THE Salter-Harris classification is a radiologic

Advanced Emergency Nursing Journal Vol. 29, No. 1, pp. 10 19 Copyright c 2007 Wolters Kluwer Health Lippincott Williams & Wilkins Radiology R O U N D S Column Editor: Jonathan Lee Salter-Harris Fractures Mary Jo Cerepani, MSN, CRNP, CEN; Denise Ramponi, MSN, CRNP, CEN Abstract Pediatric 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 possible growth plate injuries. Therefore, the advanced practice nurse must never be complacent when assessing an orthopedic injury. A radiologic examination is required in every child where a growth plate injury is suspect. Permanent damage and growth plate arrest may occur if this type of injury is not properly diagnosed and appropriately treated. This article outlines Salter-Harris fractures I V for the pediatric population. Using actual cases studies, this article provides a logical approach to the assessment 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 radiologic classification system that was developed in the 1960s to describe fractures involving the growth plate in pediatric patients (Cluett, 2003). It divides these fractures into categories based on the extent of damage to the growth plate. The growth plate can also be referred to as the physis or the epiphyseal plate. Children have open growth plates until after adolescence. This area is more susceptible to trauma. While ligamentous injuries are very uncommon in children, fractures involving the growth plate are more common and may result in bone growth delay or arrest. From the UPMC, Emergency Resource Management, Inc, Pittsburgh, Pa (Ms Cerepani); and the Heritage Valley Health System, Sewickley and Beaver, Pa (Ms Romponi). Corresponding author: Mary Jo Cerepani, MSN, CRNP, CEN, 2 Hot Metal, Pittsburgh, PA 15203 (e-mail: ceremj@upmc.edu). DEFINITION A long bone is divided into four parts (see Table 1 and Figure 1). The end plate of the bone near the joint is known as the epiphysis. The growth plate, epiphyseal plate, or physis is the area where longitudinal bone growth occurs and is weaker than surrounding structures making it prone to injury. The metaphysis is the funnel-shaped end of the shaft of the bone. The shaft of the bone is the diaphysis. TYPES Generally, there are five types of growth plate fractures that can place a pediatric patient at risk for bone growth disturbance. The SALTR mnemonic is an easy way to remember the Salter-Harris classification system (see Table 2 and Figure 2). When using the SALTR mnemonic, the APN must have the epiphysis or endplate of the bone held inferiorly in 10

January March 2007 Vol. 29, No. 1 Salter-Harris Fractures 11 Table 1. Definition of terms Table 2. SALTR mnemonic 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 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 relation to the x-ray to the accurately identify the type of fracture. This is illustrated in the Salter II pictures. An x-ray should be performed in any child with pain over the growth plate after any traumatic injury. There may be a paucity of clinical findings other than pain in this area. Children with pain over the growth plate should be immobilized and referred to an orthopedist even if the x-ray has negative findings, because types I and V fractures x-rays may initially appear normal. Some facilities obtain comparison views for any child younger than 16 years. The WEAK mnemonic can be used to determine which joints may benefit from comparison films (i.e., wrists, elbows, ankles, knees; see Table 3). Some clinicians have abandoned the use of comparison films because any tenderness over the growth plate warrants immobilization and orthopedist referral, regardless of the x-ray findings. Type I The epiphysis is separated or slipped from the metaphysis. On x-ray, there is soft tissue swelling near the epiphyseal line, widening of the epiphyseal line, and displacement of the epiphysis from the metaphysis. There may be a bony avulsion at the periosteal attachment (Harris & Harris, 2000). The width of the physis or growth plate can be increased or can appear slipped. Type I Salter-Harris fractures occur most commonly in the distal tibia and fibula (Simon & Koenigsknecht, 2001). The patient examination is the most important component of assessment in these fractures as x-ray findings can be very subtle. The patient will be point tender over the growth plate and any tenderness over the growth plate warrants reevaluation by an orthopedist. Growth disturbances rarely occur as a result of type I fractures (Green, Yurko, & Griffin, 2005). Figure 1. Bone anatomy.

