illnesshacker: Medical information and health advice you can trust.

Salter-Harris Type Fractures – Types, Symptoms, Treatment

Salter-Harris Type Fractures/ A Salter-Harris fracture is a pediatric fracture that involves the epiphyseal plate. These fractures can occur in any bone that has a growth plate but frequently occur in the distal radius. The Salter-Harris scheme was first developed by Doctors William Harris and Robert Salter in 1963 and remains the most common classification system for epiphyseal fractures. Salter-Harris fractures are graded I through IX, with I through V being the most frequently used in clinical practice. Type I is a fracture that runs transversely through the growth plate. Type II runs through the growth plate and the metaphysis. Type III involves the growth plate and epiphysis. Type IV is a fracture of metaphysis, epiphysis, and growth plate. Type V is a complete direct compression fracture of the growth plate. Each of these has a different prognosis and management. [rx][rx][rx]

A Salter-Harris fracture is a fracture that involves the epiphyseal plate or growth plate of a bone, specifically the zone of provisional calcification.^[rx] It is thus a form of child bone fracture. It is a common injury found in children, occurring in 15% of childhood long bone fractures.^[rx] This type of fracture and its classification system is named for Robert B. Salter and William H. Harris, who created and published this classification system in the Journal of Bone and Joint Surgery in 1963.^[rx]

Types of Salter-Harris Type Fractures

Salter-Harris Fracture Types

There are nine types of Salter-Harris fractures; types I to V as described by Robert B Salter and W Robert Harris in 1963, and the rarer types VI to IX which have been added subsequently:^[rx]

Type I – transverse fracture through the growth plate (also referred to as the “physis”):^[rx] 6% incidence
Type II – A fracture through the growth plate and the metaphysis, sparing the epiphysis:^[rx] 75% incidence, takes approximately 12-90 weeks or more in the spine to heal.^[rx]
Type III-A fracture through the growth plate and epiphysis, sparing the metaphysis:^[rx] 8% incidence
Type IV – A fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis:^[rx] 10% incidence
Type V – A compression fracture of the growth plate (resulting in a decrease in the perceived space between the epiphysis and metaphysis on x-ray):^[rx] 1% incidence
Type VI – Injury to the peripheral portion of the physis and a resultant bony bridge formation which may produce an angular deformity (added in 1969 by Mercer Rang)^[rx]
Type VII – Isolated injury of the epiphyseal plate (VII-IX added in 1982 by JA Ogden)^[rx]
Type VIII – Isolated injury of the metaphysis with possible impairment of endochondral ossification
Type IX – Injury of the periosteum which may impair intramembranous ossification

You Might Also Like Test Diagnosis of Knee Dislocation - Treatment

SALTER mnemonic for classification

The mnemonic “SALTER” can be used to help remember the first five types.

N.B.: This mnemonic requires the reader to imagine the bones as long bones, with the epiphyses at the base.

I – S = Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)
II – A = Above. The fracture lies above the physis, or Away from the joint.
III – L = Lower. The fracture is below the physis in the epiphysis.
IV – TE = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.
V – R = Rammed (crushed). The physis has been crushed.

Alternatively, SALTER can be used for the first 6 types, as above but adding Type V — ‘E’ for ‘Everything’ or ‘Epiphysis’ and Type VI — ‘R’ for ‘Ring’.

Salter-Harris Type Fractures

Causes of Salter-Harris Type Fractures

Most of these injuries occur during the time of a child’s growth spurt when physis is the weakest. Active children are the most likely to encounter injuries involving the growth plate as the ligaments and joint capsules surrounding the growth plate tend to be much stronger and more stable. The ligaments and capsules are thereby able to sustain greater external loads to the joint, relative to the growth plate itself.[rx][rx]

Symptoms of Salter-Harris Type Fractures

Pain and swelling
Tenderness
A change in the shape of the injured area that is different than usual
Not being able to move or put weight on the injured arm or leg

Clinical Findings

Point tenderness
Pain
Swelling
Limitation of motion

Imaging Findings

Soft tissue swelling
Depending on the type of fracture, some displacement of the epiphysis or corner sign (Thurston-Holland fragment)
Conventional radiography remains study of first choice
CT with multiplanar reconstruction has been used in problem cases
Ultrasound can be helpful in infants whose cartilage has not yet ossified
MRI in problem cases

You Might Also Like Wounds Types, Symptoms, Treatment, Complication

Plain x-rays – Growth plate fractures are suspected in children who have tenderness and swelling localized over the growth plate or who cannot move or put weight on the affected limb.

Plain x-rays are the diagnostic test of choice – If findings are equivocal, opposite-side comparison x-rays may be helpful. Despite use of comparison views, x-rays may appear normal in Salter types I and V. If x-rays appear normal but a growth plate fracture is suspected, patients are assumed to have a fracture, a splint or cast is applied, and patients are reexamined in several days. Continued pain and tenderness suggest a growth plate fracture.

Treatment of Salter-Harris Type Fractures

Salter-Harris I and II fractures can be treated with closed reduction and casting or splinting. The reduction should be performed carefully to avoid damage to or grating of the physis on any metaphyseal bone fragments.[rx][rx][rx]

Salter-Harris III and IV fractures usually require open reduction and internal fixation (avoiding crossing the physis).

Salter V fracture diagnosis may be delayed unless there is a high degree of clinical suspicion and often the diagnosis is not made at the initial presentation. An emergent orthopedic consultation should be obtained if the fracture is recognized. As these fractures involve the germinal matrix, they have a potential for growth arrest.

In all cases, a reexamination in seven to ten days is necessary to monitor proper reduction and healing. This is also important to determine whether any complications, such as growth arrest, have occurred. If clinically indicated, an additional follow-up radiograph at six and 12 months may be obtained to reassess for any growth arrest.

A cast or splint – may be used to help prevent movement in the injured area until more treatment is done. Some Salter-Harris fractures take up to 14 days before they can be seen on an x-ray. Your child’s injury may need to be put in a cast or splint if a Salter-Harris fracture is known or suspected. This will help prevent more injury to the growth plate and surrounding bone. If the bone is not displaced (moved out of place), your child may get a cast to secure the bone as it heals. Casts are also used after reduction (when the bone is put back into place) or surgery.
Surgery – may be needed to repair certain types of Salter-Harris fractures. Pins or screws will be placed inside the broken bone. These hold the bone pieces together in the correct places.

You Might Also Like Greenstick and Buckle/Torus Fractures - Symptoms, Treatment

Complications of Salter-Harris Type Fractures

The complications include growth arrest with potential for deformity and limb length discrepancy. An entrapment of periosteum within the fracture is a rare complication which requires an MRI scan. Beware that entrapped periosteum can prevent a complete reduction of the fracture.
In general, the higher the number, the more likely the complication so that Salter-Harris types Iv and V have the highest associated complications.
Greater risk for complication comes with fracture of distal tibia followed by the distal femur
The primary complication is growth plate disturbance, Early closure, Limb length discrepancy, Closure of only a portion of the plate resulting in angular deformity.