Salter-Harris Fracture

The classification system of Salter and Harris which separates fractures into five main types is most widely used (Salter and Harris 1963) (Fig. 10.5). Other fracture types have since been added to the original classification (Ogden 1981 Rang 1983). In a further classification Peterson added additional categories (Peterson et al. 1994) while including type I to IV Salter Harris injuries, type V is deleted and two new types of fractures metaphyseal fractures with linear injuries that pass into the growth plate, and major trauma that results in destruction of part of the physis. 

Fig. 10.5. Salter Harris classification of growth plate fractures...

Fig. 12.23. The classification of triradiate cartridge injuries based upon the Salter-Harris classification. (i)Shear injury (ii) fracture (iii) compressive injury...

With Salter-Harris (SH) 1 fractures, there is just separation through the distal femoral physis. 

Fig. 14.5a,b. AP and lateral radiographs of the knee demonstrating a Salter-Harris 11 fracture of the distal femur with posterior displacement... 

Salter-Harris I and II injuries which are reducible and stable can be treated in a long-leg cast non-weight bearing for 6-8 weeks. This may fail if a sleeve of periosteum becomes interposed within the physis (Sponsellar and Beaty 1996). Unstable or irreducible fractures or SH III and IV injuries require open reduction and internal fixation, preferably using cannulated screw fixation. 

One can separate these fractures using the Salter-Harris classification (Fig. 14.7) ... 

In adults ankle fractures are traditionally classified according to the forces involved in producing the injury (Lauge-Hansen 1950). In children, the presence of the physis allows the same forces to produce different injury patterns. The Salter-Harris classification of physeal fractures is well recognised. Therefore, Dias and Tachdjian (1978) modified the Lauge-Hansen classification to include the Salter-Harris classification and describe physeal injuries of the ankle in children. In the original classification there were four types of injury, each with a two-part name ... 

The first part of the name refers to the position of the foot at the moment of the injury. The second part indicates the direction of the abnormal force applied to the ankle. A further four types of fracture - juvenile Tillaux, triplane, axial compression and miscellaneous physeal injuries - were added later to complete the classification. Whilst this classification is useful in understanding the deforming forces of the fracture, and hence the type of manoeuvre needed to achieve a satisfactory closed reduction, the Salter-Harris classification is easier to commit to memory and provides a better predictor of outcome in terms of complications (Spiegel et al. 1978). 

For paediatric ankle injuries with normal radiographs, high resolution ultrasound has been shown to be useful in diagnosing occult fractures (SiMANOVSKY et al. 2005) and ligamentous injuries (Farley et al. 2001). The majority of these occult fractures are Salter-Harris I or II fractures of the distal fibular physis. If left undiagnosed and untreated the majority of such injuries would have a satisfactory outcome. 

Fig. 15.2a-d. Salter-Harris Type II fracture of distal tibia. a,b Initial films, c After closed reduction the gap on the medial side of the physis was deemed to be too great (> 3 mm), d At open reduction interposed periosteal soft-tissue was removed from the medial side and fixation was achieved with a single cannulated screw... 

These are usually Salter-Harris Type I or II fractures caused by a supination-inversion injury. They may not be evident on plain X-ray and are often incorrectiy diagnosed as an ankle sprain. Ultrasound is very accurate in detecting the cortical discontinuity, periosteal elevation and subperiosteal fluid which accompanies these fractures (Simanovsky et aL 2005). Where these injuries occur in isolation they should be managed in a below-knee walking cast for 3 to 4 weeks. Significantly displaced distal fibular fractures associated with Salter-Harris Type III or IV injuries usually reduce with re-... 

Glearly, it is important to use appropriate radiological investigations to not only identify the type of fracture in terms of Salter-Harris classification but also its severity in terms of magnitude of displacement, both before and after reduction. For this GT scans are invaluable. During follow-up close observance of growth arrest lines may provide an early indication of PPG. 

