Orthonotes
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Type I: Through physis only (slip) — good prognosis; often in younger children. Type II: Through physis and metaphysis (Thurston–Holland fragment) — most common; good prognosis. Type III: Through physis and epiphysis into joint — needs anatomic reduction (articular). Type IV: Through metaphysis, physis, and epiphysis — high risk of growth arrest; ORIF often required. Type V: Crush injury to physis — rare, poor prognosis; often diagnosed retrospectively by growth arrest. Extended: Rang VI–IX (periosteal injury, perichondrial ring, etc.) are occasionally referenced for completeness.
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The Salter-Harris (SH) classification of physeal (growth plate) fractures is the most universally used and clinically important classification system in paediatric orthopaedics. Introduced by Robert Salter and W. Robert Harris in 1963, it describes five types of physeal injury based on the relationship of the fracture line to the physis (growth plate), the epiphysis, and the metaphysis. The classification directly predicts the risk of growth disturbance, guides surgical decision-making (whether to reduce, how to fix, and how to follow up), and communicates fracture severity between clinicians. A dedicated article on growth plate zones and biology is provided separately (see Epiphyseal Growth Plate — Zones & Regulation, Article 165); this article focuses on the classification system, clinical application, and the fracture-specific implications of each type.
| Type | SALTR Mnemonic | Fracture Pattern | Germinal Cell Status | Growth Arrest Risk | Treatment Principle |
|---|---|---|---|---|---|
| Type I | S — Straight (Slip) through the physis | The fracture passes entirely through the physis — the growth plate is the fracture plane; the epiphysis separates from the metaphysis at the level of the zone of hypertrophy/ZPC (the weakest zone); NO metaphyseal fragment; NO epiphyseal fragment; the fracture involves the physis alone; if undisplaced, the X-ray may appear NORMAL (only widening of the physeal gap may be seen) | Germinal cells remain with the epiphysis (above the fracture line) — INTACT; the fracture plane is below the germinal zone | LOW — germinal cells preserved; excellent healing potential; growth arrest is uncommon unless the blood supply to the epiphysis is disrupted (e.g., Type I SUFE carries AVN risk despite being Type I because the proximal femoral physis is intracapsular) | Closed reduction if displaced; above-elbow or above-knee cast as appropriate; avoid repeated manipulations (each attempt risks further physeal damage); K-wire fixation if unstable or if repeated reductions are required; follow-up X-rays at 3–4 months to detect occult growth arrest |
| Type II | A — Above the physis (metaphyseal fragment) | The fracture passes through the physis AND exits through the METAPHYSIS; a triangular metaphyseal fragment (the Thurston-Holland fragment) remains attached to the epiphysis (it is on the compression side of the fracture); the fracture line travels through the zone of hypertrophy/ZPC and then `exits` through the adjacent metaphyseal cortex; this is the MOST COMMON physeal fracture (~75% of all Salter-Harris injuries); the metaphyseal fragment is pathognomonic of Type II | Germinal cells remain with the epiphysis (and the attached Thurston-Holland fragment) — INTACT; fracture plane is below the germinal zone | LOW — germinal cells preserved; most Type II injuries heal without growth disturbance; the metaphyseal fragment may make reduction more stable; the most favourable intra-articular physeal fracture variant | Closed reduction for displaced fractures; cast immobilisation; the metaphyseal fragment provides a bony lever for reduction and a stable hinge; must achieve anatomical or near-anatomical reduction (particularly when the physis involves a weight-bearing joint); percutaneous K-wires if unstable; follow-up at 4–6 weeks then 3 months |
| Type III | L — Lower (through the epiphysis, intra-articular) | The fracture passes through the PHYSIS and then vertically through the EPIPHYSIS into the joint; the fracture exits through the articular surface, creating an intra-articular fragment of epiphysis + attached physis; the fracture divides the epiphysis into two parts — the unfixed fragment (which may displace) and the attached fragment; the fracture line is: vertical through the epiphysis (articular surface to physis) + horizontal through the physis | The germinal cells in the FRACTURED portion of the epiphysis may be damaged if the fracture line passes through them; the other portion of the epiphysis remains intact; the articular surface is disrupted | MODERATE — growth arrest depends on the extent of physeal damage in the fractured portion; the articular step-off is also a risk for post-traumatic arthritis; the Tillaux fracture (distal tibia) is a Type III example | Anatomical reduction of the articular surface is mandatory (<2 mm step-off); ORIF if closed reduction fails or if articular step-off >2 mm; fixation must AVOID crossing the remaining open physis (use horizontal screws in the epiphysis); follow-up for growth disturbance; the articular surface takes priority in reduction |
