Children, Diseases, Fracture

Salter harris fracture (growth plate fracture)

Salter harris fracture mainly refers to the growth plate fracture or epiphyseal fracture in children. The fracture of the growth plate occurs at the end parts of the bone. These areas, called growth plates, allow children’s bones to grow longer. Growth plate fractures mostly occur in children and adolescents. In the following article, we will introduce the growth plate fracture in detail.

Navigation : Overview | Causes | Symptoms | Types | Examination | Diagnosis | Treatment | Prevention | Recovery | Prognosis

Overview

The epiphysis is the part of the bone that grows before the bone develops and matures. The center is the center of ossification and the surrounding cartilage and Periepiphyseal ring(Ranvier zone).

Limb buds are visible at the fifth week of the embryo, and the initial shape of the cartilage is recognized at the sixth week. Blood vessels enter the cartilage at 3 months, osteoclasts and osteoblasts begin to ossify in the cartilage. At the same time, a medullary cavity appeared. There is an active growth zone at each end of the medullary cavity, called the epiphysis.

The epiphyseal plate is the cartilage region of the long bones, such as the arms and lower limbs. The epiphyseal plate lengthens the bones until the child reaches full height. When growth is complete, the epiphyseal plate is replaced by bone. Bones grow at different rates, but all epiphyseal plates are replaced by bone at age 20.

Salter harris fracture

Because cartilage is more fragile than bone, growth plates are particularly prone to fracture. When the epiphyseal plate is broken, the bone may stop growing or grow malformed. If the joint is involved, it may be permanently damaged, leading to arthritis.

The fracture site may go straight through the epiphyseal plate, separating the cartilage from the bone. Some fracture is above or below the epiphyseal plate. Sometimes it goes completely through the end of the bone into the joint. The most severe type of fracture is a compression fracture when the epiphyseal plate is crushed.


Causes

The following causes Salter harris fracture. This is also a common cause of most bone fractures.

  • A fracture caused by an accident, such as a fall or car crash.
  • The bone is subjected to repeated stress, resulting in a strained fracture.

The external forces that cause epiphyseal injury are shearing, pulling, splitting and squeezing. These external forces can act alone, but most of them are combined forces. About 80% of the Salter harris fractures were caused by the external force pulling directly to the epiphyseal center or the avulsion of the articular capsule due to the ligaments associated with the epiphysis.


Symptoms

  • epiphyseal parts severe pain.
  • Swelling, heat rising, reddening.
  • Movement difficulty.
  • Outer shape deformity of the injured part.

Types

There are several classification methods for growth plate fracture, the most commonly used is Salter harris classification. Salter and Harris divided growth plate fracture into 5 types according to the mechanism of fracture, the location of injury in epiphyseal cell layer and its influence on the growth of epiphyseal plate, and appearance of X-ray film. Then Rang (type 6) and Ogden (type 7) types were added.

Salter harris fracture classification

Salter harris fracture
Salter harris fracture

type 1

About 5% Salter harris fractures are type 1. The fracture line only passes through the cartilage of epiphyseal plate. The prognosis is good. Because cartilage fracture cannot be shown on X-ray, it is difficult to diagnose without displacement. The neonatal epiphysis has not been ossified, and diagnosis is more difficult. This kind of fracture usually appears periosteal reaction after a few days. X-ray shows that the space of the epiphyseal plate is wider than the opposite side and the epiphyseal plate is angularly deformed.

type 1 Salter harris fracture
type 1 Salter harris fracture

type 2

This type is very common. About 75% Salter harris fractures are type 2. Fracture lines run through the epiphyseal plate and then extend to the metaphysis. Generally, the prognosis is good. Premature closure of the epiphyseal plate may occur in the knee and ankle.

type 2 Salter harris fracture
type 2 Salter harris fracture

type 3

Rare type. About 75% Salter harris fractures are type 3. The fracture line passes through the epiphysis to the cartilage but does not involve metaphysis. If the treatment is timely, the prognosis will be good. It is rare for growth to stop. If there is no shift X-ray difficult to detect, must take multi-directional X-ray. If there is displacement, must be treated in time, otherwise, the articular surface is irregular, prone to joint disease.

type 3 Salter harris fracture
type 3 Salter harris fracture

type 4

About 12% Salter harris fractures are type 4. Fracture line from metaphysis through the epiphyseal plate into epiphysis, the most likely to cause epiphyseal premature closure and angulation deformity. Common in the elbow joint and distal tibia.

type 4 Salter harris fracture
type 4 Salter harris fracture

type 5

very rare type. Less then 1% Salter harris fractures are type 5. The epiphyseal plate compresses completely or partially, the prognosis is extremely poor. The early diagnosis was difficult. X-ray showed that the epiphyseal plate cartilage became narrow. Early closure of epiphysis, short limbs, conical epiphysis or diagonal deformity will occur in late stage.

type 5 Salter harris fracture
type 5 Salter harris fracture

Type 6 (Rang type)

The bone bridge and angulation deformity can be formed by the injury of the Ranvier zone at the edge of the epiphyseal plate.

