Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Salter-Harris Fracture Imaging

  • Author: William H Moore, MD; Chief Editor: Felix S Chew, MD, MBA, MEd  more...
 
Updated: May 23, 2016
 

Overview

Salter-Harris fractures are fractures through a growth plate; therefore, they are unique to pediatric patients. These fractures (radiographs of which are presented below) are categorized according to the involvement of the physis, metaphysis, and epiphysis. The classification of the injuries is important, because it affects patient treatment and provides clues to possible long-term complications.[1, 2, 3]

Salter-Harris type II fracture of the distal tibia Salter-Harris type II fracture of the distal tibia
Salter-Harris type III fracture of the distal tibi Salter-Harris type III fracture of the distal tibia
Salter-Harris type IV fracture of the distal tibia Salter-Harris type IV fracture of the distal tibia

When all types of Salter-Harris fractures are considered, the rate of growth disturbance they cause is approximately 30%. However, only 2% of Salter-Harris fractures result in a significant functional disturbance.

See Common Pediatric Sports and Recreational Injuries, a Critical Images slideshow, to help recognize some of the more common injuries and conditions associated with pediatric recreational activities.

The basic Salter-Harris fractures include the following[1, 4, 5, 6, 7, 2, 8] :

Type I

A type 1 fracture (illustrated below) is a transverse fracture through the hypertrophic zone of the physis. In this injury, the width of the physis is increased. The growing zone of the physis usually is not injured, and growth disturbance is uncommon.

Salter-Harris fracture type I Salter-Harris fracture type I

On clinical examination, the child has point tenderness at the epiphyseal plate, which is suggestive of a type I fracture.

Type II

The most common type of Salter-Harris fracture, a type II fracture (illustrated below) occurs through the physis and metaphysis; the epiphysis is not involved in the injury.

Salter-Harris fracture type II Salter-Harris fracture type II

These fractures may cause minimal shortening; however, the injuries rarely result in functional limitations.

Type III

A type III fracture (illustrated below) is a fracture through the physis and epiphysis. This fracture passes through the hypertrophic layer of the physis and extends to split the epiphysis, inevitably damaging the reproductive layer of the physis.[5, 6, 9]

Salter-Harris fracture type III Salter-Harris fracture type III

This type of fracture is prone to chronic disability, because by crossing the physis, the fracture extends into the articular surface of the bone.

However, type III fractures rarely result in significant deformity; therefore, they have a relatively favorable prognosis.

An ankle fracture termed a Tillaux fracture is a type of Salter-Harris type III fracture that is prone to disability.

The treatment for type III fractures is often surgical.

Type IV

A Type IV fracture (illustrated below) involves all 3 elements of the bone, passing through the epiphysis, physis, and metaphysis.[4, 9]

Salter-Harris fracture type IV Salter-Harris fracture type IV

Similar to a type III fracture, a type IV fracture is an intra-articular fracture; thus, it can result in chronic disability.

By interfering with the growing layer of cartilage cells, these fractures can cause premature focal fusion of the involved bone. Therefore, these injuries can cause deformity of the joint.

Type V

A type V injury (illustrated below) is a compression or crush injury of the epiphyseal plate, with no associated epiphyseal or metaphyseal fracture.[8]

Salter-Harris fracture type V Salter-Harris fracture type V

This fracture is associated with growth disturbances at the physis. Initially, diagnosis may be difficult, and it often is made retrospectively after premature closure of the physis is observed. In the older teenagers, the diagnosis is particularly difficult.

The clinical history is paramount in the diagnosis of this fracture. A typical history is that of an axial load injury.

Type V injuries have a poor functional prognosis.

Types VI-IX

Rare types of Salter-Harris fractures include the following:

  • Type VI - Injury to the perichondral structures
  • Type VII - Isolated injury to the epiphyseal plate
  • Type VIII - Isolated injury to the metaphysis, with a potential injury related to endochondral ossification
  • Type IX - Injury to the periosteum that may interfere with membranous growth

Preferred examination

Radiography always is the preferred examination in a suspected fracture. The use of another modality should not be considered until appropriate plain film radiography has been performed.[10, 11, 12, 13, 14, 15, 16]

In cases of severe injury in which the patient has acute pain, appropriate radiographic examination of the involved area may be difficult because of inadequate patient positioning. In these cases, computed tomography (CT) scanning may be beneficial in evaluating the injury after a radiologist has evaluated the plain radiographs.[17]

However, the cost of CT may prohibit its use in all cases in which the area of interest is suboptimally evaluated. CT should be considered only when radiographic findings are insufficient. Typically, an orthopedic surgeon and a radiologist make the decision to perform CT.

