What are the types and characteristics of the Salter‑Harris classification of pediatric growth‑plate fractures?

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Salter-Harris Classification of Pediatric Growth Plate Fractures

The Salter-Harris classification system divides growth plate fractures into five distinct types based on the anatomical structures involved, with Type II being the most common (representing approximately 87% of cases) and Type V being the rarest. 1, 2

The Five Types

Type I: Fracture Through the Growth Plate Only

  • The fracture line runs entirely through the physis (growth plate)
  • The epiphysis separates from the metaphysis
  • No involvement of bone above or below the growth plate
  • Generally has excellent prognosis with minimal risk of growth disturbance
  • Least common type, representing only about 1% of epiphyseal fractures 2

Type II: Fracture Through Growth Plate and Metaphysis

  • Most common type, accounting for approximately 87% of all epiphyseal fractures 2
  • Fracture extends through the physis and into the metaphysis (the flared portion of bone below the growth plate)
  • Creates a metaphyseal fragment (Thurston-Holland sign)
  • Generally good prognosis with low risk of growth arrest
  • Most frequently seen in distal radius (454 cases), finger phalanges (224 cases), and distal humerus (95 cases) 2

Type III: Fracture Through Growth Plate and Epiphysis

  • Fracture extends through the physis and into the epiphysis (the bone end above the growth plate)
  • Intra-articular fracture that involves the joint surface
  • Requires anatomic reduction to restore joint congruity
  • Moderate risk of growth disturbance and post-traumatic arthritis
  • Relatively uncommon, representing only about 2% of cases 2

Type IV: Fracture Through Growth Plate, Epiphysis, and Metaphysis

  • Fracture line crosses all three structures: metaphysis, physis, and epiphysis
  • Intra-articular fracture with significant risk of complications
  • Requires precise anatomic reduction and often surgical fixation
  • High risk of growth arrest and angular deformity if not perfectly aligned
  • Represents approximately 9% of epiphyseal fractures 2
  • Poor outcomes reported in 29-32% of cases 3

Type V: Crush or Compression Injury

  • Compression injury to the growth plate without visible fracture line
  • Extremely rare (only 1 case in 1147 fractures in one large series) 2
  • Often missed on initial radiographs
  • Highest risk of premature growth arrest
  • Diagnosis may be retrospective when growth disturbance becomes apparent

Clinical Significance and Prognosis

The classification directly correlates with prognosis: Types I and II generally heal without growth disturbance, while Types III, IV, and V carry progressively higher risks of complications including growth arrest, angular deformity, and limb length discrepancy. 1, 4

Risk of Growth Disturbance:

  • Type I: Minimal risk
  • Type II: Low risk (5-10%)
  • Type III: Moderate risk (10-25%)
  • Type IV: High risk (25-40%)
  • Type V: Very high risk (>50%)

Treatment Implications:

  • Types I and II: Often managed with closed reduction and casting if minimally displaced
  • Types III and IV: Almost always require open reduction and internal fixation to restore joint surface and growth plate alignment 3
  • Type V: Difficult to treat acutely; management focuses on addressing subsequent growth arrest

Common Pitfalls

The most critical error is missing a Type V injury on initial presentation, as these compression injuries may not show obvious fracture lines on radiographs but will later manifest as growth arrest. Serial radiographs and close follow-up are essential when mechanism suggests compression injury.

Additional pitfalls include:

  • Accepting inadequate reduction in Types III and IV fractures, leading to post-traumatic arthritis
  • Failing to recognize that even "nondisplaced" distal femur fractures often require surgical fixation 3
  • Underestimating the complexity of Type IV fractures, which have poor outcomes in nearly one-third of cases despite treatment 3

Up to 10% of all physeal fractures result in growth disturbances requiring secondary surgical intervention 4, emphasizing the importance of accurate initial classification and appropriate treatment selection.

References

1
Research

Growth plate injuries: Salter-Harris classification.

American family physician, 1992

3
Research

Growth plate fractures of the distal femur.

Journal of pediatric orthopedics, 2012

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