Salter-Harris fractures: Difference between revisions
 
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*The higher the classification, the higher the likelihood of growth abnormalities
*The higher the classification, the higher the likelihood of growth abnormalities
*If physis fracture missed may lead to premature closure and bone growth arrest
*If physis fracture missed may lead to premature closure and bone growth arrest
*Ligaments stronger than bones in kids - more likely to fracture than sprain
*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>
*Repetitive stress injury may also lead to fracture
**Suspect if point tenderness over physis and neg x-ray


===Mnemonic===
===Mnemonic===
*S 1 - Slipped (thru epiphysis)
*S 1 - Slipped (through physis/growth plate)
*A 2 - Above (epiphysis c metaphysis fracture)
*A 2 - Above (physis with metaphysis fracture)
*L 3 - Lower (thru epiphysis)
*L 3 - Lower (physis  with epiphysis fracture)
*T 4 - Through (epi and meta)
*T 4 - Through (physis, metaphysis and epiphysis fracture)
*R 5 - Rammed (growth plate crushed)
*R 5 - Rammed (growth plate crushed)


==Diagnosis==
===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
|-
|}
 
==Clinical Features==
*Trauma with point tenderness over a non-closed (pediatric) physis
 
==Differential Diagnosis==
*Sprain
*Contusion
*Other fracture
 
==Evaluation==
[[File:Salter_Harris.jpg|thumb|Salter Harris Types]]
[[File:Salter_Harris.jpg|thumb|Salter Harris Types]]
===Type 1 (Slip)===
===Type 1 (Slip)===
*fracture through hypertrophic zone of physis (epiphysis separates from metaphysis)
**Growing cells remain on the epiphysis in continuity with blood supply
***Good prognosis
*Occurs mostly in infants and todlers
*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)===
*Most common type of fracture
*fracture through physis and out through piece of metaphyseal bone
**Growing cells remain on the epiphysis in continuity with blood supply
**Good prognosis
*X-ray shows triangular fragment of metaphysis with out injury to epiphysis
*X-ray shows triangular fragment of metaphysis with out injury to epiphysis


===Type 3 (Below)===
===Type 3 (Below)===
*Intra-articular fracture
**fracture extends from epiphysis through physis
*X-ray shows epiphyseal fragment not associated with etaphyseal fracture
*X-ray shows epiphyseal fragment not associated with etaphyseal fracture
*Greater the displacement greater chance of vascular supply compromise
*Greater the displacement greater chance of vascular supply compromise


===Type 4 (Both)===
===Type 4 (Both)===
*fracture starts at articular surface and extends through epiphysis, physis, metaphysics
*fracture starts at articular surface and extends through epiphysis, physis, metaphysis
**
<gallery>
File: Salter_harris.JPG |Salter-Harris IV fracture of the distal tibia with associated distal fibular fracture that does not involve the physis
</gallery>


===Type 5 (Crush)===
===Type 5 (Crush)===
*Physis compression fracture
[[File: Salter_harris.JPG|thumb|Salter-Harris IV fracture of the distal tibia with associated distal fibular fracture that does not involve the physis]]
**Typically occurs at knee or ankle
*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
*Highest chance of growth arrest
*Suspect based on mechanism of injury, joint effusion


==Management==
==Management==
*Types 1-2 - Splint, ortho f/u
{{General Fracture Management}}
**Type 1 - may result in disrupted bone growth; may need IF
 
**Type 2 - most common type of growth plate fracture, but generally heal well; may need IF
===Type I===
*Types 3-4 - Splint, ortho consult
Radiograph-negative ankle injury (peds)
**Type 3 - more common in older children; requires IF to ensure proper alignment of growth plate and joint surface
Low risk mechanism
**Type 4 - commonly stop bone growth; require IF
*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>
*Type 5 - Casting, NWB, ortho consult / f/u
**Return to activities as tolerated by pain
**Almost always growth disturbance
**Follow up with pediatrician
**Cast immobilization or surgery
 
===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>
 
===Type III-V===
*Splint, ortho consult
 
==Disposition==
*Outpatient


==See Also==
==See Also==
*[[Fractures]]
*[[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==
<references/>
<references/>
*POSNA (Pediatric Orthopaedic Society of North America) - http://orthoinfo.aaos.org/topic.cfm?topic=A00040


[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Orthopedics]]
[[Category:Orthopedics]]

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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