HWN Suggests

The Reading Room: Salter-Harris Classification of Fractures

Let’s take a break for a second and take a crack at explaining the importance of understanding Salter-Harris fractures. They are the perfect example of how children are not tiny adults. Salter-Harris fractures only occur in children due to the differences in bone anatomy. The growth plate (or physis) of growing bone is cartilaginous and sits between the distal epiphysis and the metaphysis and is responsible for lengthening as children grow. Compared to other parts of the bone, the physis is the weakest, causing it to be more easily injured. More significant Salter-Harris injuries can lead to permanent growth arrest so correct classification is essential..

read full article

Featured

 EBM Lecture Handout #6: Salter Harris 1 Injuries

The traditional teaching about Salter-Harris 1 injuries goes something like this: Because the injury is directly to the growth plate, these injuries will be invisible on x-ray. In children, ligaments are stronger than bone, so if there is pain near a growth plate, we should assume that it is an injury to the bone not the ligament. Therefore, we should cast (or splint) all children with tenderness near the growth plate, regardless of x-ray findings. This myth is based on a few misunderstandings... Bottom line: Children do get sprains. The idea that ligament is stronger than bone is a myth. The incidence of true growth plate injuries is very low, and even those that occur are of questionable clinical relevance.

 SplintER Series: Salter-Harris Fractures

Thankfully, Dr. Salter left his name as a perfect building block for remembering the types.

Articles of Interest

Salter-Harris Fractures

Salter-Harris fractures are fractures that involve the physis (growth plate) of long bones. The physis is an area of cartilage that actively develops into new bone, increasing the bones length. Because the area is actively growing, it is prone to fracture. Thus, Salter-Harris fractures are the most common type of pediatric fracture. These fractures are important to recognize because they can lead to growth arrest if they are not diagnosed and treated promptly.

An aide-mémoire for the Salter–Harris classification of paediatric growth plate fractures

The individual configurations of the different fracture types can be seen to resemble the number of the classification system they represent. As a result, even during a busy on-call shift, this aide-mémoire can allow quick and easy recall of the classification, allowing correct identification of the fracture type.

Displaced distal tibial Salter-Harris II fractures should we be operating?

Salter-Harris II fractures of the distal tibia affect children frequently, and when they are displaced present a treatment dilemma. Treatment primarily aims to restore alignment and prevent premature physeal closure, as this can lead to angular deformity, limb length difference, or both. Current literature is of poor methodological quality and is contradictory as to whether conservative or surgical management is superior in avoiding complications and adverse outcomes.

Growing pains: Salter-Harris classification of physeal injuries

Plain radiographs are the standard imaging modality for physeal fractures. Images should be obtained in at least two planes. Appropriate pain management is important in patients with potential fractures to help optimize positioning, making interpretation of the imaging study easier. There are cases in which a fracture may not be evident immediately on plain radiography. Nondisplaced Salter-Harris type I fractures will sometimes present with normal radiographs or have only subtle findings such as growth plate widening or surrounding soft-tissue swelling.

Orthopedic Pitfalls in the ED: Pediatric Growth Plate Injuries

Although problems after injury to the physis are uncommon, missed injuries to this area can lead to premature closure with resultant focal bone growth arrest. Fortunately, fractures across the physis usually occur in a predictable pattern. Knowledge of these patterns is key for the emergency physician to avoid this potential orthopedic pitfall.

Pediatric Fractures -- Salter Harris Classification System

The Salter Harris Classification System is used in pediatric epiphyseal fractures. The higher the type of fracture the poorer the prognosis.

Salter Harris Fracture Type II

Although physical injuries are relatively common amongst and specific to pediatric patients, the proximal tibia is rare for type II Salter-Harris fractures. This injury poses a risk for permanent damage to bone growth if not accurately identified and treated but has favorable outcomes when adequately managed.

Salter-Harris Classification

Anatomy Matters. Kids are not aliens… they are just little humans with different anatomy and physiology that must be taken into account.

Salter-Harris Classification of Physeal Fractures

The Salter-Harris classification system is used to grade fractures that occur in children which involve the growth plate (‘physis’) of a long bone (e.g. tibia or humerus). The classification is based on the involvement of the metaphysis, physis or epiphysis. Salter-Harris fractures are usually the result of a traumatic incident, like a fall. An underlying bone infection (e.g. osteomyelitis) may also present as a Type V injury. Physeal injuries have the potential for growth disturbance, growth arrest and resulting deformity. In some cases, intervention may be required to prevent premature physeal closure.

Salter-Harris Fractures

Salter-Harris Fractures refer to fractures that involve the growth plate (physis). Therefore, these fractures are applicable specifically to the pediatric population, occurring most often during periods of rapid growth (growth spurts) when the growth plate is at its weakest, close to age ranges where children tend to participate in high-risk activities (11-12 in girls and 12-14 in boys).

The Acute Occult Salter-Harris Injuries in Children

Traditionally, the appearance of a fracture line on plain radiographs is needed for the primary diagnosis of a fracture. In the acute occult or obscure Salter-Harris injuries in children, there is no evidence of a fracture line at the initial anteroposterior and lateral radiographic survey. Occult undisplaced physeal fractures and specific bone bruises are the two subgroups of the acute occult Salter-Harris injuries in children. Such injuries should be clinically suspected, since they are always followed by a varying severity of tenderness, swelling, pain and refusal to use the injured extremity, and appropriately treated.

Tiny Tips: SALTR for Pediatric Growth-plate Fractures

Up to one half of all children’s visits to the ED are orthopedic in nature. Of these visits, approximately 35% are fractures that involve the growth plate, or physis, of a developing bone.

Resources

Life in the Fastlane

Salter-Harris classification of fractures describes injuries involving the epiphyseal plate of any bone. Epiphyseal injuries are significant in patients who are still ‘growing’ and significant complications, such as disturbance of growth, are avoided by recognition of such an injury to the epiphyseal plate

Physiopedia

The bones of growing children contain four sections including the diaphysis (shaft), metaphysis, and epiphysis (end). The metaphysis and epiphysis are separated by the physis (growth plate). Salter-Harris fractures are unique to children because they involve the growth plate. Cartilage grows from the epiphysis up toward the metaphysis and neovascularization develops from the metaphysis toward the epiphysis.

Radiopaedia

The Salter-Harris classification was proposed by Salter and Harris in 1963 1 and, at the time of writing (January 2023) remains the most widely used system for describing physeal fractures.