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
• 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

Mnemonic

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

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)

• 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 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, metaphysics

Type 5 (Crush)

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

• 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

Type I

• Most: Splint, ortho follow up
• lateral ankle:
  • Removable ankle brace
  • Return to activities as tolerated by pain
  • No ortho followup

Type II

• Most: Splint, ortho follow up
• Ankle: Removable ankle brace

Type III-V

• Splint, ortho consult

Disposition

• Outpatient

See Also

• Fractures

External Links

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