Injuries of the medial end of the clavicle account for under 1% of clavicle fractures in children. They can occur if there is compression to the shoulder during contact sports such as ruby. Rather than the sternoclavicular dislocation seen in adults, which they mimic, these are Salter-Harris type I or II fractures (Denham andDiNGLEv 1967). They are poorly seen on radiographs and CT or MR imaging are indicated, especially if (with posterior displacement) there is evidence of dysphagia or respiratory or vascular compromise (Fig. 17.2). If there is evidence of... 

Fractures of the proximal humerus are uncommon - those involving the physis represent about 3% of physeal injuries (Schwendenwein et al. 2004). In children under 10 the fracture is typically metaphyseal, whilst in adolescence it is a Salter-Harris type 11 fracture. Salter-Harris type 111 fractures have been described in association with dislocation of the shoulder (Wang et al. 1997). 

Injury to the proximal humerus can be either a metaphyseal fracture or more typically a Salter-Harris type 1 physeal separation. This will not be evident on the plain film as the proximal humeral physis does not start to ossify until 3-6 months of age. The radiological finding of widening of the joint space occurs in physeal separation, dislocation, brachial plexus palsy and septic arthritis. Ultrasound maybe indicated to clarify the diagnosis (Zieger et al. 1987). However, since healing is rapid at this age periosteal new bone will often be apparent within 10-14 days. 

Wang P Jr, Koval KJ, Lehman W, Strongwater A, Grant A, Zuckerman JD (1997) Salter-Harris type 111 fracture-dislocation of the proximal humerus. J Pediatr Orthop... 

Milch Type 1 (Fig. 18.11) The fracture line exits lateral to the capitellar trochlear groove and the lateral crista remains intact for the ulna to articulate with. This corresponds to a Salter-Harris type IV physeal injury. 

Fig. 18.11. a Milch type I fracture ofthe lateral condyle, b corresponding CT image showing the fracture through the capitel-lum (Milch type I or Salter Harris type IV). c,d Milch type II fracture in different patients... 

Physeal fractures are Salter-Harris type I and II. They are avulsion type injuries. Younger children tend to sustain type I apophyseal avulsions where the fracture line may extend to the coronoid process almost like a sleeve fracture and not therefore break the articular surface (Fig. 18.19). Older children are more likely to sustain Salter-Harris type II equivalent injuries. A small metaphyseal flake of bone may be apparent on radiographs. 

Surgical treatment may be required in certain cases, such as where there is a Salter-Harris III or IV fracture with a large dorsal fragment of over 50% of the joint surface, or where there is an open fracture. Another specific case is the Seymour fracture (Seymour 1966) where a mallet deformity is associated with avulsion of the nail bed from the epony-chial fold (Fig. 19.5). Reduction of this fracture can only be achieved after removal of interposed nail bed matrix at operation. Another problem fracture occurs where there is a Salter-Harris I or II fracture... 

Of the finger metacarpal fractures involving the physis, 85% are Salter-Harris type II, with a simi-... 

Fig. 19.20. Salter-Harris II fracture of the little finger metacarpal...

Type B and C fractures are Salter-Harris II injuries. Type B injuries are the more common, and have the metaphyseal spur on the medial side, and apex lateral angulation due to the pull of abductor pollicis longus (Fig. 19.29). Type C fractures have the opposite pattern, i.e. the spur is lateral and the angulation is apex medial (Figs. 19.30,19.31). Angulated Type C fractures are more difficult to treat by closed reduction than type B, but both are problematic. 

TypeD fractures are intra-articular Salter-Harris 111 or IV injuries of the proximal thumb metacarpal, resembling the adult Bennett s fracture (Fig. 19.32). These injuries are fortunately not common, as they can be very difficult to treat. Open reduction and internal fixation are often required... 

Fig. 19.32. Small Salter-Harris 111 fracture at the base of the thumb metacarpal, type D fracture...

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