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Childhood Fractures

The Salter or Salter-Harris classification of fractures refers to a specific group of fractures limited to children. These fractures involve an injury to the open physis or growth plate. Radiographs may be sufficient to make the diagnosis. In some instances, a CT scan or MRI may aid diagnosis. See below for further discussion and examples.


Pediatric Orthopedics

InBrief

childhood fractures

Distal Femoral Physeal Fracture

by Allan Strongwater, M.D.


distal femur fracture
Normal knee joint x-ray of a child showing the distal femur and proximal tibia and fibula. The Xray also shows the physis (growth plate or epiphyseal plate), metaphysis and epiphysis of the distal femur and proximal tibia.

A distal femoral physeal fracture is a fracture that requires an open growth plate and hence is limited to children. The fracture is classified according to the Salter-Harris classification as grades I-V (see below). This fracture may be difficult to diagnose and may have very serious sequela including distal femoral growth abnormality.


Signs and Symptoms

This fracture is due to trauma. Pain and swelling, especially a large knee effusion is not uncommon as the physis is intra-articular to the knee. Radiographs are not always sufficient to make the diagnosis, especially in types I (physeal distraction fracture) and V (physeal compression fracture), in which case MRI can be very helpful.

Causes and Risk Factors

Trauma is the causative agent in this injury. This fracture is not uncommonly seen during aggressive sports such as football, hockey, basketball and the like. Juvenile osteoporosis and other childhood illness resulting in osteoporosis or osteomalacia (osteogenesis imperfecta) are predisposing factors to this injury.

Diagnostic Evaluation and Differential Diagnosis

If there is a question of a distal femoral physeal fracture radiographs of the distal femur should be obtained. Due to the proximity of the distal femoral physis to the collateral ligaments and other intra-articular structures the differential diagnosis includes ligamentous sprains, meniscal injury, and distal metaphyseal femur fracture.

Pearl

The distal femoral physis is responsible for approximately 0.6 cm. of longitudinal growth annually. Injury to the physis may result in slowed growth or growth arrest leading to shortening of the affected femur. Angular deformity is also possible and not uncommonly seen following Salter-Harris type IV or V fracture.

The physis or growth plate is the thin cartilage plate at the end of each of the developing long bones. The physis is found in children and adolescents and is generally weaker than the surrounding ligaments.


Treatment and Recommended Follow-Up

Treatment of this potentially serious problem is best left to a pediatric orthopaedic surgeon. Immediate treatment should consist of immobilization of the affected extremity and neurovascular examination of the limb. Once the patient is stable, imaging studies of the distal femur should be obtained. Closed reduction and cast application may be sufficient for Salter-Harris types I and V. However accurate reduction of the joint surface in type III and IV fractures is essential.



Salter-Harris Classification of Fractures

The Salter or Salter-Harris classification of fractures refers to a specific group of fractures limited to children. These fractures involve an injury to the open physis or growth plate. Radiographs are usually sufficient to make the diagnosis. In some instances, a CT scan or MRI may aid diagnosis.


Salter 1 Fracture


A Salter 1 fracture involves an injury to the open physis or growth plate. It is a pure distraction injury with force separating the epiphysis of a bone from the metaphysis.

Patients with a Salter 1 fracture present with local pain and refuse to use the injured body part. Local swelling and tenderness on examination may be apparent.

Causes and Risk Factors

A Salter 1 fracture is the result of trauma to a child and should raise suspicion of child abuse.

Diagnostic Evaluation

Plain radiograph is usually sufficient for diagnosis of a Salter 1 fracture. Magnetic resonance imaging may be necessary when a history of trauma is unclear, and the possibility of infection exists.

Treatment and Recommended Follow-up

Casting or splinting of the affected area is usually sufficient to treat a Salter 1 fracture. Immobilization for 4-6 weeks is required. These fractures usually have an excellent prognosis, and the physis usually heals with no growth disturbance. However, the child should be followed for at least 1 year for early detection of growth plate problems.


Salter 2 Fracture

salter 2 fracture
Distal Tibia Epiphisiolysis Salter Harris type 2. Lateral view

A Salter 2 fracture involves a fracture line that passes from the metaphysis into the physis and traverses the physis but does not pass into the epiphysis or joint.


Signs and Symptoms

Presents with local pain, refusal to use the injured body part, local swelling and tenderness on examination.

Diagnostic Evaluation

Plain radiograph is usually sufficient for diagnosis. MRI may be necessary in some rare instances in which a history of trauma is unclear, and the possibility of type 3 or 4 fracture exists.