If an additional study is performed, its purpose is to determine the appropriate management and to assist in surgical planning. Thus, the surgeon performing the operation is best suited to request the imaging study. When further definition of fractures may help in making management decisions or when the injury does not respond to conservative management, the radiologist or orthopedic surgeon can recommend an appropriate examination to perform after plain radiography.

Currently, 2 radiologic examinations can be performed to further evaluate fractures: (1) CT scanning with multiplanar reconstruction and (2) magnetic resonance imaging (MRI). MRI depicts marrow edema, whereas CT shows cross-sectional bone detail and tomographic multiplanar information. At the present time, MRI is not the standard of care. CT is used more commonly; typically, it is used for planning surgery.

The disadvantages of MRI that limit its routine use include the modality's expense, time requirement, and availability. In children, particularly very young children, sedation and even general anesthesia may be required to perform MRI scans. As techniques and software improve, the use of MRI in the acute trauma setting is likely to increase.

Thawrani et al[18] recently published an article looking at the interobserver agreement on classification and surgical management in complex ankle fracture with the use of CT scanning. They found no increase in interobserver reliability to classify the fracture or with regard to the treatment decision.

Recently, Taggart et al[19] reported that the use of point-of-care ultrasonography in the emergency department setting could correctly diagnose Salter-Harris fractures. Findings of periosteal fluid at the level of the metaphysis and widening of the physis allowed for the diagnosis of a fracture.

Next

Radiography

Radiographic findings vary according to the type of Salter-Harris fracture.

With a type I fracture, initial radiographs may suggest separation of the physis, but this separation may not be apparent. However, soft-tissue swelling is present, and its center typically overlies the physis. Follow-up radiographs obtained 7-10 days after injury help establish the diagnosis. New bone growth (ie, adjacent sclerosis and periosteal reaction) along the epiphyseal plate confirms the diagnosis of a Salter-Harris type I fracture.

In a type II fracture (seen below), the fracture line passes through the metaphysis into the epiphyseal plate, but no fracture is observed in the epiphysis. The metaphyseal fragment is sometimes called the Thurston-Holland fragment.

Salter-Harris type II fracture of the distal tibia Salter-Harris type II fracture of the distal tibia

A type III fracture (presented below) passes through the hypertrophic layer of the physis and extends to split the epiphysis. The fracture crosses the physis and extends into the articular surface of the bone.

Salter-Harris type III fracture of the distal tibi Salter-Harris type III fracture of the distal tibia

A Type IV fracture (seen below) passes through the epiphysis, physis, and metaphysis. Similar to a type III fracture, a type IV fracture is an intra-articular injury.

In a type V injury, initial plain radiographs may not show a fracture line, similar to images of type I fractures. However, soft-tissue swelling at the physis is present. A compression or crush injury of the epiphyseal plate is present without associated epiphyseal or metaphyseal fracture.

In a study of radiography versus subsequent CT for diagnosis of Salter Harris type III fractures, Salter Harris type IV fractures, J. Tillaux fractures, and triplane fractures in 64 patients, CT was found to be essential in patients with transitional distal tibial fractures, as well as in patients with displaced Salter-Harris III and IV fractures to make accurate diagnoses and to select appropriate treatment. In patients who received initial radiographic examination, surgical treatment was chosen for 18 patients and nonsurgical for 46. For patients who underwent CT scanning, 42 patients were found to require surgical treatment and only 22 nonsurgical.[17]

Previous
Next

Computed Tomography

CT scanning has an important role in the evaluation of epiphyseal injuries. Rogers and Poznanski[10] discussed the role of CT along with the use of a bone algorithm and multiplanar reconstruction of multiplanar initial images. With CT, a considerable amount of information regarding the nature of the fracture can be gathered. CT techniques typically are used in patients prior to surgery, after a fracture is diagnosed on the basis of plain radiographic findings.

Multiplanar CT findings are similar to plain radiographic findings.

The computer program is able to compensate for imprecise patient positioning. True lateral and true anteroposterior (AP) views of the bone in question can be obtained. As with any study, physicians who request these costly studies should have the knowledge and experience needed to interpret the images. Orthopedic surgeons may be the ones to request CT examinations; however, any physician can order them in consultation with a radiologist.

