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 | ||
* | *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=== | ===Mnemonic=== | ||
*S 1 - Slipped ( | *S 1 - Slipped (through physis/growth plate) | ||
*A 2 - Above ( | *A 2 - Above (physis with metaphysis fracture) | ||
*L 3 - Lower ( | *L 3 - Lower (physis with epiphysis fracture) | ||
*T 4 - Through ( | *T 4 - Through (physis, metaphysis and epiphysis fracture) | ||
*R 5 - Rammed (growth plate crushed) | *R 5 - Rammed (growth plate crushed) | ||
===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== | ==Clinical Features== | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
*Sprain | |||
*Contusion | |||
*Other fracture | |||
==Evaluation== | ==Evaluation== | ||
[[File:Salter_Harris.jpg|thumb|Salter Harris Types]] | [[File:Salter_Harris.jpg|thumb|Salter Harris Types]] | ||
===Type 1 (Slip)=== | ===Type 1 (Slip)=== | ||
*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) | ||
===Type 2 (Above)=== | ===Type 2 (Above)=== | ||
*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)=== | ||
*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, | *fracture starts at articular surface and extends through epiphysis, physis, metaphysis | ||
===Type 5 (Crush)=== | ===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 | **May confuse for Type 1 injury | ||
**X-ray findings may be minimal | **X-ray findings may be minimal | ||
==Management== | ==Management== | ||
* | {{General Fracture Management}} | ||
** | |||
**Type | ===Type I=== | ||
* | *Most: Splint, ortho follow up | ||
* | *[[Radiograph-negative ankle injury (peds)|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<ref>. 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== | ==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/> | ||
[[Category:Pediatrics]] | [[Category:Pediatrics]] | ||
[[Category:Orthopedics]] | [[Category:Orthopedics]] |
Revision as of 05:18, 18 September 2019
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
Type 1 (Slip)
- Suspect if point tenderness over a physis
- X-ray findings are subtle (epiphyseal displacement) or absent (clinical diagnosis)
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)
- X-ray shows physis compression fracture
- May confuse for Type 1 injury
- X-ray findings may be minimal
Management
General Fracture Management
- Acute pain management
- Open fractures require immediate IV antibiotics and urgent surgical washout
- Neurovascular compromise from fracture requires emergent reduction and/or orthopedic intervention
- Consider risk for compartment syndrome
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[2]
Type III-V
- Splint, ortho consult
Disposition
- Outpatient
See Also
- 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
- ↑ Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Joint Surg Am. 2012; 94(13):1234-1244.
- ↑ . 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.