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
Aetiology of premature partial growth plate arrest
- 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: ?
- Infection: 10%
- Tumour: 5%
- Iatrogenic (pins, staples): 2%
- Irradiation: 2%
- Burns: 1%
Location of physeal arrest
- Distal Femur: 39%
- Proximal Tibia: 18%
- Distal Tibia: 30%
- Distal Radius: 5%
- Distal Ulna: 3%
- Distal Fibula: 1%
- Proximal Humerus: 1%
- Proximal Phalanx Great Toe: 1%
- Pelvis (tri-radiate): 1%
Types of Bridge formation
- 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
- 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
- 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
- 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
- Inert, mouldable to cavity and easily removed
- Needs special authorisation for use
- Must be sterilised, infections reported
- Fractures at site of insertion reported
- 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 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.
There are nine types of Salter–Harris fractures; types I to V as described by Robert B Salter and W Robert Harris in 1963, and the rarer types VI to IX which have been added subsequently:
- Type I – transverse fracture through the growth plate (also referred to as the "physis"): 6% incidence
- Type II – A fracture through the growth plate and the metaphysis, sparing the epiphysis: 75% incidence, takes approximately 2–3 weeks or more in the spine to heal.
- Type III – A fracture through growth plate and epiphysis, sparing the metaphysis: 8% incidence
- Type IV – A fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis: 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): 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)
- Type VII – Isolated injury of the epiphyseal plate (VII–IX added in 1982 by JA Ogden)
- 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
The mnemonic "SALTER" can be used to help remember the first five types.
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
|Salter–Harris fracture radiographs with insets showing fracture lines.|
Fractures in children generally heal relatively fast, but may take several weeks to heal. Most growth plate fractures heal without any lasting effects. Rarely, bridging bone may form across the fracture, causing stunted growth and/or curving. In such cases, the bridging bone may need to be surgically removed. A growth plate fracture may also stimulate growth, causing a longer bone than the corresponding bone on the other side. Therefore, the American Academy of Orthopaedic Surgeons recommends regular follow-up for at least a year after a growth plate fracture.
- ^ abcdefg"Growth Plate Fractures". orthoinfo.aaos.org, by the American Academy of Orthopaedic Surgeons. Retrieved 2018-02-05. Last Reviewed: October 2014
- ^ 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.
- ^Salter-Harris Fracture Imaging at eMedicine
- ^"S.H. Type I – Wheeless' Textbook of Orthopaedics". Wheelessonline.com. September 13, 2011. Retrieved August 27, 2013.
- ^"S.H. Type II – Wheeless' Textbook of Orthopaedics". Wheelessonline.com. September 13, 2011. Retrieved August 27, 2013.
- ^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.
- ^"Salter Harris Type III Frx – Wheeless' Textbook of Orthopaedics". Wheelessonline.com. September 13, 2011. Retrieved August 27, 2013.
- ^"Salter Harris: Type IV – Wheeless' Textbook of Orthopaedics". Wheelessonline.com. September 13, 2011. Retrieved August 27, 2013.
- ^"Type V – Wheeless' Textbook of Orthopaedics". Wheelessonline.com. September 13, 2011. Retrieved August 27, 2013.
- ^Rang, Mercer, ed. (1968). The Growth Plate and Its Disorders. Harcourt Brace/Churchill Livingstone. ISBN 978-0-443-00568-8.
- ^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.
- ^Davis, Ryan (2006). Blueprints Radiology. ISBN 9781405104609. Retrieved March 3, 2008.
- ^"Salter-Harris Fractures". OrthoConsult. Retrieved 5 February 2017.
- ^Tidey, Brian. "Salter-Harris Fractures". Retrieved March 3, 2008.