The advantages of CT scanning over MRI are its greater availability and the faster speed in obtaining images. The disadvantage of CT scanning is that the modality requires a relatively large dose of radiation for diagnostic imaging. Raw-data images typically are obtained with 1-mm sections and a high milliampere technique; however, the high collimation reduces the total amount of exposure.

In the near future, multi–detector row technology is likely to affect the utility of CT in the detailed evaluation of fractures.

Previous
Next

Magnetic Resonance Imaging

On MRIs, the typical findings of Salter-Harris fractures include a signal void on T1-weighted images. On T2-weighted images, increased signal intensity, which is consistent with edema, is depicted around the fracture site.

MRI can be used in surgical planning. Craig et al[20] discussed the use of MRI in evaluating partial closure of the growth plates. Patients with functional or growth abnormalities were examined with MRI, and the exact nature of the defects were well described. These findings helped orthopedic surgeons plan appropriate surgery.

Based on their research, Craig et al suggested that a sagittal 3-dimensional (3D) spoiled gradient-recalled (SPGR) sequence is the best sequence for the evaluation of the physeal plate. In addition to using the SPGR sequence, the study's authors examined patients using 2-dimensional (2D) sagittal and coronal fast spin-echo sequences (with an echo train length of 3) and 3-mm-thick sections with a 1-mm gap. The field of view was 14 cm. They also used 2D axial and coronal fast spin-echo imaging with fat saturation (with an echo train length of 8) and 5-mm-thick sections with a 1.5-cm gap. The field of view was 18 cm.

To the author's knowledge, no group has used SPGR alone in the examination of children with trauma.

Degree of confidence

The evaluation of Salter-Harris injuries in children is a new use for MRI technology, and no standard is uniformly accepted at this time. Salter-Harris I fractures of the distal fibula have been found to be rare in children with radiographic fracture-negative lateral ankle injuries. In a prospective cohort study of 135 children (age range, 5-12 yr) in pediatric EDs who underwent ankle MRI for Salter-Harris type I fracture of the distal fibula, only 4 patients were found to have Salter-Harris type 1 fractures, and 2 of these were partial growth plate injuries.[21]

MRI is limited in the assessment of acute injuries because of the length of time involved in the examination. Another limitation is the relative isolation of the patient within the machine.

MRI has limited utility in the evaluation of Salter-Harris fractures. Therefore, it is most efficiently applied by specialists with specific treatment questions. Orthopedic surgeons are the most appropriate physicians to request MRI; however, in consultation, a radiologist and a clinician may determine a specific need for MRI findings in a given case. Consultation with an orthopedic surgeon is likely to be helpful in complicated injuries that require treatment.

In a study of 31 pediatric patients (mean age 10±2.86 yr) seen in an ED with a clinical suspicion of Salter-Harris type I fracture of the distal fibula who underwent MRI, none of the patients turned out to have Salter-Harris fracture. The majority of the injuries were ligamentous lesions, bone contusions, or joint effusions.[22]

Close and Strouse[11] found evidence that MRI can reveal fractures not seen on plain radiographs. The authors retrospectively evaluated 315 consecutive knee MRIs in children with a history of trauma. They reported that MRI revealed 8 additional fractures that were not fully identified on plain radiographs, and of the 8 fractures found with MRI, 7 had MRI findings that changed the clinical management.

This study was limited because of its retrospective nature and selection bias; however, the authors indicated that MRI is better than plain radiography in delineating the exact nature of an injury. In complex cases, this advantage may be of clinical importance.

The ability of MRI to reveal Salter-Harris fractures that were not seen on radiographs is demonstrated in the image below.

Coronal MRI obtained several weeks after an initia Coronal MRI obtained several weeks after an initial radiograph was obtained to assess ligamentous injury shows an unexpected finding of a Salter-Harris type III fracture.

Carey et al[12] reviewed the correlation between MRI results and plain radiographic findings in Salter-Harris fractures and found a trend similar to that of Close and Strouse.[11] A Finnish study revealed no misclassification in patients with minor ankle fractures; MRI was helpful in evaluating complex injuries in the ankle.[13]

A study performed by Petite et al[14] revealed a small benefit in the use of MRI versus plain radiography They found a misclassification rate of only 3% in patients with acute trauma. This study was limited because only gradient-echo imaging was used. (Carey et al[12] and Close and Strouse[11] used multiple MRI techniques.) The conclusion of Petite et al[14] is similar to that of the other studies: MRI can be helpful in complex cases or when plain radiographic findings are normal and the clinical findings are highly suggestive of fracture.

