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DISTAL RADIUS GROWTH PLATE FRACTURE (SALTER II )

Introduction

Although the bones of adults and children share many of the same risks for fracture, children are uniquely susceptible to physeal fracture, as their bones are still growing, and the growth plate is the weakest part of the growing bone. Growth plates are located at the ends of the long bones, and they help determine the ultimate length and shape of mature bones. Thus, these fractures require prompt attention. If not treated properly, an arm or leg could grow to be crooked or of unequal length compared to the other limb. In 1963, Salter and Harris proposed a classification system for pediatric physeal fractures. The Type II fracture is the most common type of physeal fracture. In the Salter/Harris classification, the higher the number, the more likely the growth plate will be permanently damaged and bone deformity will occur.

Related Anatomy

  • Long bones: ulna, radius, femur, tibia, fibula
  • Growth plate (physis)
  • Metaphysis
  • Epiphysis (proximal, distal)

Incidence and Related Conditions

  • Type II fractures occur after age 10 years
  • Physeal fractures are twice as likely in boys as in girls; girls finish growing earlier than do boys (14 vs 16 y)
  • 33% of all growth plate fractures occur during competitive sports (eg, football, basketball, gymnastics); ~20 occur during recreational sporting activities (eg, biking, skiing, skateboarding)
Clinical Presentation Photos and Related Diagrams
  • Silver Fork Deformity from Salter II Distal Radius Fracture
    Silver Fork Deformity from Salter II Distal Radius Fracture
Basic Science Photos and Related Diagrams
  • Normal Growth Plate A = diaphysis; B = metaphysis; C = growth plate (epiphyseal plate); D = epiphysis
    Normal Growth Plate A = diaphysis; B = metaphysis; C = growth plate (epiphyseal plate); D = epiphysis(Hover over right edge to see more images)
  • Salter I Fracture - Fracture line through growth plate (physis) but non displaced (Hover over right edge to see more images)
    Salter I Fracture - Fracture line through growth plate (physis) but non displaced (Hover over right edge to see more images)
  • Salter II Fracture - Fracture line through growth plate (physis) and metaphysis. The metaphyseal fragment is called the Thurston-Holland fragment.
    Salter II Fracture - Fracture line through growth plate (physis) and metaphysis. The metaphyseal fragment is called the Thurston-Holland fragment.
  • Salter III Fracture - Fracture line through growth plate (physis) and the epiphysis and articular surface.
    Salter III Fracture - Fracture line through growth plate (physis) and the epiphysis and articular surface.
  • Salter IV Fracture - A vertical fracture line through metaphysis, the growth plate (physis) and the epiphysis and articular surface.
    Salter IV Fracture - A vertical fracture line through metaphysis, the growth plate (physis) and the epiphysis and articular surface.
  • Salter V Fracture - A compression-type fracture line in the physis with extension in multiple directions. Growth plate (physis) damage is likely.
    Salter V Fracture - A compression-type fracture line in the physis with extension in multiple directions. Growth plate (physis) damage is likely.
  • Histology of the normal Epiphysis, Growth Plate and Metaphysis: A = Articular cartilage; B = Subchondral bone; C = Cancellous bone; D = Medullary cavity; E = Cancellous bone; F = Resting cartilage; G = Proliferating cartilage; H = Hypertrophy; I – Calcification; J = Vascular invasion
    Histology of the normal Epiphysis, Growth Plate and Metaphysis: A = Articular cartilage; B = Subchondral bone; C = Cancellous bone; D = Medullary cavity; E = Cancellous bone; F = Resting cartilage; G = Proliferating cartilage; H = Hypertrophy; I – Calcification; J = Vascular invasion
Symptoms
History of trauma - fall on the outstretched hand (FOOSH)
Pain, swelling and bruising of the wrist
Pain with wrist motion or pressure on the wrist area
Wrist deformity (silver fork deformity)
Patient is a growing child
Typical History
  • A junior high school soccer player fell over a teammate during a scrimmage and landed on her outstretched left hand and wrist.  She is complaining of pain, swelling and deformity in the right wrist.  The team’s athletic trainer has applied a wrist splint and ice pack while the patient waits for a ride to the local emergency room.