Pearl to Know

Salter 2 fracture is a fracture across the physis (growth plate), and into the metaphysis. This fracture usually has a good prognosis, but growth disturbance is possible resulting in shortening or more commonly angulation. This fracture is usually evident on plain xray. MRI may be helpful in confirming the diagnosis in rare cases. Physical examination usually demonstrates mild swelling and tenderness with the child refusing to use the affected body part.


Treatment and Recommended Follow-Up

Cast or splint is usually sufficient. Immobilization for 4 to 6 weeks is required. In some cases surgical reduction with fixation may be necessary. Salter Harris type 2 fractures usually have an excellent prognosis. The physis usually heals with no growth disturbance. However, the child should be followed for at least one year for early detection of growth plate problems including shortening and angulation of growth.


Salter 3 Fracture


The Salter 3 fracture demonstrates a fracture line that passes from the physis into the epiphysis and usually exits into the joint. Accurate reduction is required to avoid growth and joint problems.

It typically presents with local pain, refusal to use the injured body part, local swelling and point tenderness on examination.

Diagnostic Evaluation

Plain radiograph is usually sufficient for diagnosis, however, CT scan may be necessary in some instances in which a history of trauma is unclear or the fracture cannot be visualized.

Treatment and Recommended Follow-Up

Accurate anatomic reduction is essential to avoid joint dysfunction and or growth abnormality. Referral to a pediatric orthopaedic surgeon is necessary. Salter Harris type 3 fractures usually have a guarded prognosis due to the potential growth plate abnormality and intra-articular injury. The child should be followed for at least one year for early detection of growth plate problems.

Pearl to Know

Salter 3 fracture is an intra-articular fracture. The fracture line passes through the physis and into the epiphysis, often entering the articular surface of the joint. This fracture may not be evident on plain Xray. CT scan may be helpful in confirming the diagnosis. Physical examination usually demonstrates mild swelling and tenderness with the child refusing to use the affected body part. Careful follow up for at least one year is necessary to make an early diagnosis and intervene if growth injury becomes evident.


Salter 4 Fracture


The Salter 4 fracture line passes from the metaphysis across the physis into the epiphysis and exits into the joint, disrupting the articular cartilage. This fracture has a poorer prognosis that types 1-3 because of the more frequent occurrence of a physeal growth arrest resulting in shortening and or angulation of growth.

Signs and Symptoms

Presents with local pain, refusal to use the injured body part, local swelling and tenderness on examination.

Diagnostic Evaluation

Plain radiograph is usually sufficient for diagnosis. CT scan may be necessary in some instances in which the extent of the fracture is unclear.

Pearl to Know

Salter 4 fracture has a poorer prognosis as the fracture passes from the metaphysis, across the physis into the epiphysis and exits into the joint, damaging the physis and articular cartilage. This fracture may not be evident on plain Xray. CT scan may be helpful in confirming the extent of the fracture and the diagnosis. Physical examination usually demonstrates mild swelling and tenderness with the child refusing to use the affected body part.

Treatment and Recommended Follow-Up

Because this fracture crosses the physis and the joint surface, accurate anatomic reduction is necessary to avoid growth problems including shortening and angulation of growth. Reduction is necessary to avoid premature arthritis of the joint. Salter Harris type 4 fractures have a poorer prognosis compared to Salter types 1,2,3. The physis injury may result in growth irregularity resulting in shortening or angulation and the joint injury may predispose to early mechanical arthritis of the joint. Following orthopaedic treatment the child should be followed for at least one year to detect early growth plate irregularities.


Salter 5 Fracture


The Salter 5 fracture is relatively rare; it is a severe injury to the physis due to axial compression, crushing the physis. Growth plate problems are relatively frequent after this injury. Careful follow-up is necessary. Radiographs are often insufficient to make a conclusive diagnosis, a CT scan or MRI may aid diagnosis (see diagnostic evaluation).


Signs and Symptoms

This fracture usually presents with relatively little swelling. It presents with local pain, refusal to use the injured body part despite minimal radiographic signs, and tenderness on examination.

Diagnostic Evaluation

Plain radiograph may not be sufficient for diagnosis. CT scan may be necessary in some instances to confirm the diagnosis.

Pearl to Know

Salter 5 fracture is a pure compression injury with force compressing the epiphysis of a bone. This fracture may not be evident on plain Xray. MRI may be helpful in confirming the diagnosis. Physical examination usually demonstrates mild swelling and tenderness with the child refusing to use the affected body part.

Treatment and Recommended Follow-Up

Cast or splint is usually sufficient. Immobilization for 4 to 6 weeks is required. Careful follow-up for not less than one year is necessary so that early intervention can be initiated if a growth arrest occurs. Salter Harris type 5 fractures usually have a poor prognosis resulting in early growth plate arrest with limb length shortening. The child should be followed for at least one year for early detection of growth plate problems.


 

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