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Epiphyseal Fracture

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Epiphyseal Fracture, Growth Plate Fracture, Salter Fracture, Salter-Harris Fracture, Physeal Injury

  • See Also
  1. Fractures in Children
  2. Growth Plate
  • Epidemiology
  1. Epiphysis involved in 20% of Pediatric Fractures
  2. Distal radius is the most commonly involved Physeal Injury (44%)
  • Pathophysiology
  1. See Growth Plate (Physis)
  2. Children have Growth Plates that are much weaker than ligaments (by a factor of 2-5 fold)
  3. Joint Trauma that would otherwise cause a ligamentous sprain in adults, results in a physeal Fracture in children
    1. Physeal Fractures may occur with minimal overlying Soft Tissue Injury
    2. However, suspect a concurrent type 3-4 physeal Fracture, when children sustain a Ligament Sprain
  • Images
  1. OrthoFractureSalterHarris.jpg
  • Grading
  • Mnemonic for Salter Fracture (SALTER)
  1. Same as the epiphysis or Slip or Separate the epiphysis from the shaft
  2. Above the Physis (proximal to the Physis)
  3. Low anatomic or lower than the Physis (Below or distal to the Physis)
  4. Through the Growth Plate (Epiphysis and Metaphysis)
  5. Everything (Compressed)
  6. Round, ruined or Rang
  • Grading
  • Salter-Harris classification
  1. Salter I
    1. Most common in newborns and young children (9% of Growth Plate injuries overall)
    2. Fracture line through the Growth Plate (Physis)
      1. Epiphysis separates from diaphysis (shaft) and Metaphysis through the Physis
      2. Fracture occurs through the hypertrophic cell layer (weakest part of the Physis)
      3. Fracture does not extend into metaphysis or epiphysis
    3. XRay is typically normal (or Physis may be wider) until callus formation is visible by 10 days after Fracture
    4. Diagnosed clinically based on point tenderness over the epiphysis
    5. Managed with Splinting and then Casting
    6. Prognosis excellent
  2. Salter II
    1. Most common overall Epiphyseal Fracture (75% of Epiphyseal Fractures)
    2. Similar to Type 1
      1. Fracture through the Physis with separation of Physis from metaphysis
      2. Unlike Type I, has a small metaphysis triangle Fracture (Fracture exit site)
    3. Bony Fracture triangular fragment known as Thurston-Holland Fragment
      1. Up to 50% displacement will completely remodel and heal within 1.5 years
      2. Distal Radius Fractures are most common Type II Salter Harris Fracture
      3. Distal Tibia Type II Fractures are higher risk for premature physeal closure and angular deformity
    4. Treated with immobilization (Casting or Splinting)
    5. Prognosis excellent with immobilization (although joint instability is possible)
  3. Salter III
    1. Uncommon and more complicated Fracture
    2. Similar to Type 2, but intraarticular Fracture through epiphysis
      1. Fracture through the Physis with separation of Physis from metaphysis
      2. Unlike Type II, Fracture exit is intraarticular, through epiphysis and into the joint
      3. Tillaux Fracture (anterolateral distal tibia Fracture in teens) is an example of type III Fracture
    3. May disrupt the Epiphyseal Plate proliferative and reserve zones
      1. Risk of Delayed Growth and post-Traumatic Arthritis
    4. Alignment is critical for good prognosis and maintained function
      1. Immobilize and obtain urgent orthopedic Consultation
      2. Consider reduction
      3. ORIF is often necessary (if instability or >2mm articular surface displacement)
  4. Salter IV
    1. Accounts for 12% of Fractures
    2. Intraarticular Fracture extending completely through Growth Plate and out of metaphysis
      1. From joint through epiphysis, Physis, and out through metaphysis
      2. Unstable Fracture
      3. Triplane Fractures (distal tibia Fracture in teens) are a Type IV example
    3. Needs perfect reduction (often open reduction is required)
    4. Poor prognosis, lost blood supply and high risk of growth failure (especially femur or tibia)
