Salter Harris Fracture Classification Amir Hooshang Vahedi MD - Physiatrist  

What are Salter fractures? Fractures involving the epiphyseal plate at the end of the long bone of a growing child Growth plate fractures account for 15-20% of major long bone fractures and 34% of hand fractures in childhood Classified into 5 types based on fracture line

Why is this important? The type generally correlates with the potential for future growth disturbance (and consequently the aggressiveness of treatment required)

Anatomy Long bones—longer in one dimension than other bones and consist of a shaft and two ends Diaphysis—the shaft of a long bone Epiphysis—the two expanded ends of a long bone Metaphysis—the flared portion of the bone between the diaphysis and the epiphysis (it extends from the diaphysis to the epiphyseal line) Epiphyseal plate—the disk of cartilage between the metaphysis and the epiphysis of an immature long bone permitting growth in length

Anatomy Review

Salter Harris Growth Plate Fracture Classification Type What is Broken Off I: The entire epiphysis II: Entire epiphysis + portion of the metaphysis III: Portion of the epiphysis IV: Portion of the epiphysis + portion of the metaphysis V: Nothing “broken off;” compression injury of the epiphyseal plate

Salter Harris I Fracture thru the physis without involvement of the bone of the epiphysis or metaphysis May be radiologically undetectable Dx is usually clinical based on swelling and tenderness in the region of the physis Growth plate remains attached to the epiphysis Likelihood that bone will grow normally is excellent (unless there is damage to the blood supply of the growth plate) Type I The epiphysis is completely separated from the end of the bone or the metaphysis, through the deep layer of the growth plate. The growth plate remains attached to the epiphysis. The doctor has to put the fracture back into place if it is significantly displaced. Type I injuries generally require a cast to keep the fracture in place as it heals. Unless there is damage to the blood supply to the growth plate, the likelihood that the bone will grow normally is excellent. These do not displace unless the periosteum is worn. They are caused by shearing, torsion, or avulsion forces. They may be difficult to detect radiologically without stress views. Affects 6%.

Salter Harris I

Salter Harris II Fracture involving part of the metaphysis and extending to the physis Most common type Usually caused by a fixed supination and external rotation force Typically reset and immobilized Type II This is the most common type of growth plate fracture. The epiphysis, together with the growth plate, is separated from the metaphysis. Like type I fractures, type II fractures typically have to be put back into place and immobilized. The plane of the facture passes through much of the growth plate but includes a piece of the metaphyseal bone on one side. The periosteum is intact on the side with the metaphyseal fragment, but is torn on the opposite side. Affects 75%.

Salter Harris II

Salter Harris III Fracture involving the epiphysis and extending to the physis Occurs only rarely (usually at the lower end of the tibia) Surgery sometimes necessary Prognosis is good if the blood supply to the separated portion of the epiphysis is still intact and if the fracture is not displaced Type III This fracture occurs only rarely, usually at the lower end of the tibia, one of the long bones of the lower leg. It happens when a fracture runs completely through the epiphysis and separates part of the epiphysis and growth plate from the metaphysis. Surgery is sometimes necessary to restore the joint surface to normal. The outlook or prognosis for growth is good if the blood supply to the separated portion of the epiphysis is still intact and if the fracture is not displaced. This includes a piece of the epiphysis. Tends to occur in teenagers. Affects 8%.

Salter Harris III

Salter Harris IV Fracture involving the epiphysis, metaphysis, and extending to the physis Surgery is needed (restore joint surface/align growth plate) Occurs most commonly at the end of the humerus near the elbow Prognosis for growth is poor, unless perfect alignment is achieved and maintained during healing Type IV This fracture runs through the epiphysis, across the growth plate, and into the metaphysis. Surgery is needed to restore the joint surface to normal and to perfectly align the growth plate. Unless perfect alignment is achieved and maintained during healing, prognosis for growth is poor. This injury occurs most commonly at the end of the humerus (the upper arm bone) near the elbow. Includes metaphysis and epiphysis. It is usually intra-articular. Most commonly fracture of the lateral condyle. Affects 10%.

Salter Harris IV

Salter Harris V Occurs when the end of the bone is crushed and the growth plate compressed Uncommon May be radiologically undetectable May be evident only retrospectively when growth disturbance first begins to appear Hx of significant axial loading force and significant tenderness in the area of the epiphyseal plate, should suggest the possibility of a type V injury Occurs most likely at the knee or ankle Prognosis is poor (premature stunting of growth is almost inevitable) Type V This uncommon injury occurs when the end of the bone is crushed and the growth plate is compressed. It is most likely to occur at the knee or ankle. Prognosis is poor, since premature stunting of growth is almost inevitable. A newer classification, called the Peterson classification, adds a type VI fracture, in which a portion of the epiphysis, growth plate, and metaphysis is missing. This usually occurs with an open wound or compound fracture, often involving lawnmowers, farm machinery, snowmobiles, or gunshot wounds. All type VI fractures require surgery, and most will require later reconstructive or corrective surgery. Bone growth is almost always stunted. Crush injury of the growth plate from axial loading. Exceedingly rare! May lead to progressive angular deformity if part of the growth plate is damaged and bony ridge develops. Growth cessation at end of limb may occur if the entire growth plate is involved. Injuries may not be recognized until cessation of growth is noticed. Affects 10%.

Salter Harris V