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 metaphyseal fracture, producing a triangular fragment of the metaphysis. Type II fractures are the most common type of growth plate fracture (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 intraarticular 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 (Cummings, 2006). On physical examination the patient will have point tenderness over the growth plate. Open reduction is usually necessary for these types of fractures to prevent growth disturbance. The blood supply that enters from the epiphyseal surface must be adequate for a good prognosis to be accomplished. If there is not a proper blood supply, avascular necrosis may result. Immobilization for 4 6 weeks with close

January March 2007 Vol. 29, No. 1 Salter-Harris Fractures 13 observation from the orthopedic physician is indicated. Type IV This fracture involves the epiphysis, physis, and metaphysis. The lateral condyle of the humerus is a common site for this fracture (Simon & Koenigsknecht, 2001). On physical examination, the patient will often have point tenderness and swelling at the growth plate. Open reduction and internal fixation are required in most cases. Immobilization for 4 6 weeks with close observation from the orthopedic surgeon is indicated postoperatively. Growth disturbance and joint deformity can occur with type IV injuries. In addition, prognosis may be poor if precise reduction is not achieved, because this is an intra-articular fracture. Type V This injury involves a crush injury to the growth plate with no epiphyseal or metaphyseal fracture. Type V fractures usually involve an axial load mechanism of injury, such as a fall from a height. The knee and the distal tibial physis are common sites of injury (Harris & Harris, 2000). These types of fractures are very difficult to detect since the epiphysis does not appear to be displaced. The initial x-ray may appear normal. In type V injuries, comparison films can be helpful. Treatment is to avoid weight bearing and to have close observation by the orthopedic physician (Harris & Harris, 2000). Unfortunately, Salter-Harris type V fractures are often diagnosed in retrospect only when growth arrest is discovered (Simon & Koenigsknecht, 2001). Therefore, pediatric patients sustaining an injury with open growth plates and point tenderness over their growth plate require clinical suspicion for physis injuries. Early immobilization and prompt orthopedic referral are indicated with any patient with tenderness over the growth plate. A Salter V fracture can arrest bone growth and has a poor prognosis for normal 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 sustained an injury to her right ankle just prior to arrival. Her mother described an eversion injury to the right ankle. The patient was point tender over the growth plate of the distal tibia. X-rays revealed a Salter I fracture of the distal tibia with mild separation of the growth plate (see Figure 3). A second example is included, not involving this case, which demonstrated a Salter I fracture of the distal radius with slippage of the physis (see Figure 4). Management A posterior ankle splint was applied by the APN and remained in place until seen by the orthopedic physician within 24 48 hr. The child was discharged with instructions to use crutches with no weight bearing. The patient returned to normal activities after 3 weeks of immobilization. Figure 3. Salter-Harris type I.

14 Advanced Emergency Nursing Journal aftercare instructions. He was placed in a thumb cast for 4 weeks. After 1 month, the patient was able to resume normal activities without restriction. 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 sustained a right thumb injury after catching a football. He described a hyperextension injury. Tenderness and swelling were noted on the ulnar aspect of the first MCP joint of the right thumb. The patient had ecchymosis of the volar aspect of the thumb and thenar area. The x-ray revealed a Salter II fracture of the MCP joint of the right thumb, with slippage of the proximal phalanx and a fracture through the metaphysis (see Figure 5). Another example of a Salter-Harris II fracture of the distal radius is included for reference (see Figure 6). Management The patient was placed in a thumb spica splint and referred to an orthopedic physician within 24 48 hr. He was given fracture 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 emergency department (ED) with a parent, stating that he was complaining of right knee pain and swelling. His injury was sustained during a collision with another player while playing basketball. His right foot was planted as he tried to catch the ball and another player struck him in the medial aspect of the knee. He fell to the ground and was unable to bear weight immediately after the incident. He presented to the ED with a very swollen and painful right knee. X-ray findings revealed a fracture through the epiphysis with separation of the physis of the distal femur (see Figure 7). A Salter-Harris III fracture of the distal tibia is included for reference (see Figure 8). Management The patient was given fracture instructions and a knee immobilizer with no weight bearing. He was immediately referred to the orthopedic surgeon for consultation, hospital admission within 24 48 hr, and operative intervention. 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 with parents, complaining of an injury to his right ankle. The patient stated that while playing deck hockey he twisted his right ankle (eversion injury). On clinical examination, the patient s right ankle was noted to have significant pain and swelling over the medial malleolus with point tenderness. The patient was unable to bear weight. X-ray findings revealed a fracture through the epiphysis of the

January March 2007 Vol. 29, No. 1 Salter-Harris Fractures 15 Figure 5. Salter-Harris type II fracture. distal tibia extending through the physis and into the metaphysis of the distal tibia (see Figure 9). Management A sugar tong splint was applied by the APN with the foot held in a 90 degree position in relation to the ankle. Fracture aftercare in- structions were given to the patient. The orthopedic physician was consulted since all Salter type IV fractures require urgent surgical reduction and internal fixation (Canale, 2003). Table 4. Discharge instructions for patients with orthopedic injuries (including the RICE mnemonic) Figure 6. Salter-Harris II distal radius. 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)].

