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)

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, metaphysics	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)

• 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