Growth Plate Fractures in Children: Salter-Harris Classification, Diagnosis, and Treatment

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Growth Plate Fractures in Children: Salter-Harris Classification, Diagnosis, and Treatment

Anatomy of the Growth Plate (Physis)

The physis is the growth plate located between the metaphysis and the epiphysis.

Metaphysis: The bone located on the opposite side of the physis, away from the joint.

Epiphysis: The secondary ossification center, located between the growth plate and the articular cartilage.

Growth Plate Zones

The growth plate consists of three primary zones:

Reserve Zone

Proliferating Zone

Hypertrophic Zone

Salter-Harris Classification of Growth Plate Fractures

One of the most widely used classification systems for growth plate fractures is the Salter-Harris classification:

Type I: Fracture through the growth plate, often without displacement.

Type II: Fracture through the growth plate and metaphysis, sparing the epiphysis. (Good prognosis)

Type III: Fracture through the growth plate and epiphysis, sparing the metaphysis. (Involves joint, usually requires surgery)

Type IV: Fracture through all three elements: the growth plate, metaphysis, and epiphysis. (Worse outcome, requires surgery)

Type V: Compression fracture of the growth plate. (Worst prognosis, difficult to diagnose)

Growth Plate Fractures by Site

Clavicle

Proximal Clavicle Physeal Fracture: The secondary ossification center at the proximal clavicle appears at 17-18 years and fuses at 22-25 years. Medial clavicle injuries in patients under 25 years should be suspected as growth plate injuries, not sternoclavicular injuries.

Distal Clavicle Physeal Fracture: Rare; mimics acromioclavicular (AC) joint separation. Usually treated with a sling.

Humerus

Proximal Humerus:

80% of humeral growth occurs here.

Most injuries are Salter-Harris Type I or II.

Significant remodeling potential, especially in young children. Treated conservatively with a sling.

Little Leaguer’s Shoulder: A stress fracture due to overuse. Treatment includes rest and cessation of throwing.

Distal Humerus:

Transepiphyseal Separation:

Newborns

Older children (Consider child abuse in these cases.)

If displaced, treatment is closed reduction and pinning.

Signs of child abuse: Multiple fractures at different healing stages, corner fractures, posterior rib fractures, femur fractures before walking age.

Lateral Condylar Fracture

Most are Salter-Harris Type IV.

Best diagnosed with internal rotation oblique views.

MILCH Classification:

Type I: Fracture lateral to the trochlear groove.

Type II: Fracture extends into the trochlear groove.

JAKOB Classification:

Type A: Intact articular surface.

Type B: Fracture extends into joint but no fragment rotation.

Type C: Fragment is rotated and displaced.

Treatment:

Nondisplaced: Long-arm cast (4-6 weeks). Close follow-up in the first two weeks.

Displaced: Open Reduction and Internal Fixation (ORIF).

Complications:

Nonunion → Cubitus valgus, tardy ulnar nerve palsy.

Physeal growth arrest.

Avascular Necrosis (AVN) due to posterior blood supply disruption.

Proximal Ulna (Olecranon) Fractures

Can be mistaken for normal growth plate development.

The olecranon ossification center appears at 9 years and fuses at 16 years.

Patients cannot extend the arm.

May be associated with osteogenesis imperfecta.


QUIZZES
1) What is the most common Salter-Harris fracture type?

A. Type I

B. Type II ✅

C. Type III

D. Type IV

Explanation: Type II fractures are the most common, occurring at the metaphysis and growth plate.

2)What injury is commonly mistaken for AC joint separation?

A. Proximal clavicle fracture

B. Distal clavicle physeal fracture ✅

C. Humeral shaft fracture

D. Glenoid fracture

Explanation: A distal clavicle physeal fracture mimics AC joint separation but involves the growth plate.

3)At what age does the proximal humerus growth plate contribute significantly to bone growth?

A. 2-5 years

B. 10-15 years ✅

C. 16-18 years

D. 20-25 years

Explanation: The proximal humerus growth plate plays a major role in growth during adolescence.

4)Which of the following requires ORIF as a primary treatment?

A. Type I growth plate fracture

B. Displaced lateral condylar fracture ✅

C. Greenstick fracture

D. Buckle fracture

Explanation: Displaced lateral condylar fractures require ORIF to prevent complications.