| Type IV | TE — Through Everything (metaphysis + physis + epiphysis) | The fracture passes through ALL THREE zones — METAPHYSIS + PHYSIS + EPIPHYSIS; the fracture line is vertical (splits the entire proximal end of the bone from top to bottom, crossing all layers); the fracture is INTRA-ARTICULAR; creates two fragments — one with the articular surface of the epiphysis + the physis + the metaphysis; the classical example is the lateral condyle fracture of the humerus in children | The fracture line CROSSES the entire physis — the germinal zone is directly disrupted by the fracture; physeal bar formation is common if the fracture is not anatomically reduced (the metaphyseal and epiphyseal portions heal with bony bridging across the fractured physis) | HIGH — physeal bar formation is the most serious risk; if the metaphyseal and epiphyseal fragments heal with any step-off across the physis, bony bridging (a `physeal bar`) forms, causing growth arrest (partial or complete); angular deformity + shortening; ORIF is typically required; anatomical reduction is critical to prevent bar formation | ORIF (open reduction + internal fixation) for displaced fractures; anatomical reduction of both the articular surface AND the physis; K-wires or screws as appropriate; fixation must not cross the remaining open physis (epiphyseal screws only, parallel to the joint); long-term follow-up for growth disturbance (12–18 months) |
| Type V | R — Rammed (Crush injury to the physis) | An axial COMPRESSION injury that crushes the physis without creating a discrete fracture line; the growth plate cells are destroyed by compressive force; there is NO displacement and NO visible fracture on plain X-ray; the diagnosis is typically made RETROSPECTIVELY when growth arrest is detected weeks to months after the injury | The germinal cells are directly CRUSHED by the compressive force; widespread physeal cell death; the worst biological scenario for growth | VERY HIGH — physeal arrest (complete or partial) is expected; the diagnosis is retrospective (made when growth arrest is seen on serial X-rays); Harris growth arrest lines (dense metaphyseal bands) may appear after any physeal insult and indicate growth arrest followed by resumption; MRI can sometimes show early physeal oedema | No acute treatment possible (fracture not visible at the time); long-term observation; if partial physeal bar forms → bar resection + fat graft interposition (Langenskiöld) if <50% bar involvement and adequate growth remaining; corrective osteotomy for angular deformity; epiphysiodesis of the contralateral limb for LLD |
| Salter-Harris Type | Clinical Example | Key Points |
|---|---|---|
| Type I | SUFE (Slipped Upper Femoral Epiphysis) — the epiphysis slips through the physis; distal radial physeal injury in a young child (may look like a sprained wrist); medial clavicle physeal separation | X-ray may be normal (only physeal widening); diagnose clinically — tenderness directly over the physis; treat as physeal fracture even if X-ray normal; SUFE has additional AVN risk due to intracapsular location |
| Type II | Distal radius physeal fracture — the most common Type II site; distal fibula physeal fracture; metacarpal physeal fractures; Thurston-Holland fragment is the hallmark | Most common physeal fracture type (75%); Thurston-Holland fragment on the compression side; excellent prognosis; closed reduction + cast for most cases |
| Type III | Tillaux fracture (anterolateral distal tibial epiphysis) — a transitional fracture; Salter-Harris III of the distal femur; proximal tibial SH-III | Intra-articular — articular reduction is the priority; CT assesses articular displacement; >2 mm step-off = ORIF; transitional fractures are specific SH-III variants in adolescents (see Tillaux article) |
| Type IV | Lateral condyle fracture of the humerus (the MOST IMPORTANT Type IV example); triplane fracture (distal tibia — see article 158); Salter-Harris IV of the distal femur | Lateral condyle fracture = Type IV; fragment largely cartilaginous; high physeal bar risk; ORIF mandatory for displaced fractures; non-union + cubitus valgus + tardy UNP = classical complications of missed/inadequately treated lateral condyle fracture |
| Type V | Axial loading injury of the distal radius (not a complete fracture — the child presents with wrist pain after a FOOSH, X-ray is normal, but growth arrest develops over the following months); distal tibial physis crush from prolonged traction or compartment syndrome | Diagnosis is RETROSPECTIVE; normal X-ray at the time of injury; growth arrest recognised on serial follow-up X-rays; Harris lines may appear; MRI is the most sensitive early investigation; counsel family about growth arrest risk at the time of any physeal injury in a child |
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