A Pediatric Radiology Textbook and Pediatric Radiology Digital Library
Salter-Harris Fracture
Etiology: Trauma
Imaging Radiograph: Fracture appearance acronym in relation to growth plate is SALTR – I = Slipped, II = Above (into metaphysis), III = beLow (into epiphysis), IV = Through, V = Rammed — Salter-Harris Type I is fracture through physis — Salter-Harris Type II is fracture through physis and metaphysis — Salter-Harris Type III is fracture through physis and epiphysis — Salter-Harris Type IV is fracture through epiphysis to metaphysis — Salter-Harris Type V is crush injury to physis
Note: Salter Harris Type I fracture is hard to diagnose, look for asymmetry or offset of physis, contralateral comparison can help
DDX:
Complications: Up to 10% of physeal fractures result in growth arrest requiring treatment — Central bony bridges can cause longitudinal growth disturbances while peripheral bony bridges can result in angular deformities — Bony bridges may begin forming 1-2 months after injury but may not become clinically or radiologically evident until years later during adolescent growth spurt so children at risk for bridge formation should be followed until skeletal maturity — Radiographs: Bony bridge may be directly visualized, indirectly you may see narrowing of physis and growth recovery lines and angular deformity and longitudinal growth restrictions
Treatment:
Clinical: 15-30% of pediatric fractures involve the physis
Radiology Cases of Salter-Harris Fracture
Radiology Cases of Salter-Harris Type I Fracture
AP radiograph of the ankle shows a tremendous amount of swelling of the lateral malleolus with the apex of the swelling centered on the distal fibular physis. There is a small bony fragment near the physis as well thought to be from an avulsion injury.AP (left) and oblique (right) radiographs of the ankle show a large amount of soft tissue swelling with its apex over the fibular physis. There is a transverse lucent line through the epiphysis of the fibula.AP radiograph of the pelvis (upper left) shows the left femoral metaphysis to be displaced laterally from its epiphysis. This is better demonstrated on the coronal CT without contrast of the pelvis (upper right) and 3D CT of the pelvis (below)AP (above) and frogleg (below) radiographs of the pelvis shows the right femoral head to be flat and enlarged with femoral neck shortening. The left femoral epiphysis is slipped posteromedially.AP radiograph of the pelvis shows a fracture through the left physeal growth plate causing the femoral epiphysis to sublux off of the femoral metaphysis. This is more clearly seen on the coronal 2D reconstruction CT of the pelvis.Frogleg radiograph of the pelvis shows a fracture through the right physeal growth plate causing the femoral epiphysis to sublux off of the femoral metaphysis.
Radiology Cases of Salter-Harris Type II Fracture
Lateral radiograph of the wrist shows a fracture through the radial physis and extending up into the radial metaphysis.AP (left) and lateral (right) radiographs of the first toe show soft tissue swelling around the toe and a small bone fragment in the center of the distal physis anteriorly.Lateral radiograph of the ankle (above right) shows a bony discontinuity through the posterior aspect of the tibial plafond extending to the physis without an articular step-off which is better seen on the sagittal CT without contrast of the ankle (below).
Radiology Cases of Salter-Harris Type III Fracture
AP (upper left), mortise (upper right) and lateral (lower left) radiographs of the ankle show a lucency through the lateral aspect of the tibial epiphysis that is better demonstrated on the sagittal CT 2D reconstruction without contrast of the ankle (lower right)AP radiograph of the ankle shows a lucent line through the medial aspect of the tibial epiphysis.Lateral radiograph of the hand shows a fracture line through the physis and extending into the epiphysis of the fourth middle phalanx. There is a fracture fragment displaced dorsally.
Radiology Cases of Salter-Harris Type IV Fracture
AP (left upper) and lateral (right upper) radiographs of the ankle show a sagittal fracture through the tibial epiphysis, an axial fracture through the physis, and a coronal fracture through the tibial metaphysis. This is better demonstrated on the coronal (lower left) and sagittal (lower right) CT 2D reconstructions without contrast of the ankle.Coronal (left) and sagittal (right) CT 2D reconstructions without contrast of the ankle show a sagittal fracture through the tibial epiphysis, an axial fracture through the physis, and a coronal fracture through the tibial metaphysis.AP radiograph of the knee (left) shows a double density projecting over the lateral aspect of the proximal tibia. Lateral radiograph of the knee (middle) shows a moderate suprapatellar joint effusion and elevation of the tibial tubercle away from the tibia. Sagittal CT without contrast of the knee (right) shows a fracture line involving the tibial tubercle and extending superiorly into the tibial epiphysis.AP radiograph of the hand shows a linear lucency in the fourth middle phalanx extending from the metaphysis through the physis and into the epiphysis. There is associated cortical irregularity along the medial aspect of the metaphsis.
