Growth Plate Fractures Explained with X-Ray Examples

Growth plate fractures are Fractures affecting the growing part of the bone (physis) in children

15-30% of fractures in children involve injury to the growth plate

The growth plate (physis) is relatively weak, that is why it fractures commonly in children

If the fracture injures the reproductive layers of the growth plate, it may result in premature ossification and growth arrest

Classification

Growth plate fractures are classified according to Salter-Harris classification

This classification is based on the fracture location in relation to the physis, metaphysis and epiphysis, fracture pattern, and prognosis

It’s on five grades

Salter 1

Transverse fracture through the hypertrophic or calcified zone of the plate
Growth plate state: not injured
Good prognosis

Salter 2

Transverse fracture through the growth plate and it deviates away from the physis to split off a triangular metaphyseal fragment of bone
Growth plate state: not injured
Most common grade
Good prognosis

Salter 3

Transverse fracture through the physis and then deviates to the epiphysis
Growth plate state: injured
Intra articular
Poor prognosis

Salter 4

Fracture location: fracture travels through the epiphysis, physis and metaphysis and it is liable to displacement which if happened result in asymmetrical growth
Growth plate state: injured
Intra articular
Poor prognosis

Salter 5

Fracture location: longitudinal compression injury of the physis
Growth plate state: compression injury
Worst prognosis

Mechanism of injury

Growth plate fractures are caused by many types of injuries including:

Falls
Road traffic accidents
Sporting activities

In the hip, slipped upper femoral epiphysis is Salter 1 fracture that can occur without traumatic event

Clinical features

Patient present with pain, tenderness and swelling after traumatic event (mostly fall)

If the injury involves a lower extremity, the patient is unable to bear weight on the affected side

Deformity is rare

Examination is difficult

X ray imaging

It is hard to tell if there is a fracture or not on x ray because

The physis (growth plate) is radiolucent
epiphysis is incompletely ossified

The younger the child, the larger the radiolucent part on x ray thus the harder to look for fractures

The easiest way is to x ray the contralateral joint and compare them

There is usually widening of the physeal gap, incongruity of the joint , tilting of the epiphysis

if there is displacement then it is easier to diagnose

Salter 5 are quite hard to diagnose

Treatment

Salter 1 and 2 treated with closed reduction and then casting or splinting, the reduction is through gentle manipulation to avoid injuring the physis

Salter 3 and 4 treated with open reduction and internal fixation with avoiding crossing the physis

Reexamination with X ray in seven to ten days is necessary to check for late displacement and additional X ray done in 6- 12 months to assess for growth arrest

Complications

Bone growth arrest

Grade 1 and 2 Salter Harris have good prognosis (bone growth not affected) if reduced properly except injuries around knee joint involving distal femoral physis or proximal tibial physis, because growth plates there doesn’t have linear shape, so linear fracture would pass through the hypertrophic layer of the growth plate thus affecting growth

Grade 3 and 4 may result in premature fusion of parts of the growth plate and lead to asymmetrical growth

Grade 5 fractures always cause premature fusion of parts of the growth plate and lead to asymmetrical growth