Previous
Next

Ultrasonography

Ultrasonography (US) has a limited role in the diagnosis of fractures. Hubner et al found that Salter-Harris type I fractures and nondisplaced fractures with less than 1 mm of separation were reliably detected with US.[15] However, complex fractures were more difficult to assess with the modality. The study compared primary US diagnosis of fractures with diagnosis using plain radiography.

Previous
Next

Nuclear Imaging

Although nuclear medicine studies had a role in the diagnosis of Salter-Harris fractures in the past, MRI and CT scanning have replaced them in the evaluation of subtle fractures.

Previous
 
Contributor Information and Disclosures
Author

William H Moore, MD Associate Professor, Department of Radiology, Clinical Director, Radiology Information Technology, NYU Langone Medical Center

William H Moore, MD is a member of the following medical societies: Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Marta Hernanz-Schulman, MD, FAAP, FACR Professor, Radiology and Radiological Sciences, Professor of Pediatrics, Department of Radiology, Vice-Chair in Pediatrics, Medical Director, Diagnostic Imaging, Vanderbilt Children's Hospital

Marta Hernanz-Schulman, MD, FAAP, FACR is a member of the following medical societies: American Institute of Ultrasound in Medicine, American Roentgen Ray Society

Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, Vice Chairman for Academic Innovation, Section Head of Musculoskeletal Radiology, University of Washington School of Medicine

Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Additional Contributors

Beverly P Wood, MD, MSEd, PhD Professor Emerita of Radiology and Pediatrics, Division of Medical Education, Keck School of Medicine, University of Southern California; Professor of Radiology, Loma Linda University School of Medicine

Beverly P Wood, MD, MSEd, PhD is a member of the following medical societies: American Academy of Pediatrics, Association of University Radiologists, American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Medical Association, American Roentgen Ray Society, Radiological Society of North America, Society for Pediatric Radiology

Disclosure: Nothing to disclose.

Acknowledgements

Thomas H Smith, MD Associate Professor, Departments of Radiology and Pediatrics, State University of New York at Stony Brook

Thomas H Smith, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Radiology, American Medical Association, Radiological Society of North America, and Society for Pediatric Radiology

Disclosure: Nothing to disclose.

References
  1. Mubarak SJ, Kim JR, Edmonds EW, Pring ME, Bastrom TP. Classification of proximal tibial fractures in children. J Child Orthop. 2009 Mar 17. [Medline].

  2. Brown JH, DeLuca SA. Growth plate injuries: Salter-Harris classification. Am Fam Physician. 1992 Oct. 46(4):1180-4. [Medline].

  3. Podeszwa DA, Mubarak SJ. Physeal fractures of the distal tibia and fibula (Salter-Harris Type I, II, III, and IV fractures). J Pediatr Orthop. 2012 Jun. 32 Suppl 1:S62-8. [Medline].

  4. Cottalorda J, Béranger V, Louahem D, Camilleri JP, Launay F, Diméglio A, et al. Salter-Harris Type III and IV medial malleolar fractures: growth arrest: is it a fate? A retrospective study of 48 cases with open reduction. J Pediatr Orthop. 2008 Sep. 28(6):652-5. [Medline].

  5. Sabharwal S, Henry P, Behrens F. Two cases of missed Salter-Harris III coronal plane fracture of the lateral femoral condyle. Am J Orthop. 2008 Feb. 37(2):100-3. [Medline].

  6. McKissick RC, Gilley JS, DeLee JC. Salter-Harris type III fractures of the medial distal femoral physis--a fracture pattern related to the closure of the growth plate: report of 3 cases and discussion of pathogenesis. Am J Sports Med. 2008 Mar. 36(3):572-6. [Medline].

  7. Cox G, Thambapillay S, Templeton PA. Compartment syndrome with an isolated Salter Harris II fracture of the distal tibia. J Orthop Trauma. 2008 Feb. 22(2):148-50. [Medline].

  8. Keret D, Mendez AA, Harcke HT, MacEwen GD. Type V physeal injury: a case report. J Pediatr Orthop. 1990 Jul-Aug. 10(4):545-8. [Medline].

