Salter-Harris fractures: Difference between revisions

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==Background==
==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 ([[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>


===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)


S 1- Slipped (thru epiphysis)
===Fracture Chart===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Type'''
| 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
|-
|}


A 2- Above (epiphysis c metaphysis fx)
==Clinical Features==
*Trauma with point tenderness over a non-closed (pediatric) physis


L 3- Lower (thru epiphysis)
==Differential Diagnosis==
*Sprain
*Contusion
*Other fracture


T 4- Through (epi and meta)
==Evaluation==
[[File:Salter_Harris.jpg|thumb|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


R 5- Rammed (growth plate crushed)
===Type 2 (Above)===
*X-ray shows triangular fragment of metaphysis with out injury to epiphysis


(*reference joint is below*)
===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


- most significant diff btwn adult and child bones is presenece of physis/ growth plate
===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


- is composed of proliferating cartilage cells and lacks inherent strength and therfore easily damaged.
==Management==
{{General Fracture Management}}


- injury can happen at any age but most common during period of rapid growth
===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


- if missed- prematume closure and bone growth arrest
===Type II===
*Most: Splint, ortho follow up
*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>


- most common after age 10
===Type III-V===
*Splint, ortho consult


- more in boys- more active and later skeletal maturity than girls
==Disposition==
*Outpatient


- funtion of physis is for rapid longitudinal bone growth
==See Also==
*[[Fractures]]
*[[Radiograph-negative ankle injury (peds)]]
*[[Triplane fracture]] (type IV fracture of distal tibia)


- distal radius most common site
==External Links==
*POSNA (Pediatric Orthopaedic Society of North America) - http://orthoinfo.aaos.org/topic.cfm?topic=A00040


- ligaments stronger than bones in kids- more likely to fx than sprain
==References==
<references/>


- repetitive stress injury can also cause it
[[Category:Pediatrics]]
 
[[Category:Orthopedics]]
- suspect if point tenderness over physis and neg xray
 
 
Physis zones- epiphysis to metaphys. Blood supply from epiphysis
 
1- resting cells
 
2- proliferating cells
 
3- hypertophic/ maturing cells- weakest link were fx occurs
 
4- zone of provisional calcification
 
- higher the salter #, the more physeal arrest and joint incongruity because of injury to vascular supply to physis
 
 
==Types==
 
 
Type 1- slip
 
- slip through epiphysis
 
- mostly in infants and todlers
 
- by shearing torsion avulsion
 
- fx thru hypertrophic zone with growing cells remaining on the epiphysis in continuity with blood supply
 
- no osseous fx
 
- good prognosis
 
 
Type 2- above
 
- fx thru\above metaphysis. fx thru hypertrophic zone of physis and then above thru metaphysis.
 
- most common type of fx
 
- segment of metaphyseal bone called Thurston Holland fragment
 
 
Type 3- below
 
- intraarticular fx
 
- relatively rare
 
- the greater displacement, greater chance of vasc supply compromise and greater chance of growth disturbance
 
 
Type 4- both
 
- starts at articular surface thru epiphysis thru physisi thru metaphys
 
- mostly at distal humerus
 
 
Type 5- crush
 
- most rare type
 
- highest chance of growth arrest
 
- compression crushes cells of zone of reserve and proliferation
 
- minimal or no displacement of epiphysis
 
- usually at knee or ankle by severe adduction abductn
 
- usually dx in retrospect once bone growth abnormality already seen
 
 
==Diagnosis==
 
 
X rays
 
- can have acute fx ang neg x ray- look for point tenderness over physis
 
- 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 1 2- splint
 
- type 3-4- surg, probably ORIF
 
- type 5- ortho, casting and nonwt bearing
 
 
 
 
[[Category:Peds]]

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

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

External Links

References

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