advanced emergency nursing journal vol. 29, no. 1, pp....

LWW/AENJ LWWJ302-13 January 24, 2007 19:54 Char Count= 0

Advanced Emergency Nursing JournalVol. 29, No. 1, pp. 10–19

Copyright c© 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

RadiologyR O U N D SColumn Editor: Jonathan Lee

Salter-Harris FracturesMary Jo Cerepani, MSN, CRNP, CEN; Denise Ramponi, MSN, CRNP, CEN

AbstractPediatric patients are often examined in emergency departments for various orthopedic problems.One of the major concerns with the pediatric patient is the diagnosis and treatment of possiblegrowth plate injuries. Therefore, the advanced practice nurse must never be complacent whenassessing an orthopedic injury. A radiologic examination is required in every child where a growthplate injury is suspect. Permanent damage and growth plate arrest may occur if this type of injury isnot properly diagnosed and appropriately treated. This article outlines Salter-Harris fractures I–V forthe pediatric population. Using actual cases studies, this article provides a logical approach to theassessment and interpretation of radiology films in pediatric patients with traumatic bony injuries.Comprehensive management of these types of injuries is also addressed. Key words: epiphysis,growth disturbance, growth plate, immobilization, metaphysis, physis

THE Salter-Harris classification is a radio-logic classification system that was de-veloped in the 1960s to describe frac-

tures involving the growth plate in pediatricpatients (Cluett, 2003). It divides these frac-tures into categories based on the extent ofdamage to the growth plate. The growth platecan also be referred to as the physis or theepiphyseal plate. Children have open growthplates until after adolescence. This area ismore susceptible to trauma. While ligamen-tous injuries are very uncommon in children,fractures involving the growth plate are morecommon and may result in bone growth delayor arrest.

From the UPMC, Emergency Resource Management,Inc, Pittsburgh, Pa (Ms Cerepani); and the HeritageValley Health System, Sewickley and Beaver, Pa (MsRomponi).

Corresponding author: Mary Jo Cerepani, MSN, CRNP,CEN, 2 Hot Metal, Pittsburgh, PA 15203 (e-mail:[email protected]).

DEFINITION

A long bone is divided into four parts (seeTable 1 and Figure 1). The end plate of thebone near the joint is known as the epiphysis.The growth plate, epiphyseal plate, or physisis the area where longitudinal bone growthoccurs and is weaker than surroundingstructures making it prone to injury. Themetaphysis is the funnel-shaped end of theshaft of the bone. The shaft of the bone is thediaphysis.

TYPES

Generally, there are five types of growth platefractures that can place a pediatric patientat risk for bone growth disturbance. TheSALTR mnemonic is an easy way to remem-ber the Salter-Harris classification system (seeTable 2 and Figure 2). When using the SALTRmnemonic, the APN must have the epiph-ysis or endplate of the bone held inferiorly in

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January–March 2007 � Vol. 29, No. 1 Salter-Harris Fractures 11

Table 1. Definition of terms

Physis: cartilaginous growth plate; also

referred to as the epiphyseal plate or

growth plate.

Epiphysis: secondary ossification center at

the end of long bones; separated by physis

from the metaphysis.

Metaphysis: widened portion or funnel

shape portion of bone adjacent to the

physis.

Diaphysis: shaft of the long bone

relation to the x-ray to the accurately iden-tify the type of fracture. This is illustrated inthe Salter II pictures. An x-ray should be per-formed in any child with pain over the growthplate after any traumatic injury. There may bea paucity of clinical findings other than pain inthis area. Children with pain over the growthplate should be immobilized and referred toan orthopedist even if the x-ray has nega-tive findings, because types I and V fracturesx-rays may initially appear normal. Some fa-cilities obtain comparison views for any childyounger than 16 years. The WEAK mnemoniccan be used to determine which joints maybenefit from comparison films (i.e., wrists, el-bows, ankles, knees; see Table 3). Some clini-cians have abandoned the use of comparisonfilms because any tenderness over the growthplate warrants immobilization and orthope-dist referral, regardless of the x-ray findings.

Figure 1. Bone anatomy.

Table 2. SALTR mnemonic

S—fracture involves a Slip or Separation of

the growth plate

A—fracture is Above the growth plate

L—fracture is Lower than growth plate

T—fracture is Through the growth plate

R—fracture involves a cRush of the growth

plate

Type I

The epiphysis is separated or slipped fromthe metaphysis. On x-ray, there is soft tissueswelling near the epiphyseal line, widening ofthe epiphyseal line, and displacement of theepiphysis from the metaphysis. There may bea bony avulsion at the periosteal attachment(Harris & Harris, 2000). The width of the ph-ysis or growth plate can be increased or canappear slipped. Type I Salter-Harris fracturesoccur most commonly in the distal tibia andfibula (Simon & Koenigsknecht, 2001).

