Case Study of the Week: Salter-Harris Fracture

Dealing with kids can be tricky.  Not only do you have to win over a child with your demeanor, or more effectively a snack, to entice them to actually let you examen their injury, many children are unable to communicate their symptoms making diagnosis difficult.  "My leg hurts" can mean a number of different medical problems and that's the only clue you may get in diagnosing pediatric patients

Not only is diagnosing kids difficult, some illnesses and injuries can have lasting implications for their future.  Misdiagnosing some types of fractures, for example, could mean problems with use of the affected limb for life.  This is why NPs and PA's must be aware of Salter-Harris fractures and their varying classifications. 

Case Presentation

A tearful four year-old male presents to your clinic after falling off the swing at the park.  He complains of right wrist pain.  He denies numbness and tingling in the affected arm.  His mother states that he has no prior medical history and is generally healthy and active.  The patients's vital signs are within normal limits.

On exam you note tenderness over the patient's right radius with mild swelling.  You note no obvious deformity.  The patient is able to move his fingers appropriately but experiences intense pain with range of motion of the affected wrist.  His vascular function is intact with a capillary refill of less than 2 seconds.  Sensation of the fingers also remains intact.  Based on this patient's symptoms, exam and mechanism of injury you order an X-Ray suspecting a fracture of the distal radius.  

Looking at the X-Ray you observe a fracture crossing through the growth plate and into the metaphysis.  You diagnose the patient with a Salter-Harris Type II fracture and place the patient in a cast arranging follow-up with a pediatric orthopedist.

Salter-Harris Fractures

Salter-Harris fractures are fractures involving the epiphyseal plate (growth plate).  They occur in children and make up about 35% of all fracture injuries in children.  While most Salter-Harris fractures heal without complication, 2% of these injuries result in decreased function of the affected limb.  It is important that more serious Salter-Harris fractures are followed closely by a specialist to prevent or reduce complications.

Salter-Harris fractures are classified in nine categories with the first five being most common.

  • Type 1- These are known as "slipped" based on their appearance.  They pass through the growth plate, do not involve the rest of the bone and have an excellent prognosis.
  • Type II- Type II Salter-Harris fractures are the most common type.  In a type II fracture, the fracture passes through most of the growth plate and into the metaphysis, the main portion of the bone.  These types of fractures also have a good prognosis.
  • Type III- In this category, the fracture passes along the growth plate down into the epiphysis, the lower part of the bone.  
  • Type IV- Type IV Salter-Harris fractures involve all three elements of the bone.  The fracture passes trough the metaphysis, through the growth plate and into the epiphysis.  These fractures have a poor prognosis as they interfere with cartilage cells and can cause premature fusion of the growth plate potentially causing permanent deformity. 
  • Type V- Type V fractures are crushing injuries where the growth plate is damaged by direct compression but no associated fracture is observed.  These types of injuries are difficult to diagnose.  Diagnosis is often retrospective after premature closure of the growth plate is observed.  These injuries have a poor prognosis ofter resulting in long-term complications. 

Management and Outcome

Fractures that are significantly displaced (more than 20 degrees) need to be reduced before splinting or casting.  Repeat X-Rays should be taken post reduction to ensure proper placement has been achieved.  In patients with fractures more than five days old, reduction is not advised as this increases risk of growth plate injury.  

For Salter-Harris fractures of the radius, a below-elbow splint or cast is applied for four to six weeks depending on the type of injury.  Patients with Type III fractures and above or with significant displacement should always be referred to an orthopedist immediately.  Patients with Type I or Type II fractures should follow-up within five days.

Discussion

Most Salter-Harris fractures heal without complication.  However, more serious types of Salter-Harris fractures can result in long-term complications.  NPs and PA's must know how to identify and treat these types of childhood fractures and recognizing immediate specialist referral is necessary.  

 

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