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Salter-Harris Fracture: Types, Symptoms and Treatment

A Salter-Harris fracture is a bone fracture in children and adolescents that involves the growth plate. Depending on the type, it may affect normal bone development.

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A Salter-Harris fracture is a bone fracture in children and adolescents that involves the growth plate. Depending on the type, it may affect normal bone development.

What is a Salter-Harris Fracture?

A Salter-Harris fracture is a bone fracture that involves the growth plate (also called the epiphyseal plate or physis) of a growing bone. This type of fracture occurs exclusively in children and adolescents, as adults no longer have active growth plates. The growth plate is a layer of cartilage near the ends of long bones where new bone tissue is produced. Because it is mechanically weaker than the surrounding bone, it is especially vulnerable to injury.

The Salter-Harris classification was introduced in 1963 by Canadian physicians Robert B. Salter and W. Robert Harris and remains the most widely used system for categorizing these injuries worldwide.

Classification of Salter-Harris Fractures

The classification system includes five types based on the location and extent of injury to the growth plate:

Type I: The fracture runs entirely through the growth plate, without involving the bone itself. This type can be difficult to detect on X-ray and generally has an excellent prognosis.
Type II: The most common type. The fracture passes through the growth plate and a portion of the metaphysis (the region of bone adjacent to the growth plate). Prognosis is typically very good.
Type III: The fracture extends through the growth plate and into the epiphysis (the end of the bone near the joint). Accurate realignment is essential, as the joint surface is involved.
Type IV: The fracture crosses the epiphysis, growth plate, and metaphysis entirely. Surgical treatment is often required, and the risk of growth disturbance is significant.
Type V: The rarest and most severe type. It involves a crushing or compression injury of the growth plate with no visible fracture line. The risk of permanent growth disturbance is high.

Causes and Risk Factors

Salter-Harris fractures commonly result from:

Falls during sports or play activities
Direct blows to the bone
Twisting or hyperextension of joints
Road traffic accidents

The most frequently affected sites include the wrist, ankle, lower leg, and fingers. Children between the ages of 10 and 16 are at the highest risk, as bone growth is most active during this period.

Symptoms

Typical symptoms of a Salter-Harris fracture include:

Pain at or near the affected joint or bone
Swelling and tenderness directly over the growth plate
Reduced range of motion in the affected joint
Visible deformity or malalignment of the bone (in more severe types)
Bruising around the injured area

Diagnosis

Diagnosis is based on a thorough physical examination and imaging studies:

X-ray: The standard initial imaging tool. Type I fractures may not be visible and are sometimes diagnosed based on clinical findings alone.
MRI (Magnetic Resonance Imaging): Particularly useful for visualizing cartilage structures and diagnosing Type I and Type V fractures.
CT (Computed Tomography): Used for complex fractures (Types III and IV) to assist with surgical planning.
Ultrasound: A supplementary option, especially in infants and young children.

Treatment

Treatment depends on the fracture type, the location of the injury, and the age of the child:

Conservative Treatment

Type I and Type II fractures without significant displacement are usually managed conservatively with immobilization in a cast or splint. The immobilization period typically lasts three to six weeks, depending on the age of the child and the bone involved.

Surgical Treatment

Types III, IV, and V fractures, as well as significantly displaced Type II fractures, often require surgical realignment and fixation using Kirschner wires, screws, or plates. The primary goal is to restore the anatomical alignment of the growth plate and minimize the risk of growth disturbances.

Follow-Up Care

Regular follow-up examinations are necessary after treatment to monitor ongoing bone growth. For higher-grade fractures, follow-up should continue for at least one to two years.

Possible Complications

The most significant complication is growth disturbance caused by damage to the growth plate. This can lead to:

Leg length discrepancy or angular deformity
Premature closure of the growth plate (physeal arrest)
Restricted joint function

The risk of these complications is highest with Type IV and Type V fractures.

References

Salter RB, Harris WR. Injuries involving the epiphyseal plate. Journal of Bone and Joint Surgery. 1963;45(3):587-622.
Rockwood CA, Wilkins KE, Beaty JH. Fractures in Children. 8th ed. Lippincott Williams and Wilkins; 2015.
Staheli LT. Fundamentals of Pediatric Orthopedics. 5th ed. Wolters Kluwer; 2016.

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