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Salter Harris Fracture

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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

Salter Harris II

  • Fracture line in metaphysis
  • Fracture fragment termed 'Thurston Holland fragment'

Salter Harris III

  • Fracture line in epiphysis

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