Salter-Harris fractures

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
• Ligaments stronger than bones in kids - more likely to fracture than sprain
• Repetitive stress injury may also lead to fracture
  • Suspect if point tenderness over physis and neg x-ray

Mnemonic

• S 1 - Slipped (thru epiphysis)
• A 2 - Above (epiphysis c metaphysis fracture)
• L 3 - Lower (thru epiphysis)
• T 4 - Through (epi and meta)
• R 5 - Rammed (growth plate crushed)

Diagnosis

Salter Harris Types

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
• X-ray findings are subtle (epiphyseal displacement) or absent (clinical diagnosis)

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

Type 3 (Below)

• Intra-articular fracture
  • fracture extends from epiphysis through physis
• X-ray shows epiphyseal fragment not a/w metaphyseal fracture
• Greater the displacement greater chance of vasc supply compromise

Type 4 (Both)

• fracture starts at articular surface and extends through epiphysis, physis, metaphysics

• 

  Salter-Harris IV fracture of the distal tibia with associated distal fibular fracture that does not involve the physis

Type 5 (Crush)

• Physis compression fracture
  • Typically occurs at knee or ankle
• May confuse for Type 1 injury
  • X-ray findings may be minimal
• Highest chance of growth arrest
• Suspect based on mechanism of injury, joint effusion

Management

• Types 1-2 - Splint, ortho f/u
  • 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
• Types 3-4 - Splint, ortho consult
  • Type 3 - more common in older children; requires IF to ensure proper alignment of growth plate and joint surface
  • Type 4 - commonly stop bone growth; require IF
• Type 5 - Casting, NWB, ortho consult / f/u
  • Almost always growth disturbance
  • Cast immobilization or surgery

See Also

• Fractures

References

• POSNA (Pediatric Orthopaedic Society of North America) - http://orthoinfo.aaos.org/topic.cfm?topic=A00040