16 Advanced Emergency Nursing Journal Figure 7. Salter-Harris III distal femur. Figure 8. Salter-Harris III distal tibia.

January March 2007 Vol. 29, No. 1 Salter-Harris Fractures 17 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 ED complaining of right lower leg pain. The patient sustained an axial load injury to the right ankle. On clinical examination, the patient was noted to have significant pain and swelling over the right distal tibia with point tenderness. The patient was unable to bear weight on the right leg. X-ray findings revealed a Salter V fracture of the right distal tibia through the epiphysis of the distal tibia extending through the physis and into the metaphysis of the distal tibia. These injuries can also often occur in the knee from an axial load injury, such as smashing a dashboard or a direct crush injury. Salter-Harris V fractures often initially have normal x-ray findings with altered physeal closure. Type V fractures are often found in retrospect when growth problems occur. An example of a type V fracture of the distal tibial physis is included for 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.

18 Advanced Emergency Nursing Journal Table 5. Summary: Salter-Harris fractures Radiologic Management/ Type of injury Common sites findings complications Type I: Epiphysis is separated or slipped from metaphysis Type II: The epiphyseal plate is slipped with a metaphyseal fracture, producing a triangular fragment of the metaphysis. Type III: The epiphyseal plate is slipped with an intra-articular fragment of the epiphysis. Type IV: This fracture involves the epiphysis, physis, and metaphysis. Type V: A crush injury to the growth plate with no epiphyseal or metaphyseal fractures. Fractures occur most commonly in the distal tibia and fibula Type II fractures are the most common type of growth plate fracture 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 The lateral condyle of the humerus is a common site for a type IV injury. 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. 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 X-rays reveal slippage of the epiphyseal plate with a metaphyseal fracture. X-ray findings reveal a fracture through the epiphysis with separation of the physis of the bone X-ray findings reveal a fracture through the epiphysis of the bone extending through the physis and into the metaphysis of the bone 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 Immediate orthopedic referral Pain management Splint Immediate orthopedic referral Pain management Splint Immediate orthopedic referral Pain management Immobilization for 4 6 weeks Open reduction may be necessary Complication: Avascular necrosis Immediate orthopedic 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. Immediate orthopedic referral Pain management Early immobilization Avoid weight bearing Complications: bone growth arrest Poor prognosis for normal growth

January March 2007 Vol. 29, No. 1 Salter-Harris Fractures 19 IV fracture of the distal tibia, and the open arrow depicts the type I distal fibula fracture (Harris & Harris, 2000). Management Salter-Harris V fractures are most commonly diagnosed by the orthopedist when there is altered physeal closure. This injury is often diagnosed at a later time after the initial injury. These injuries also require anatomical surgical reduction. SUMMARY A summary of Salter-Harris fractures I V can be found in Table 5. It is critical for APNs to be thorough and complete in their assessment of the pediatric patient who sustains an orthopedic injury. A radiologic examination is required in every child where a growth plate injury is suspect. Permanent damage and growth plate arrest may occur if this type of injury is not properly diagnosed and appropriately treated. Comprehensive management of pediatric patients with Salter- Harris fractures may result in better functional outcomes and decrease permanent disability in pediatric patients with these types of injuries. REFERENCES Canale, S. T. (2003). Fractures and dislocations in children. In S. T. Canale (Ed.), Campbell s operative orthopaedics (10th ed., pp. 1392 1538). St Louis, MO: Mosby. Cluett, J. (2003). Salter-Harris fracture classification. Retrieved 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 fractures. In J. H. Beaty & J. R. Kasser (Eds.), Rockwood and Wilkins fractures in children (6th ed., pp. 1078 1126). Philadelphia, PA: Lippincott Williams & Wilkins. Geiderman, J. M. (2006). General principles of orthopedic injuries. In J. A. Marx, R. S. Hockberger, & R. M. Walls (Eds.), Rosen s emergency medicine: Concepts and clinical practice (6th ed., pp. 549 576). Philadelphia, PA: Mosby, Elsevier. Green, W., & Yurko, G. L. (2005). Essentials of musculoskeletal care (3rd ed.). Rosemont, IL: American Academy of Orthopaedic Surgeons. Harris, J. H., & Harris, W. H. (2000). The radiology of emergency medicine (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Simon, R. R., & Koenigsknecht, S. J. (2001). Emergency orthopedics: The extremities (4th ed.). New York: McGraw-Hill.