The patient examination is the most impor-tant component of assessment in these frac-tures as x-ray findings can be very subtle. Thepatient will be point tender over the growthplate and any tenderness over the growthplate warrants reevaluation by an orthopedist.Growth disturbances rarely occur as a resultof type I fractures (Green, Yurko, & Griffin,2005).


12 Advanced Emergency Nursing Journal

Figure 2. Salter-Harris fractures. From Emergency Orthopedics by Simon, R. R., & Koenigsknecht, S. J.

(2001). (3rd ed., p. 78). New York: McGraw-Hill.

Type II

The epiphyseal plate is slipped with a meta-physeal fracture, producing a triangular frag-ment of the metaphysis. Type II fractures arethe most common type of growth plate frac-ture (Geiderman, 2006).

Table 3. WEAK mnemonic

Joints that may benefit from comparison

films

W = Wrists

E = Elbows

A = Ankles

K = Knees

Type III

The epiphyseal plate is slipped with an intra-articular fragment of the epiphysis. The mostcommon site for a Salter III fracture is thedistal tibial epiphysis, usually seen in anolder child with a partially closed physis(Cummings, 2006). On physical examinationthe patient will have point tenderness overthe growth plate. Open reduction is usu-ally necessary for these types of fractures toprevent growth disturbance. The blood sup-ply that enters from the epiphyseal surfacemust be adequate for a good prognosis tobe accomplished. If there is not a properblood supply, avascular necrosis may result.Immobilization for 4–6 weeks with close



observation from the orthopedic physician isindicated.

Type IV

This fracture involves the epiphysis, physis,and metaphysis. The lateral condyle of thehumerus is a common site for this fracture(Simon & Koenigsknecht, 2001). On physi-cal examination, the patient will often havepoint tenderness and swelling at the growthplate. Open reduction and internal fixationare required in most cases. Immobilizationfor 4–6 weeks with close observation fromthe orthopedic surgeon is indicated postop-eratively. Growth disturbance and joint de-formity can occur with type IV injuries. Inaddition, prognosis may be poor if precise re-duction is not achieved, because this is anintra-articular fracture.

Type V

This injury involves a crush injury to thegrowth plate with no epiphyseal or metaphy-seal fracture. Type V fractures usually involvean axial load mechanism of injury, such as afall from a height. The knee and the distal tib-ial physis are common sites of injury (Harris& Harris, 2000). These types of fractures arevery difficult to detect since the epiphysisdoes not appear to be displaced. The initialx-ray may appear normal. In type V injuries,comparison films can be helpful. Treatment isto avoid weight bearing and to have close ob-servation by the orthopedic physician (Harris& Harris, 2000). Unfortunately, Salter-Harristype V fractures are often diagnosed in retro-spect only when growth arrest is discovered(Simon & Koenigsknecht, 2001).

Therefore, pediatric patients sustaining aninjury with open growth plates and point ten-derness over their growth plate require clini-cal suspicion for physis injuries. Early immobi-lization and prompt orthopedic referral are in-dicated with any patient with tenderness overthe growth plate. A Salter V fracture can arrestbone growth and has a poor prognosis for nor-mal growth (Crowther, 2004).

Case #1: Salter-Harris Fracture Type I of the

Right Distal Tibia (Through the Hypertropic

Zone of the Physis)

A 9-year-old female playing kickball sustainedan injury to her right ankle just prior to ar-rival. Her mother described an eversion injuryto the right ankle. The patient was point ten-der over the growth plate of the distal tibia.X-rays revealed a Salter I fracture of the distaltibia with mild separation of the growth plate(see Figure 3). A second example is included,not involving this case, which demonstrateda Salter I fracture of the distal radius with slip-page of the physis (see Figure 4).

Management

A posterior ankle splint was applied by theAPN and remained in place until seen bythe orthopedic physician within 24–48 hr.The child was discharged with instructions touse crutches with no weight bearing. Thepatient returned to normal activities after 3weeks of immobilization.

Figure 3. Salter-Harris type I.



Figure 4. Salter-Harris I distal radius.

Case #2: Salter-Harris Fracture Type II Right

Thumb (Physis Separation and Fracture Line

Extends Through the Metaphysis)

A 13-year-old male playing football sustaineda right thumb injury after catching a football.He described a hyperextension injury. Tender-ness and swelling were noted on the ulnar as-pect of the first MCP joint of the right thumb.The patient had ecchymosis of the volar as-pect of the thumb and thenar area. The x-rayrevealed a Salter II fracture of the MCP jointof the right thumb, with slippage of the prox-imal phalanx and a fracture through the meta-physis (see Figure 5). Another example of aSalter-Harris II fracture of the distal radius isincluded for reference (see Figure 6).

