Physeal Injuries in Children Salter-Harris Classification

In pediatric bone, the primary areas of growth include the physis and the epiphysis.

Physeal injuries may occur in the skeletally immature population from acute trauma, as well as from chronic overuse and repetitive loading.

In 1963, Salter and Harris described a classification scheme for acute injuries to the physis (1)[C].

Although most physeal fractures heal well, growth plate injuries can lead to complications including avascular necrosis, premature growth arrest, or angular deformities.

Occurs most commonly after 10 yrs of age but can be seen in any skeletally immature patient

Typical age range: 10–16 yrs of age; median age: 13 yrs

Predominant gender: Boys > Girls

Most common time frame: Spring through summer months (more outdoor playtime)

Most common bone location: Distal radial physis

Most common type of physeal injury: Salter-Harris type II (75%)

Skeletal immaturity

Falls, especially while running or playing

Competitive organized sports, especially contact sports

Recreational sports, including skiing/snowboarding, skateboarding, and bicycling

Overuse training activities that cause repetitive loading and stress, such as gymnastics, cheerleading, throwing, and running

Monitor training demands, especially in young athletes during periods of heightened growth

Cross-training to avoid overuse and repetition

Overtraining prevention: Alternate periods of heavy training with designated periods of rest.

There are 2 types of epiphyses: Traction epiphyses (apophyses), where major tendons originate or insert into bone, and pressure epiphyses, at the ends of long bones.

Traction epiphyses shape and strengthen bone but do not add longitudinal growth; hence their injury typically does not cause longitudinal growth arrest.

Pressure epiphyses add longitudinal growth to long bones.

The physis, located between the epiphysis and the metaphysis of long bones, serves as the area of rapid longitudinal bone growth.

Injury to the physis or pressure epiphyses may result in growth disturbance.

The active physis consists of 4 zones of cells separated by cartilage matrix; the 3rd zone (hypertrophic zone) is the area most susceptible to injury and cleavage.

The epiphysis provides the nutrient blood supply to the physis; epiphyseal injury can cause disruption of normal growth and maturation owing to compromised vascular supply.

Fall onto an outstretched hand (FOOSH) is a common mechanism of distal radius growth plate injury (2)[C].

Abduction, adduction, and twisting mechanisms are especially common in tibial physeal injuries and other lower extremity growth plate injuries (1,2)[C].

Severe abduction or adduction mechanisms in the ankle or knee can cause type V crush injury to the physis (1,2)[C].

Patient often reports “sprain” of a joint.

Chronic stress injuries to the physis may present with a history of intense training with minimal rest or with overuse repetitive motion, such as baseball pitchers or gymnasts. Patients complain of focal pain at the area of the physis (2,3,4)[C].

Swelling

Ecchymosis

Focal tenderness to palpation

Limited range of motion owing to pain

Refusal to bear weight

Bone fractures

Sprains: Physeal injuries most commonly mistaken for sprains

Ligamentous rupture

Dislocation

Estimates range from 30–75% of all physeal injuries lead to some type of growth disturbance or angular deformity (1,3,4)[C].

However, current estimates predict only 1–10% of these patients demonstrate significant functional deficits requiring surgical intervention (4,5)[C].

Typically, Salter-Harris type I and II fractures have a good to excellent prognosis. Types III and IV have a poorer prognosis, and type V injury invariably results in growth disturbance with the worst prognosis (1,2,4,5)[C].

Younger children have a worse prognosis owing to longer duration of remaining growth that may be affected (1)[C].

Other indicators of poor prognosis include compromised epiphyseal blood supply, repeated or forceful manipulation of physis during reduction, and open physeal fracture (1)[C].

Calcaneal apophysitis (Sever disease)

Osgood-Schlatter disease

813.42 Other closed fractures of distal end of radius (alone)

821.22 Fracture of lower epiphysis of femur, closed

824.8 Unspecified fracture of ankle, closed