This presentation discusses epiphyseal injuries, also known as Salter-Harris fractures, which occur through the growth plate in children. It covers the anatomy of the growth plate and its zones, the Salter-Harris classification system for these fractures, principles of management including maintenance of growth potential and reduction, and treatment approaches depending on the fracture type. Complications like physeal arrest and their treatment options are also summarized.

1. Morning five minute presentation
By:- Dr. Abdulshekur Abduljebar (MD, GSR3)

2.  Osseous Anatomy
 Growth Plate Histology
 Epiphyseal injuries
 Classification
 Management Principles
 Management By Type
 Complications
 Treatment Options for Complications
 References

3.  Epiphysis
 Secondary Ossification Center
 The epiphysis is the bone located
between the articular surface and
the physis
 Epiphyseal Plate/Physis
 Metaphysis
 Bone adjacent to the physis on the
opposite side of the epiphysis.
 Diaphysis
 The shaft of the bone

4.  Zones of the Physis
 Germinal Zone
 Minimally active, scattered
chondrocytes
 Proliferative Zone
 Columns of chondrocytes actively
dividing
 Hypertrophic Zone
 Chondrocytes accumulate and
release calcium
 Weakest zone of physis
 Zone of endochondral ossification

5.  These are fractures through a growth
plate
 They are unique to pediatric patients
 Injuries and fractures at the region of
epiphyseal plate carry the bad and serious
complications.
 Physeal fractures account for 15% to
30% of all bony injuries in children and
commonly occur in the tibia.
 Each plate growth rate is different
and disappear at different time.
Location Avg grt (mm/yr) % of bone Ltl grt
Prxl Humerus 7mm 80%
DisaHumerus 2mm 20%
Prxal Radius 1.75mm 25%
Distal Radius 5.25mm 75%
Promal Ulna 5.5mm 80%
Distal Ulna 1.5mm 20%
Prxl Femur 3.5mm 30%
Distal Femur 9mm 70%
Proximl Tibia 6mm 60%
Distal Tibia 3-5mm 40%
Levine RH, Foris LA, Nezwek TA, Waseem M. Salter-Harris
Fractures. StatPearls. StatPearls Publishing; 2021.

6.  Classification of any injury is important
 Salter-Harris is the most widely used classification for epiphyseal injuries
 The classification is based on:-
 Mechanism of injury
 Relationship of # line to the physis
 Method of treatment
 Prognosis
 Other historical classification systems used for epiphyseal injuries
 Poland
 Bergenfeldt
 Aitken
 Peterson

7.  A type 1 fracture is a transverse
fracture through hypertrophic zone of
the physis
 A type II fracture is a fracture through
physis and metaphysis
 A type III fracture is a fracture through
physis and epiphysis.
 Type IV fracture involves all 3
elements of the bone.
 Type V fracture is compression or
crush injury of the epiphyseal plate
with no associated metaphyseal injury.

8.  X-ray:- It is difficult to assess as the physis is radiolucent and the
epiphysis is incompletely ossified.
 What to look for?
1. The physeal widening of the gap
2. Tilting of the epiphysis
3. Repeating X ray within few days
4. Comparing the injured side with the normal
 Sometimes advanced imaging is needed.
 CT Scan
 MRI

9.  Achieve fracture healing with maintenance of growth potential
 Achieve acceptable reduction and alignment
 Maintenance of achieved reduction and alignment
 Limit iatrogenic injury to physis
 Repeated, forceful reduction attempts
 Hardware across physis

10.  Type 1
1. Undisplaced
• P/Exam:- tenderness, swelling at physis
• Normal radiographs
• Casting/immobilization for 2-4 weeks
2. Displaced
• P/Exam:- obvious deformity and pain
• Displacement seen on radiographs
• Reduce efficiently either by closed or open reduction
• internal fixation should be with smooth wires or pins
 Reduces risk of iatrogenic physeal injury

11.  Treatment options for Type 2 include:
• Closed reduction and casting
• Closed reduction and percutaneous
screw or wire fixation
 Screw for larger metaphyseal
fragment
 Wires crossing physis for smaller
metaphyseal fragment

12.  Treatment options for type 3 include:
• Closed reduction and casting
• Closed vs open reduction, screw
fixation
 Screw along width of epiphysis avoiding
physis
 Screws in epiphysis may increase
pressure on adjacent articular cartilage
and are often removed quickly after
fracture healing
 Advanced imaging may be needed to
plan intervention

13.  Treatment for type 4 is surgery
 Anatomic reduction of physis
required to minimize risk of physeal
bar
 CT is crucial and gives 3D
visualization of fracture patterns;
Essential for surgical planning
 Fixation best accomplished from
epiphysis to epiphysis and/or
metaphysis to metaphysis

14.  Treatment for type 5
 It is very difficult initial diagnosis as minimal
displacement
 Late diagnosis after complication of physeal
arrest and deformity has occurred
 Initial nonoperative treatment

15.  When an entire physis arrests
 Longitudinal bone growth ceases completely at that physis
 When only part of physis arrests
 Angular deformity associated with shortening
 Often a much more difficult problem to address
 How to pick?
 Loss of abnormal physeal contour
 Sharply defined connection between epiphysis and metaphysis
 Tapering of Harris growth arrest line towards area of growth arrest
 Obvious angular deformity or segment shortening

16.  Surgical Physeal Arrest Resection
 Removal of arrest with continuation of physeal growth
 Complete Physis Arrest
 Ablation of growth in physis on one or both sides
 Hemi-ephiphysiodesis (angular) vs epiphysiodesis (growth correction of affected
and/or unaffected side)
 Treatment of angular or growth deformities
 Guided growth
 Osteotomies
 Fixators

17. Levine RH, Foris LA, Nezwek TA, Waseem M. Salter-Harris Fractures.
StatPearls. StatPearls Publishing; 2021.