Management

The patient was placed in a thumb spicasplint and referred to an orthopedic physi-cian within 24–48 hr. He was given fracture

aftercare instructions. He was placed in athumb cast for 4 weeks. After 1 month, thepatient was able to resume normal activitieswithout restriction.

Case #3: Salter-Harris Fracture Type III Right

Knee (Separation of the Physis With Fracture

Through the Epiphysis)

A 13-year-old boy presented to the emergencydepartment (ED) with a parent, stating thathe was complaining of right knee pain andswelling. His injury was sustained during acollision with another player while playingbasketball. His right foot was planted as hetried to catch the ball and another playerstruck him in the medial aspect of the knee.He fell to the ground and was unable to bearweight immediately after the incident. He pre-sented to the ED with a very swollen andpainful right knee.

X-ray findings revealed a fracture throughthe epiphysis with separation of the physis ofthe distal femur (see Figure 7). A Salter-HarrisIII fracture of the distal tibia is included forreference (see Figure 8).

Management

The patient was given fracture instructionsand a knee immobilizer with no weightbearing. He was immediately referred to theorthopedic surgeon for consultation, hospitaladmission within 24–48 hr, and operativeintervention.

Case #4: Salter-Harris Type IV Fracture of the

Right Ankle—Fracture of the Right Medial

Malleolus (Fracture Extends Through the

Epiphysis, Physis, and Into the Metaphysis)

An 11-year-old male presented to the ED withparents, complaining of an injury to his rightankle. The patient stated that while playingdeck hockey he twisted his right ankle (ev-ersion injury). On clinical examination, thepatient’s right ankle was noted to have sig-nificant pain and swelling over the medialmalleolus with point tenderness. The patientwas unable to bear weight. X-ray findings re-vealed a fracture through the epiphysis of the



Figure 5. Salter-Harris type II fracture.

distal tibia extending through the physis andinto the metaphysis of the distal tibia (seeFigure 9).

Management

A sugar tong splint was applied by the APNwith the foot held in a 90 degree position inrelation to the ankle. Fracture aftercare in-

Figure 6. Salter-Harris II distal radius.

structions were given to the patient. The or-thopedic physician was consulted since allSalter type IV fractures require urgent surgi-cal reduction and internal fixation (Canale,2003).

Table 4. Discharge instructions for patientswith orthopedic injuries (including the RICEmnemonic)

Immediate orthopedic referral

R = Rest

I = Ice

C = Compression (e.g., ace wrap)

E = Elevation of the injured part

Immobilization (specify the type of splint

and/or sling ordered)

Crutches if indicated and/or specific

instructions regarding no weight-bearing

Pain control [Nonnarcotic analgesia (e.g.,

Non steroidal anti-inflammatory

drugs—NSAIDS), Narcotic analgesia (e.g.,

Tylenol Elixir)].



Figure 7. Salter-Harris III distal femur.

Figure 8. Salter-Harris III distal tibia.



Figure 9. Salter-Harris IV distal tibia.

Case #5: Salter-Harris V of the Distal Tibia

(Compression/Crush Injury of the Epiphyseal

Plate With No Associated Epiphyseal or

Metaphyseal Fracture; Geiderman, 2006)

An adolescent patient presented to the EDcomplaining of right lower leg pain. The pa-tient sustained an axial load injury to theright ankle. On clinical examination, the pa-tient was noted to have significant pain andswelling over the right distal tibia with pointtenderness. The patient was unable to bearweight on the right leg. X-ray findings re-vealed a Salter V fracture of the right dis-tal tibia through the epiphysis of the distaltibia extending through the physis and intothe metaphysis of the distal tibia. These in-juries can also often occur in the knee froman axial load injury, such as smashing a dash-board or a direct crush injury. Salter-Harris Vfractures often initially have normal x-ray find-ings with altered physeal closure. Type Vfractures are often found in retrospect whengrowth problems occur. An example of a type

V fracture of the distal tibial physis is includedfor reference (see open arrows in Figure 10).The closed arrows show the concurrent type

Figure 10. Salter-Harris V distal tibia, Salter-Harris

IV distal tibia, and Salter-Harris I distal fibula. From

The radiology of emergency medicine by Harris,

J. H., & Harris, W. H. (2000). (4th ed., p. 851).

Philadelphia: Lippincott, Williams & Wilkins.



