Salter-Harris Epiphyseal Fractures

• General Considerations
• The epiphyseal plate (physis or growth plate) is the weakest part of the bone to shearing injuries
• The Salter-Harris classification is a means of categorizing epiphyseal plate fractures and provides clues to their prognosis
• All such these fractures, by definition, involve or extend through the epiphyseal plate so that all such fractures occur in children before the epiphyseal plate closes
• Salter-Harris I Fractures
• Occurs through the hypertrophic zone of the epiphyseal plate
• Only the epiphyseal plate is fractured
• Rarely produces complications
• May be difficult to diagnose unless there is visible displacement of the epiphysis on the metaphysis
• Slipped capital femoral epiphysis (SCFE) is an example of a Salter-Harris I fracture
• Salter-Harris II Fractures
• Most common Salter-Harris fracture -85%
• Involves both the epiphyseal plate and the metaphysis
• Small corner of metaphysis that is usually fractured produces the “corner sign”
• Rarely produces complications
• Salter-Harris III Fractures
• Involves the epiphyseal plate and the epiphysis itself
• Since the epiphysis is involved, damage to the articular cartilage can occur
• Growth disturbance is uncommon
• A Tillaux fracture of the ankle is a Salter-Harris III fracture
• Salter-Harris IV Fractures
• Involves the epiphyseal plate, metaphysis and epiphysis
• Since it, too, involves the epiphysis, the articular cartilage can be damaged
• Since these fractures involve the growing layer of cartilage, growth disturbance can result
• Salter-Harris V Fractures
• Rare
• Compression or crushing injury of epiphyseal plate
• Initial diagnosis may be difficult and not made until complication of growth disturbance at epiphyseal plate occurs resulting in angular deformities
• Associated with growth disturbance
• These injuries have the worst prognosis of the Salter-Harris fractures

• 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
• Complications
• Complications are rare
• 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 distal femur
• Primary complication is growth plate disturbance
• Early closure
• Limb length discrepancy
• Closure of only a portion of the plate resulting in angular deformity

Salter-Harris IV Fracture. White arrow points to metaphyseal fracture and yellow
arrow to a fracture of the distal tibial epiphysis in this Salter-Harris IV fracture of the ankle.
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