Type 7(Ogden type)

The fracture line passes through the epiphyseal cartilage or epiphyseal ossification center. Avulsion fracture of epiphysis is a special form of epiphyseal plate fracture. It can be seen in non-weight epiphyseal plate cartilage, such as avulsion fracture of the internal and external condyle of the elbow joint, fracture of epiphyseal ischiocele of the ulna.


Examination

Children with tenderness and swelling on the growth plate area or limb immobility or difficult to movement need to consider the growth plate fracture. It is necessary to go to the hospital in time.

  • X-ray is highly sensitive.

X-ray film can be diagnosed. If the results are suspicious, a contralateral X-ray comparison is feasible. Even using the different plane of X-ray, type 1 and type 5 Salter harris fractures still can show normal. If the X-ray is normal but still suspected of a growth plate fracture, assume that the patient has a fracture, fixed with splint or plaster, and reviewed within a few days.

  • CT and MRI are also useful auxiliary inspection methods.

Diagnosis

X-ray film can be diagnosed. If the results are suspicious, a contralateral X-ray comparison is feasible. Even using the different plane of X-ray, type 1 and type 5 Salter harris fractures still can show normal. If the X-ray is normal but still suspected of a growth plate fracture, assume that the patient has a fracture, fixed with splint or plaster, and reviewed within a few days.

Persistent pain and tenderness will support the diagnosis in this period.


Treatment

According to the Salter harris fracture types, closed reduction and open reduction and internal fixation(ORIF) can be performed.

Type 1 and 2 can be cured by closed reduction, while type 3 and 4 are often treated with ORIF.

All restores, whether closed or open, should be performed with the softest technique. Avoid painful and violent manipulation to prevent further injury to the epiphyseal plate. Direct pressure on the epiphyseal plate should be avoided with blunt instruments when open reduction.

If fracture(type 1 or type 2) happened more than 10 days with manual reduction is almost impossible. If closed reduction or open reduction is imposed, epiphyseal plates may be damaged.


Recovery

Epiphyseal injuries recover faster than normal bone fractures.

The healing time of Salter harris fracture type 1 ~ 4 is about half of the healing time of the same part metaphyseal fracture. Therefore, the late reduction of epiphyseal injury is more difficult.

Children with epiphyseal injury should be followed up regularly until epiphyseal maturation. Sometimes epiphyseal plate growth does not stop completely immediately, but grows slowly 6 months after injury and then stops. In some cases, even growth disorders do not manifest until adolescence. Close observation is necessary within 2 years after injury.


Prevention

  • Children should pay attention to safety when playing outdoor sports.
  • Make sure children wear helmets, elbow-pad, and kneepads when riding skateboards and bikes to avoid accidental falls.
  • Pay attention to proper exercise, increase sunbathing, and dietary nutrition absorption(vitamin D, calcium intake).
  • Place a thick carpet or blanket on the floor or lay a wooden floor to reduce the impact of a fall.

Prognosis

The following are the points that affect the prognosis of Salter harris fracture.

  • Fracture types: The prognosis of type 1 and 2 fractures is generally good. These fractures rarely have complications and sequelae. The prognosis of 3 types and other fractures was poor. Open surgery can even have the possibility of infection.
  • Patient ages: Once the fracture is severe or mishandled, epiphyseal growth disorders will occur. The younger the patient is, the more likely will be deformed in the future.
  • Blood supplements: The worse the blood circulation, the worse the prognosis, especially the femoral head and the radial head.
  • Malpractice: Improper manipulation or injury of epiphysis with instruments may cause growth disorders.

Because most of the Salter harris fracture occur in children. Therefore, we suggest that parents can learn more about children bone fracture. For more information please visit here “Children bone fracture causes, types, symptoms, treatment, and prevention


 

References

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  • Written by Nurmemet, MD (Emergency Medicine Specialist)
  • Medically reviewed by Merhaba, MD (Pediatrician)

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