Positive Tests, Exams or Signs
Fracture Crepitus, Deformity, Motion and Tenderness
Silver Fork Deformity
Capillary Refill
Passive Stretch Test
Sensory Exam by Nerve
Range of Motion: Active
Range of Motion: Passive
Radial Pulse
Extensor Tendon Exam
Flexor Tendon Exam
Work-up Options
Radiology studies - Computerized tomography (CT) scanning
Radiology studies - X-ray
Images (X-Ray, MRI, etc.)
  • Salter II Fracture Distal Radius Lateral View (Hover over right edge to see more images)
    Salter II Fracture Distal Radius Lateral View (Hover over right edge to see more images)
  • Salter II Fracture Distal Radius AP View
    Salter II Fracture Distal Radius AP View
Treatment Options
Conservative: 
  • Immobilization with casting for non-displaced fractures
  • Immobilization with casting for displaced fractures that can be reduced and remain stable in a cast
Operative: 
  • For displaced and/or unstable fractures
    • Open reduction
    • Internal fixation
Complications
  • Deformity
  • Bony bridge across fracture line that stunts bone growth or causes bone to angulate, grow more slowly than normal or stops growing completely at the injured site
  • Some fracture stimulate growth, causing bones to become longer than the opposite limb
Outcomes
  • Growth plate fractures must be watched carefully to ensure good long-term results
  • More complicated fractures may require follow-up visits until the child reaches skeletal maturity
  • Parents must be informed that this is a growth-related fracture, and it may affect growth even with proper care
Key Educational Points
  • This injury occurs much more frequently in boys than girls; age of maximal incidence is somewhat younger for girls than for boys -- This is thought to be associated with the greater exposure of boys to trauma and to the relative delay of epiphyseal closure in boys rather than to any intrinsic difference in epiphyseal structure between the sexes.
  • This injury is often produced by a fall on an outstretched hand.
  • The fracture line is at the junction of the bone and the epiphyseal plate. Most of these injuries are produced by a shearing force, and there is not much damage to the epiphyseal plate cells, therefore growth is not disturbed.
  • Ability to remodel residual angulation after fracture depends on the age of the patient at the time of fracture, the remaining time and the distance between the fracture and the epiphyseal plate, and the extent of residual angulation following reduction.
  • The potential for remodeling is maximal when the plane of deformity lies in the plane of motion of the adjacent joint.
  • Children under 10 years old possess the ability to correct angulation up to 28°; potential for correction is decreased with greater angulation and increasing age beyond 10 year old. Therefore, it is recommended that correction of angular deformities should be perfomed in children over 10 to 12 years of age.
  • There is a correlation between premature closure of the growth plate and multiple and/or foreceful attempts at closed reduction.
Practice and CME
References

New articles

  1. Sferopoulos NK. Classification of distal radius physeal fractures not included in the salter-harris system. Open Orthop J 2014;8:219-24. PMID: 25132871
  2. Lollino N, et al. Salter-Harris type II proximal humerus injuries: our experience with a new external fixator. Tech Hand Up Extrem Surg 2013;17(3):176-8. PMID: 23970202
  3. Waters PM, Bae DS, Montgomery KD. Surgical management of posttraumatic distal radial growth arrest in adolescents. Journal of Pediatric Orthopedics. 2002;22(6):717-724.

Reviews

  1. Verdano MA, et al. Salter-Harris type II proximal humerus injuries: state-of-the-art treatment. Musculoskelet Surg 2012;96(3):155-9. PMID: 22879059
  2. Brown JH, DeLuca SA. Growth plate injuries: Salter-Harris classification. Am Fam Physician 1992;46(4):1180-4. PMID: 1414883

Classics

  1. Lesko PD, Georgis T, Slabaugh P. Irreducible Salter-Harris type II fracture of the distal radial epiphysis. J Pediatr Orthop 1987;7(6):719-21. PMID: 3429661
  2. Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg 1963;45A:587-622.