epiphysis)
+===Type 4 (Both)===
+*fracture starts at articular surface and extends through epiphysis, physis, metaphysis
-T 4- Through (epi and meta)
+===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]]
+*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
-R 5- Rammed (growth plate crushed)
+==Management==
+{{General Fracture Management}}
-(*reference joint is below*)
+===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
+**Follow up with pediatrician
-==Diagnosis==
+===Type II===
-X rays
+*Most: Splint, ortho follow up
-* can have acute fx ang neg x ray- look for point tenderness over physis
+*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 2-3-4 can see on xray
-* type 1 - 5 can be occult
-* type 5 may have effusion
-* can also use stress radiography
-==Treatment==
+===Type III-V===
-* type 1 2- splint
+*Splint, ortho consult
-* type 3-4- surg, probably ORIF
-* type 5- ortho, casting and nonwt bearing
-[[Category:Peds]]
+==Disposition==
-[[Category:Ortho]]
+*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==
+<references/>
+[[Category:Pediatrics]]
+[[Category:Orthopedics]]