  9. Perugia D, Fabbri M, Guidi M, Lepri M, Masi V. Salter-Harris type III and IV displaced fracture of the hallux in young gymnasts: A series of four cases at 1-year follow-up. Injury. 2014 Dec. 45 Suppl 6:S39-42. [Medline].

  10. Rogers LF, Poznanski AK. Imaging of epiphyseal injuries. Radiology. 1994 May. 191(2):297-308. [Medline].

  11. Close BJ, Strouse PJ. MR of physeal fractures of the adolescent knee. Pediatr Radiol. 2000 Nov. 30(11):756-62. [Medline].

  12. Carey J, Spence L, Blickman H, Eustace S. MRI of pediatric growth plate injury: correlation with plain film radiographs and clinical outcome. Skeletal Radiol. 1998 May. 27(5):250-5. [Medline].

  13. Lohman M, Kivisaari A, Kallio P. Acute paediatric ankle trauma: MRI versus plain radiography. Skeletal Radiol. 2001 Sep. 30(9):504-11. [Medline].

  14. Petit P, Panuel M, Faure F. Acute fracture of the distal tibial physis: role of gradient-echo MR imaging versus plain film examination. AJR Am J Roentgenol. 1996 May. 166(5):1203-6. [Medline].

  15. Hubner U, Schlicht W, Outzen S, et al. Ultrasound in the diagnosis of fractures in children. J Bone Joint Surg Br. 2000 Nov. 82(8):1170-3. [Medline].

  16. Mac Nealy GA, Rogers LF, Hernandez R. Injuries of the distal tibial epiphysis: systematic radiographic evaluation. AJR Am J Roentgenol. 1982 Apr. 138(4):683-9. [Medline].

  17. Nenopoulos A, Beslikas T, Gigis I, Sayegh F, Christoforidis I, Hatzokos I. The role of CT in diagnosis and treatment of distal tibial fractures with intra-articular involvement in children. Injury. 2015 Nov. 46 (11):2177-80. [Medline].

  18. Thawrani D, Kuester V, Gabos PG, Kruse RW, Littleton AG, Rogers KJ, et al. Reliability and necessity of computerized tomography in distal tibial physeal injuries. J Pediatr Orthop. 2011. 31:745-750. [Medline]. [Full Text].

  19. Taggart I, Voskoboynik N, Shah S, Liebmann O. ED point-of-care ultrasound in the diagnosis of ankle fractures in children. Am J Emerg Med. 2012. 30:1328. [Medline]. [Full Text].

  20. Craig JG, Cramer KE, Cody DD. Premature partial closure and other deformities of the growth plate: MR imaging and three-dimensional modeling. Radiology. 1999 Mar. 210(3):835-43. [Medline].

  21. Boutis K, Plint A, Stimec J, Miller E, Babyn P, Schuh S, et al. Radiograph-Negative Lateral Ankle Injuries in Children: Occult Growth Plate Fracture or Sprain?. JAMA Pediatr. 2016 Jan. 170 (1):e154114. [Medline].

  22. Hofsli M, Torfing T, Al-Aubaidi Z. The proportion of distal fibula Salter-Harris type I epiphyseal fracture in the paediatric population with acute ankle injury: a prospective MRI study. J Pediatr Orthop B. 2016 Mar. 25 (2):126-32. [Medline].

  23. Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Joint Surg Am. 2012 Jul 3. 94(13):1234-44. [Medline].

  24. Wuerz TH, Gurd DP. Pediatric physeal ankle fracture. J Am Acad Orthop Surg. 2013 Apr. 21(4):234-44. [Medline].

 
Previous
Next
 
Salter-Harris type II fracture of the distal tibia
Salter-Harris type III fracture of the distal tibia
Salter-Harris type IV fracture of the distal tibia
Illustration of uninjured bone
Salter-Harris fracture type I
Salter-Harris fracture type II
Salter-Harris fracture type III
Salter-Harris fracture type IV
Salter-Harris fracture type V
Anteroposterior (AP) plain radiograph of the knee in a child with persistent knee pain after trauma. The radiographic findings appear normal.
Lateral view obtained in the same patient as in the previous image shows only a joint effusion.
Sagittal MRI in the same patient as in the previous 2 images.
Coronal MRI obtained several weeks after an initial radiograph was obtained to assess ligamentous injury shows an unexpected finding of a Salter-Harris type III fracture.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.