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 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 physis

Differential Diagnosis

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)

  • 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 follow up
    • 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 / follow up
    • Almost always growth disturbance
    • Cast immobilization or surgery

Disposition

See Also

References