- Clinical science
Pediatric fractures often have distinct fracture patterns due to the unique properties of growing bones. The periosteum in growing bones is thicker and stronger than in adult bones, which is why children are more prone to more incomplete fractures, such as the greenstick fracture or torus fracture. In addition, the periosteum is metabolically active. This feature also explains why childhood fractures heal faster than fractures in adults. Salter-Harris fractures are fractures of the epiphyseal plate, also known as the growth plate or the physis of long bones. These fractures only arise in children and adolescents, whose skeletal growth is not yet complete. Salter-Harris fractures are classified into 5 types according to the extent of damage to the growth plate and joint involvement.
- Definition: fractures in which the fracture line is either absent, or does not completely traverse the width of the bone (an intact periosteum and cortex is seen on at least one side of the bone)
- Mechanism of injury: usually a result of an indirect force applied along the long axis of bones such as the radius, ulna, or fibula (e.g, fall on an outstretched hand, fall from a height)
|Type of incomplete fracture||Radiographic findings||Most common site||Treatment|
|Torus fracture|| |
Immobilization with a splint or a cast for 3–4 weeks
|Greenstick fracture|| |
|Bowing fracture|| |
*Acceptable angulation on X-ray
Minor angulations in pediatric fractures do not require manual reduction because they are often compensated during remodeling and growth!
- Definition: physeal or growth plate fracture
- Most frequently occur during growth spurts at the beginning of puberty
- The most common sites are the distal radius and the distal humerus.
- Epiphyseal plate (physis, growth plate): a plate of hyaline cartilage located in the metaphysis between the epiphysis and diaphysis
- The site of long bone growth: new cartilage is formed and replaced by bone through endochondral ossification.
- Once endochondral ossification is complete and all cartilage has been replaced by bone, the plate becomes an epiphyseal line.
- The periosteum contains blood vessels which supply the bone with oxygen and nutrients for bone remodeling.
- History of trauma (e.g., fall or collision)
- Joint pain at rest or with movement
- Swelling of the joint
- Focal tenderness to palpation around the physis
- Decreased range of motion
- Inability to bear weight on the injured side
Mild clinical symptoms may lead to misdiagnosis!
- Type I: Transverse fractures of the physis, separating the epiphysis from the metaphysis
- Type II: : Transverse fractures of the metaphysis and physis. Often involves separation of a triangular section of the metaphysis.
- Type III: Transverse fractures of the physis and epiphysis. May extend to the joint, affecting the articular surface.
- Type IV: Fractures through the metaphysis, physis, and epiphysis, entering the joint.
- Type V: Impaction and disruption of the physis. Occurs due to a crush or compression injury.
SALTER: S – straight across (or slipped) (type I); A – above (type II); L – lower (type III); TE – through everything (type IV); R – ruined or rammed (type V)
X-ray: AP and lateral views (See “ ”)
- Salter-Harris fracture: physeal widening may be the only finding on x-ray
- MRI: May be helpful if radiographic findings inconclusive
Salter-Harris types I and II
- Closed reduction if displaced and immobilization in a cast with reevaluation after 7–10 days
- In case of severe dislocation or concomitant injury: surgical intervention (as performed in Salter-Harris types III and IV)
Salter-Harris types III and IV
- Open reduction is required to realign the joint surface because both these types affect the joint.
- Surgical intervention includes open reduction and internal fixation (osteosynthesis) using wires or traction screws, followed by immobilization with a cast.
Salter-Harris type V
- Treatment depends on age of injury at diagnosis.
- Disruption of growth and bone deformity (especially Salter-Harris types III–V): leads to discrepancies in limb-length or angular deformities
- Excessive limb growth (rare)