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Salter-Harris/Ogden Classification Essay

Salter-Harris classification of physeal fractures has been expanded to six types
Ogden (J Ped Orthop; 1982) from his series of 443 physeal fractures has added another three

  • Ogden VII : Epiphyseal fractures not involving physis
  • Ogden VIII : Metaphyseal fractures affecting later growth
  • Ogden IX : Periosteal damage affecting later growth

Salter-Harris I

Salter-Harris II

Salter-Harris III

Salter-Harris IV

Salter-Harris V

Salter-Harris VI

Ogden VII

Ogden VIII

Ogden IX

Aetiology of premature partial growth plate arrest

  1. Trauma: 80%
    • Salter-Harris Type 1: 5%
    • Salter Harris Type 2: 5%
    • Salter Harris Type 3: 5%
    • Salter Harris Type 4: 85%
    • Salter Harris Type 5: ?
  2. Infection: 10%
  3. Tumour: 5%
  4. Iatrogenic (pins, staples): 2%
  5. Irradiation: 2%
  6. Burns: 1%

Location of physeal arrest

  1. Distal Femur: 39%
  2. Proximal Tibia: 18%
  3. Distal Tibia: 30%
  4. Distal Radius: 5%
  5. Distal Ulna: 3%
  6. Distal Fibula: 1%
  7. Proximal Humerus: 1%
  8. Proximal Phalanx Great Toe: 1%
  9. Pelvis (tri-radiate): 1%

Types of Bridge formation

1. Peripheral

  • Involves the zone of Ranvier, important in latitudinal growth of the physis
  • May cause severe angular deformity
  • Needs surgical approach from the periphery, with excision of the overlying periosteum

2. Linear

  • Osseous bridge extends as a linear structure across the physis
  • The most common site is the medial malleolus
  • May also lead to significant angular deformity
  • Could be removed by making a tunnel through the bone

3. Central

  • The most severe type of injury and the most difficult to rectify surgically
  • Bridge is completely surrounded by normal cartilage
  • Affects longitudinal growth predominantly
  • Needs to be approached from the metaphysis
  • Do not replace bone excised from the bridge in filling the metaphyseal defect

Harris lines appear after restoration of growth following a physeal injury, the line being due to slowing of growth for a variable period following injury
If these lines are parallel to the physis then damage to growth is unlikely
Excision of an osseous bridge that constitutes 50% or more of the entire area of the physis usually gives a poor result

Substances used to fill defect

  • Fat
    • Autogenous, no need to remove
    • May need second incision to get graft
    • May float out with release of tourniquet
    • Shown to enlarge as growth occurs
  • Silastic
    • Inert, mouldable to cavity and easily removed
    • Needs special authorisation for use
    • Must be sterilised, infections reported
    • Fractures at site of insertion reported
  • PMMA
    • Light, inert, non-conductive, transparent (no barium)
    • Mouldable to defect, good haemostasis, No fractures reported
    • No need to remove later, but may be difficult if necessary
    • Packed sterile, no infections reported

A Salter–Harris fracture or growth plate fracture[1] is a fracture that involves the epiphyseal plate or growth plate of a bone. It is thus a form of child bone fracture. It is a common injury found in children, occurring in 15% of childhood long bone fractures.[2]

Types[edit]

There are nine types of Salter–Harris fractures; types I to V as described by Robert B Salter and W Robert Harris in 1963,[2] and the rarer types VI to IX which have been added subsequently:[3]

  • Type I – transverse fracture through the growth plate (also referred to as the "physis"):[4] 6% incidence
  • Type II – A fracture through the growth plate and the metaphysis, sparing the epiphysis:[5] 75% incidence, takes approximately 2–3 weeks or more in the spine to heal.[6]
  • Type III – A fracture through growth plate and epiphysis, sparing the metaphysis:[7] 8% incidence
  • Type IV – A fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis:[8] 10% incidence
  • Type V – A compression fracture of the growth plate (resulting in a decrease in the perceived space between the epiphysis and metaphysis on x-ray):[9] 1% incidence
  • Type VI – Injury to the peripheral portion of the physis and a resultant bony bridge formation which may produce an angular deformity (added in 1969 by Mercer Rang)[10]
  • Type VII – Isolated injury of the epiphyseal plate (VII–IX added in 1982 by JA Ogden)[11]
  • Type VIII – Isolated injury of the metaphysis with possible impairment of endochondral ossification
  • Type IX – Injury of the periosteum which may impair intramembranous ossification

SALTER mnemonic for classification[edit]

The mnemonic "SALTER" can be used to help remember the first five types.[12][13][14]

IMPORTANT NOTE: This mnemonic requires the reader to imagine the bones as long bones, with the epiphyses at the base.