      1. May result in focal fusion of bone and joint deformity
  5. Salter V
    1. Rare Fracture (<1% of Epiphyseal Fractures) requiring severe mechanism (e.g. fall from height)
    2. Crushing of Physis, most commonly in knee or ankle
      1. Reserve zone of Physis is disrupted, resulting in loss of vascular supply
      2. Results in arrest of bone growth, impaired function and extremity length discrepancy
    3. Early XRay negative (similar to Type I in this regard)
      1. Subsequent xrays demonstrate callous formation and delayed bone growth
    4. Diagnose clinically based on point tenderness
    5. Splint with orthopedic follow-up
    6. Poor prognosis
  6. Salter VI (Rang)
    1. Portion of Growth Plate sheared off
    2. Penetrating injuries
    3. Rare
  • Exam
  1. Approach: Every Extremity Injury
    1. Mnemonic: "joint above, joint below, circulation, motor and Sensation, skin and compartments"
    2. Include examination of joint above and below the involved joint
    3. Include Sensory Exam, Motor Exam, Reflex Exam and vascular exam (pulses, Capillary Refill)
    4. Include skin and compartment exam
    5. Mallon (2013) Shoulder Disorders, EM Bootcamp, Las Vegas
  2. Specific to grwoth plate injury
    1. Joint line and Growth Plate tenderness
    2. Joint instability (Ligament Sprain)
      1. Compare with opposite limb
    3. Bony deformity
  • Precautions
  • Red Flags suggestive of Physeal Injury
  1. Point tenderness over a Growth Plate (regardless of xray findings)
  2. Inability to bear weight
  3. Ligamentous sprain or instability in a child (commonly associated with underlying Grade 3-4 physeal Fracture)
    1. Ankle Sprain with rotation and supination is a risk for Tillaux Fracture, esp ages 12-15 (high risk injury)
  • Imaging
  1. XRay (2 or more views)
    1. First-line study in all suspected physeal injuries
    2. Repeat XRay in 7-10 days
    3. Do not be disarmed by a normal xray (occult physeal Fracture is common in Types 1 and 5)
  2. Advanced Imaging (CT or MRI)
    1. Indicated in suspected physeal injuries and non-diagnostic XRay
    2. May be deferred to orthopedic provider receiving referral
  • Management
  1. Analgesics
    1. Acetaminophen and Ibuprofen
    2. Opioids may be needed
  2. Fracture reduction
    1. Reduce displaced Fractures in the Emergency department prior to immobilization
    2. Evaluate neurovascular status before and after reduction/immobilization
    3. Definitive reduction should be within 5 days for Salter-Harris 1 and 2 Fractures
      1. Displaced Salter-Harris 3 and 4 Fractures often require emergent ORIF
  3. Follow-up with orthopedics or sports medicine
    1. Prompt follow-up within 7-10 days for all suspected Growth Plate injuries
    2. Urgent follow-up for all suspected Grade 3-5 Salter-Harris Fractures
    3. Repeat XRay in 7-10 days
    4. Review risks related to Growth Plate Fractures with patients and their families
      1. Physeal arrest (5-10% of all Growth Plate Fractures)
      2. Risk of bone growth arrest and Limb Length Discrepancy or angular deformity
  4. Indications for non-removable splint (if any doubt, Splinting is safest approach)
    1. Splint all Salter-Harris Fractures (with positive xray or suspected based on exam findings)
    2. Splint injuries with significant tenderness over the Growth Plate despite negative XRay
    3. Lower extremity injuries should be non-weight bearing with use of Crutches
  5. Indications for removable splint (pre-fabricated) or no splint (with follow-up for repeat exam)
    1. Minor Trauma AND
    2. Minimal tenderness AND
    3. Retained function (e.g. weight bearing)
  • References
  1. Claudius and Newman in Herbert (2015) EM:Rap 15(9): 2-3
  2. Hocker et al (2016) Crit Dec Emerg Med 30(9):3-8
  3. Sanghani, Kern and Mehta (2025) Crit Dec Emerg Med 39(2): 27-35
  4. Peterson (1994) J Pediatr Orthop 14(4): 423-30 [PubMed]
  5. Salter (1963) J Bone Joint Surg Am 45(3): 587-622 [PubMed]