What Is It, Types, Treatment, and More
Author: Corinne Tarantino, MPH
Editors: Ahaana Singh, Józia McGowan, DO, FACOI, FNAOME, CS
Illustrator: Abbey Richard
Copyeditor: Joy Mapes
What is a Salter-Harris fracture?
A Salter-Harris fracture refers to a injury, or fracture, through the growth plate of a long bone. Examples of a long bone are the humerus in the arm and the tibia in the leg. Present in children, the growth plate, also called the physeal or epiphyseal plate, is an area of cartilage that actively develops into new bone, increasing the bone’s length until the child stops growing around the ages of 14 to 18. If a Salter-Harris fracture is not diagnosed and treated quickly, it can lead to permanent growth arrest, during which the bone stops growing entirely. Salter-Harris fractures are the most common types of fractures in children, especially in those assigned male at birth, and are more likely to cause bone deformity or growth arrest at younger ages.
What is the most common type of Salter-Harris fracture?
A type II Salter-Harris fracture is the most common pediatric physeal fracture, occurring frequently in children over 10 years of age. This fracture breaks at an angle, cutting through most of the growth plate and the metaphysis, the area above the growth plate. The separated piece of the metaphysis is called a Thurston-Holland fragment.
In addition to a type II fracture, there are four other common Salter-Harris fractures types according to the Salter-Harris classification system, which is often used to classify physeal fractures. These fractures, distinguished by the specific part of the bone that has broken off, are numbered according to how intensely the fracture will affect bone growth. In general, type I fractures have the least significant effect on bone growth, and type V has the most.
A Salter-Harris type I fracture refers to a fracture line that runs straight across the growth plate, involving the cartilage without affecting the bone. Type I may cause the epiphysis, or the rounded end of the bone, to separate from the rest of the bone.
Salter-Harris type III fractures are more rare, usually occurring on the distal tibia (the bottom end of a tibia) and cutting across the growth plate, towards the epiphysis. Type III may lead to a development of posttraumatic arthritis, which is characterized by inflammation or swelling around the joint.
Type IV fractures run vertically through the growth plate and can lead to asymmetric bone growth or deformity.
Type V is the rarest type of Salter-Harris fracture, and it happens when the growth plate becomes damaged, but there is no actual break.
If not promptly treated, types III through V are more likely than types I and II to lead to growth arrest. In addition, there are four more types of Salter-Harris fractures (types VI through IX), but they are very rare.
What causes a Salter-Harris fracture?
Salter-Harris fractures usually result from a traumatic event, such as a fall or motor vehicle collision. The bone injury may also develop over time from repetitive pressure on the long bone during sports or other high-impact activities. A rotating or twisting force, like twisting the leg during a fall, typically causes types I through III. Meanwhile, types IV and V are generally due to compression or a crushing force. Occasionally, type V fractures may occur from non-traumatic causes, such as a bone infection (i.e., osteomyelitis) or death of the growth plate (i.e., epiphyseal aseptic necrosis).
What are the signs and symptoms of a Salter-Harris fracture?
Signs and symptoms of a Salter-Harris fracture will often begin with pain, followed by swelling around the end of the injured long bone. The area around the fracture may also feel painful to touch. A person with a fracture may not be able to put weight on the affected limb or may have a limited range of motion. In addition, a bone deformity may be visible as a result of the fracture.
How do you diagnose a Salter-Harris fracture?
For diagnosis, a clinician will typically conduct a medical evaluation that includes a review of the history of the event, symptoms, and a physical examination of the area. Most commonly, the medical evaluation is followed by an X-ray. Type I fractures can occasionally be seen on an X-ray as a slight separation of the epiphysis from the bone, but usually these fractures are not visible since they affect the cartilage and not the bone. Accordingly, a type I fracture diagnosis is most often based upon the symptoms and medical evaluation alone. Type V fractures are frequently missed because they involve only injury to the growth plate instead of physical breakage. These fractures are usually diagnosed during follow-up visits when there is evidence of growth arrest. However, clinical suspicion of type V fractures are important when there is a history of compression and tenderness near the growth plate.
How do you treat a Salter-Harris fracture?
Initial treatment will often focus on controlling swelling and pain. Elevation of the affected limb and icing the area may manage swelling. Pain may be treated with medications, including nonsteroidal anti-inflammatory drugs (NSAIDS) or local anesthetic injections, when necessary. Rest is frequently recommended to facilitate recovery.
Further treatment generally depends on the specific type of fracture and additional orthopedic evaluation. Type I and II fractures are often treated with a closed reduction, which involves setting a bone back in place without surgery. After realignment of the bone, a cast or splint is typically applied to keep the bone stable so it may heal properly. Children with these fractures usually recover with minimal effect on bone growth. On the other hand, type III and IV fractures usually require a surgical procedure, known as an open reduction, in order to set the bone back into its place, and internal fixation, in which metal is used to stabilize the bone, is often necessary. Since type V is frequently diagnosed weeks after the original injury, treatment options can vary significantly and depend on the severity of bone deformity or arrest.It is commonly recommended that a clinician re-examine the fracture seven to ten days after treatment begins to ensure the bones are healing properly and assess for any complications. A follow-up X-ray may also be recommended after the next 6 to 12 months to check on continued bone growth.
What are the most important facts to know about a Salter-Harris fracture?
A Salter-Harris fracture is a growth plate fracture in one of a child’s long bones. It is one of the most common bone injuries in children. There are five common types of Salter-Harris fractures, which range in severity according to their potential for growth disturbance. Type I fractures are least likely to impair bone growth, while type V is the most likely to disturb a child’s bone growth. Type II is the most common type of Salter-Harris fracture and refers to a bone fracture through the growth plate and part of the metaphysis. In addition to the 5 common types, there are 4 additional, rare types of Salter-Harris fractures. Salter-Harris fractures are usually caused by traumatic injuries and result in symptoms of pain and swelling near the end of a long bone. Diagnosis is often made through a clinical examination and X-ray. Treatment for all types of these fractures typically involves rest, application of ice, and elevation of the limb. Regarding further treatment, type I and II may require only setting the fracture and stabilizing it with a cast or splint, while type III and IV may require surgery to set the bones.
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Resources for research and reference
Aziz, F., & Doty C. (2017). Orthopedic emergencies. In C. K. Stone & R. Humphries (Eds.), CURRENT diagnosis & treatment: Emergency medicine (8th ed.). McGraw-Hill.
Cepela, D., Tartaglione, J., Dooley, T., & Patel, P. (2016). Classifications in brief: Salter-Harris classification of pediatric physeal fractures. Clinical Orthopaedics and Related Research, 474(11): 2531-2537. DOI: 10.1007/s11999-016-4891-3
Hacking, C., & Gaillard, F. (2016). Salter-Harris classification. In Radiopaedia. Retrieved March 23, 2021, from https://radiopaedia.org/articles/salter-harris-classification?lang=us
Levine, R., Foris, L., Nezwek, T., & Waseem, M. (2020). Salter Harris [sic] fractures. In StatPearls [Internet]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430688/Mayersak, R. (2020). Initial evaluation and management of orthopedic injuries. In J. Tintinalli, O. J. Ma, D. Yealy, G. Meckler, J. S. Stapczynski, D. Cline D., & S. Thomas (Eds.), Tintinalli's emergency medicine: A comprehensive study guide (9th ed.). McGraw-Hill.