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Salter Harris Fracture
From WikiSM
Contents
Other Names
- Epiphyseal Fractures
- Epiphyseal Fracture
- Physeal Fracture
- Physeal Fractures
- Salter-Harris Fractures
Background
- This page covers all salter-harris fractures and is not specific to one location or bone
- Defined as a fracture through the physis or growth plate
- Specific injury pattern only seen in children
- Salter-Harris refers to the classification system but is generally considered synonymous with pediatric physeal fracture
- Popularly understood among various specialties makes it an easy form of communication in pediatric fractures
Epidemiology
- Represent 15-30% of all pediatric fractures (need citation)
- Salter-Harris II represents 75% of physeal fractures (need citation)
- I (5-7%), III (7-10%), IV (10%), V (<1%)
Pathophysiology
- Unique principles of pediatric bone
- Elasticity
- Remodeling potential
Pathoanatomy
- Pediatric bones include two physis, peripherally capped with an epiphysis and proximally with a metaphysis
- Four growth zones:
- Resting cells or reserve zone
- Proliferating cells
- Hypertrophic/maturing cells
- Provisional calcification
- Physeal fractures occur in provisional calcification zone, however can cross zones
- In the event of fractures, blood supply can be compromised
Salter Harris I
- Fracture: occurs within the physis, leading to physeal seperation
- Occur from longitudinal force splitting epiphysis from metaphysis
- Prognosis: Favorable
Salter Harris II
- Fracture: involves the physis and metaphysis
- Most common form of SH fracture
- Fracture fragment termed 'Thurston Holland fragment'
- Prognosis: Favorable
Salter Harris III
- Fracture: extends from physis to epiphysis
- Can extend to joint joint
- Increased risk of growth retardation, altered joint mechanics, and functional impairment
- Prognosis: Poor
Salter Harris IV
- Fracture: fracture line passes through epiphysis, physis and metaphysis
- Increased risk of growth retardation, altered joint mechanics, and functional impairment
- Fracture fragment termed 'Thurston Holland fragment'
- Prognosis: Poor
Salter Harris V
- Fracture: involves crush or compression of growth plate
- Rare, may be caused by electric shock, frostbite, and irradiation
- Poor prognosis, high risk of growth arrest
- Prognosis: Poor
Other Salter Harris Fractures
- These are rare, not well documented in literature and not commonly referenced[1]
- Type VI: injury to the perichondral structures
- Type VII: isolated injury to the epiphyseal plate
- Type VIII: isolated injury to the metaphysis, with a potential injury related to endochondral ossification
- Type IX: injury to the periosteum that may interfere with membranous growth
Risk Factors
- Male > Female
Differential Diagnosis
Clinical Features
- History
- Some form of trauma
- Physical Exam
- Pain, swelling, tenderness
- Inability to bear weight in lower extremity
- Tenderness over physis in the setting of salter harris I
Evaluation
Radiographs
- Comparison to contralateral limb should be considered
Salter Harris I
- Typically normal
- May show widening of the physis
SH1 distal radius (Lateral)
SH1 distal radius (AP)
Salter Harris II
- Fracture line in metaphysis
- Fracture fragment termed 'Thurston Holland fragment'
Salter Harris III
- Fracture line in epiphysis
SH3 distal tibia (AP)
Salter Harris IV
- Fracture line through both metaphysis, physis, epiphysis
- Fracture fragment termed 'Thurston Holland fragment'
Salter Harris V
- Radiographs typically appear normal
- May see physeal widening acutely
- May be a missed diagnosis until growth arrest is seen in subsequent evaluations
MRI
Classification
Salter Harris Classification
| 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 |
Mnemonic 'SALTeR'
- 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)
Management
Salter Harris I
- Managed nonoperatively
- Does not require reduction
- Splint/ Cast appropriate for area of injury
- Repeat radiographs at ~10-14 days
Salter Harris II
- Managed nonoperatively
- May require reduction
- Splint/ Cast appropriate for area of injury
- Repeat radiographs at ~10-14 days
Salter Harris III
- Generally considered a surgical problem
- Requires evaluation by pediatric orthopedic surgeon
Salter Harris IV
- Generally considered a surgical problem
- Requires evaluation by pediatric orthopedic surgeon
Salter Harris V
- Often missed diagnosis on initial presentation
Return to Play
- Highly variable
- SH type 1 may recover quickly
- Radiographic fractures should anticipate 6 weeks of recovery time
- Surgical cases at the discretion of the surgeon
Complications
- Growth Arrest
- Growth Retardation
- Altered joint mechanics
- Functional Impairment
See Also
References
Created by:
John Kiel on 30 June 2019 19:53:56
Authors:
Last edited:
31 October 2020 00:20:54
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