Table 5. Summary: Salter-Harris fractures

Radiologic Management/

Type of injury Common sites findings complications

Type I: Epiphysis isseparated orslipped frommetaphysis

Fractures occur

most commonly

in the distal tibia

and fibula

Soft tissue swelling near

epiphyseal line, widening of

the epiphyseal line

displacement of the

epiphysis from the

metaphysis, may have bony

avulsion at the periosteal

attachment. The width of

the physis or growth plate

can be increased or can

appear slipped

Immediate orthopedic

referral

Pain management

Splint

Type II: The

epiphyseal plate is

slipped with a

metaphysealfracture,

producing a

triangular

fragment of the

metaphysis.

Type II fractures

are the most

common type of

growth plate

fracture

X-rays reveal slippage of the

epiphyseal plate with a

metaphyseal fracture.


referral

Pain management

Splint

Type III: The

epiphyseal plate is

slipped with an

intra-articular

fragment of the

epiphysis.

The most common

site for a Salter III

fracture is the

distal tibial

epiphysis, usually

seen in an older

child with a

partially closed

physis

X-ray findings reveal a fracture

through the epiphysis with

separation of the physis of

the bone


referral

Pain management

Immobilization for 4–6

weeks

Open reduction may be

necessary

Complication:

Avascular necrosis

Type IV: This

fracture involves

the epiphysis,physis, andmetaphysis.

The lateral condyle

of the humerus is

a common site

for a type IV

injury.

X-ray findings reveal a fracture

through the epiphysis of the

bone extending through the

physis and into the

metaphysis of the bone


referral

Pain management

Immobilization for 4–6

weeks

ORIF usually indicated

Complications:

Growth disturbance and

joint deformity.

Prognosis may be poor if

precise reduction is

not achieved.

Type V: A crushinjury to thegrowth plate withno epiphyseal ormetaphysealfractures.

Type V fractures

involve an axial

load mechanism

of injury, such as

a fall from a

height.

Type V fractures

often involve the

knee and the

distal tibial

physis.

Initial x-ray may appear

normal.

Comparison films can be

helpful.

Fractures are very difficult to

detect on x-ray since the

epiphysis does not appear to

be displaced.

Type V fractures are often

diagnosed in retrospect

when growth arrest is

diagnosed


referral

Pain management

Early immobilization

Avoid weight bearing

Complications: bone

growth arrest

Poor prognosis for

normal growth



IV fracture of the distal tibia, and the openarrow depicts the type I distal fibula fracture(Harris & Harris, 2000).

Management

Salter-Harris V fractures are most commonlydiagnosed by the orthopedist when there isaltered physeal closure. This injury is often di-agnosed at a later time after the initial injury.These injuries also require anatomical surgicalreduction.

SUMMARY

A summary of Salter-Harris fractures I–V canbe found in Table 5. It is critical for APNsto be thorough and complete in their assess-ment of the pediatric patient who sustainsan orthopedic injury. A radiologic examina-tion is required in every child where a growthplate injury is suspect. Permanent damageand growth plate arrest may occur if thistype of injury is not properly diagnosed andappropriately treated. Comprehensive man-agement of pediatric patients with Salter-Harris fractures may result in better functionaloutcomes and decrease permanent disabil-

ity in pediatric patients with these types ofinjuries.

REFERENCES

Canale, S. T. (2003). Fractures and dislocations in chil-

dren. In S. T. Canale (Ed.), Campbell’s operative or-thopaedics (10th ed., pp. 1392–1538). St Louis, MO:

Mosby.

Cluett, J. (2003). Salter-Harris fracture classification. Re-

trieved November 2, 2006, from www.orthopedics.

about.com

Crowther, C. L. (2004). Primary orthopedic care (2nd

ed.). St. Louis, MO: Mosby.

Cummings, R. J. (2006). Distal tibial and fibular frac-

tures. In J. H. Beaty & J. R. Kasser (Eds.), Rock-wood and Wilkins’ fractures in children (6th ed., pp.

1078–1126). Philadelphia, PA: Lippincott Williams &

Wilkins.

Geiderman, J. M. (2006). General principles of orthope-

dic injuries. In J. A. Marx, R. S. Hockberger, & R. M.

Walls (Eds.), Rosen’s emergency medicine: Conceptsand clinical practice (6th ed., pp. 549–576). Philadel-

phia, PA: Mosby, Elsevier.

Green, W., & Yurko, G. L. (2005). Essentials of mus-culoskeletal care (3rd ed.). Rosemont, IL: American

Academy of Orthopaedic Surgeons.

Harris, J. H., & Harris, W. H. (2000). The radiology ofemergency medicine (4th ed.). Philadelphia: Lippin-

cott Williams & Wilkins.

Simon, R. R., & Koenigsknecht, S. J. (2001). Emergencyorthopedics: The extremities (4th ed.). New York:

McGraw-Hill.

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