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
It was previously taught that ligaments are stronger than bones in kids (and fractures were more likely than sprains), however newer studies (to date in ankles) contradict that assumption[1]

Mnemonic

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)

Fracture Chart

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

Clinical Features

Trauma with point tenderness over a non-closed (pediatric) physis

Differential Diagnosis

Sprain
Contusion
Other fracture

Evaluation

Salter Harris Types

Type 1 (Slip)

Suspect if point tenderness over a physis
X-ray findings are subtle (epiphyseal displacement) or absent (clinical diagnosis)

Type 2 (Above)

X-ray shows triangular fragment of metaphysis with out injury to epiphysis

Type 3 (Below)

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, metaphysis

Type 5 (Crush)

Salter-Harris IV fracture of the distal tibia with associated distal fibular fracture that does not involve the physis

X-ray shows physis compression fracture
- May confuse for Type 1 injury
- X-ray findings may be minimal

Management

General Fracture Management

Acute pain management
Open fractures require immediate IV antibiotics and urgent surgical washout
Neurovascular compromise from fracture requires emergent reduction and/or orthopedic intervention
Consider risk for compartment syndrome

Type I

Most: Splint, ortho follow up
Lateral ankle:
- Removable ankle brace
- Return to activities as tolerated by pain
- No ortho followup

Type II

Most: Splint, ortho follow up
Ankle: Removable ankle brace[2]

Type III-V

Splint, ortho consult

Disposition

Outpatient

External Links

POSNA (Pediatric Orthopaedic Society of North America) - http://orthoinfo.aaos.org/topic.cfm?topic=A00040

References

Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Joint Surg Am. 2012; 94(13):1234-1244.
. Boutis K, Willan AR, Babyn P, Narayanan UG, Alman B, Schuh S. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007;119(6): e1256-e1263.

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[1] Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Joint Surg Am. 2012; 94(13):1234-1244.

[2] . Boutis K, Willan AR, Babyn P, Narayanan UG, Alman B, Schuh S. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007;119(6): e1256-e1263.