  • I – S = Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)
  • II – A = Above. The fracture lies above the physis, or Away from the joint.
  • III – L = Lower. The fracture is below the physis in the epiphysis.
  • IV – TE = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.
  • V – R = Rammed (crushed). The physis has been crushed.

(alternatively SALTER can be used for the first 6 types – as above but adding Type V: 'E' for Everything or Epiphysis and Type VI:'R' for Ring)

Salter–Harris fracture images[edit]

Salter–Harris fracture radiographs with insets showing fracture lines.

Salter–Harris I fracture of distal radius. 

Salter–Harris III fracture of big toe proximal phalanx. 

Salter–Harris IV fracture of big toe proximal phalanx. 

Prognosis[edit]

Fractures in children generally heal relatively fast, but may take several weeks to heal.[1] Most growth plate fractures heal without any lasting effects.[1] Rarely, bridging bone may form across the fracture, causing stunted growth and/or curving.[1] In such cases, the bridging bone may need to be surgically removed.[1] A growth plate fracture may also stimulate growth, causing a longer bone than the corresponding bone on the other side.[1] Therefore, the American Academy of Orthopaedic Surgeons recommends regular follow-up for at least a year after a growth plate fracture.[1]

See also[edit]

References[edit]

  1. ^ abcdefg"Growth Plate Fractures". orthoinfo.aaos.org, by the American Academy of Orthopaedic Surgeons. Retrieved 2018-02-05.  Last Reviewed: October 2014
  2. ^ abSalter RB, Harris WR (1963). "Injuries Involving the Epiphyseal Plate". J Bone Joint Surg Am. 45 (3): 587–622. Archived from the original on October 14, 2013. Retrieved October 13, 2013. 
  3. ^Salter-Harris Fracture Imaging at eMedicine
  4. ^"S.H. Type I – Wheeless' Textbook of Orthopaedics". Wheelessonline.com. September 13, 2011. Retrieved August 27, 2013. 
  5. ^"S.H. Type II – Wheeless' Textbook of Orthopaedics". Wheelessonline.com. September 13, 2011. Retrieved August 27, 2013. 
  6. ^Mirghasemi, Alireza; Mohamadi, Amin; Ara, Ali Majles; Gabaran, Narges Rahimi; Sadat, Mir Mostafa (November 2009). "Completely displaced S-1/S-2 growth plate fracture in an adolescent: case report and review of literature". Journal of Orthopaedic Trauma. 23 (10): 734–738. doi:10.1097/BOT.0b013e3181a23d8b. ISSN 1531-2291. PMID 19858983. 
  7. ^"Salter Harris Type III Frx – Wheeless' Textbook of Orthopaedics". Wheelessonline.com. September 13, 2011. Retrieved August 27, 2013. 
  8. ^"Salter Harris: Type IV – Wheeless' Textbook of Orthopaedics". Wheelessonline.com. September 13, 2011. Retrieved August 27, 2013. 
  9. ^"Type V – Wheeless' Textbook of Orthopaedics". Wheelessonline.com. September 13, 2011. Retrieved August 27, 2013. 
  10. ^Rang, Mercer, ed. (1968). The Growth Plate and Its Disorders. Harcourt Brace/Churchill Livingstone. ISBN 978-0-443-00568-8. 
  11. ^Ogden, John A. (October 1, 1982). "Skeletal Growth Mechanism Injury Patterns". Journal of Pediatric Orthopaedics. 2 (4): 371–377. doi:10.1097/01241398-198210000-00004. PMID 7142386. 
  12. ^Davis, Ryan (2006). Blueprints Radiology. ISBN 9781405104609. Retrieved March 3, 2008. 
  13. ^"Salter-Harris Fractures". OrthoConsult. Retrieved 5 February 2017. 
  14. ^Tidey, Brian. "Salter-Harris Fractures". Retrieved March 3, 2008. 
Salter Harris Fracture Types

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