CHAPTER I

INTRODUCTION
The present age, which are characterized by increasing individual participation in high-speed travel by land, sea and air, complex industry, and competitive and recreational sports, might well be called the age of injury, or the age of trauma. The present incidence of injuries is disturbingly high, and continues to rise. Indeed, trauma remains the number one killer of young people in North America. The epidemic of fatal injuries merits more research concerning both prevention and treatment, eventhough advances in traumatology during the past three decades have significantly reduced the morbidity and mortality from trauma.(1) The estimated annual cost of trauma in North America alone is over $160 billion. Approximately 10% of all hospital beds are occupied at any given time by the victims of trauma. Of all the significant injuries that be fall humans, at least two-thirds involve the musculoskeletal system, including fractures, dislocations, and associated soft tissue injuries. thus, musculoskeletal injuries have become increasingly common and important and will continue to be so throughout your life.(1) A fracture, whether of a bone, and epiphyseal plate, or a cartilaginous joint surface, is simply a structural break in continuity. Because bone are surrounded by soft tissue, the physical forces that produce a fracture, as well as the physical forces that result from sudden displacement of fracture fragments, always produce some degree of soft tissue injury as well.(1) The higher incidence of fractures in children is explained by combination of their relatively slender bones and their carefree capers. Some of this injuries, such as crack or hairline fractures, buckle fractures, and greenstick fractures, are not serious.others, such as intra-articular fractures and epiphyseal plate fractures, are very serious indeed. In children not yet walking who have a fracture or joint injury, you must consider the possible but tragic diagnosis of child abuse.(1) The overall mortality rate of children has fallen from 1 in 250 per year in 1900 to 1 in 4,000 per year in 1986; this has been attributed to improved public education, preventive

devices, and medical care. The leading cause of death in children age 1 to 14 is accidental trauma. Skeletal trauma accounts for 10% to 15% of all childhood injuries, with approximately 15% to 30% of these representing physeal injuries (phalanx fractures are the most common physeal injury). Over the past 50 years, the increasing fracture incidence in children has been mainly attributed to increased sports participation. From the ages of 0 to 16 years, 42% of boys will sustain at least one fracture compared with 27% of girls. The overall ratio of boys to girls who sustain a single, isolated fracture is 2.7:1. The peak incidence of fractures in boys occurs at age 16 years, with an incidence of 450 per 10,000 per year; the peak incidence in girls occurs at age 12 years, with an incidence of 250 per 10,000 per year. Open fractures in this population are rare (<5%).(1)

CHAPTER II
SALTER HARRIS FRACTURE Anatomy

FIGURE 1 : Anatomy of Bone Pediatric bone has a higher water content and lower mineral content per unit volume than adult bone. Therefore, pediatric bone has a lower modulus of elasticity (less brittle) and a higher ultimate strain-to-failure than adult bone. The physis (growth plate) is a unique cartilaginous structure that varies in thickness depending on age and location. It is frequently weaker than bone in torsion, shear, and bending, predisposing the child to injury through this delicate area. The physis is traditionally divided into four zones: reserve (resting/germinal), proliferative, hypertrophic, and provisional calcification (or enchondral ossification). (1)

FIGURE 2 : Zones of physeal growth plate The periosteum in a child is a thick fibrous structure (up to several millimeters) that encompasses the entire bone except the articular ends. The periosteum thickens and is continuous with the physis at the perichondral ring (ring of LaCroix), offering additional resistance to shear force. As a general rule, ligaments in children are functionally stronger than bone. Therefore, a higher proportion of injuries that produce sprains in adults result in fractures in children. The blood supply to the growing bone includes a rich metaphyseal circulation with fine capillary loops ending at the physis (in the neonate, small vessels may traverse the physis, ending in the epiphysis).(2) Because of structural differences, pediatric fractures tend to occur at lower energy than adult fractures. Most are a result of compression, torsion, or bending moments. Compression fractures are found most commonly at the metaphyseal diaphyseal junction and are referred to as buckle fractures or torus fractures. Torus fractures rarely cause physeal injury, but they may result in acute angular deformity. Because torus fractures are impacted, they are stable and rarely require manipulative reduction. If manipulated, they usually regain the original fracture deformity as swelling subsides. Torsional injuries result in two distinct patterns of fracture, depending on the maturity of the physis.(2) In the very young child with a thick periosteum, the diaphyseal bone fails before the physis, resulting in a long spiral fracture. In the older child, similar torsional injury results in a physeal fracture. Bending moments in the young child cause greenstick fractures in which the bone is incompletely fractured, resulting in a plastic deformity on the concave side of the fracture. The fracture may need to be completed to obtain an adequate reduction. Bending
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moments can also result in microscopic fractures that create plastic deformation of the bone with no visible fracture lines on plain radiographs; permanent deformity can result.(2) In the older child, bending moments result in transverse or short oblique fractures. Occasionally, a small butterfly fragment may be seen; however, because pediatric bone fails more easily in compression, there may only be a buckle of the cortex.(2)

Types of fracture in childrens

There are two special types of fractures that are limited to childhood, namely, fractures that involve the epiphyseal plate and birth fractures.(3)

Fracture that involve the epiphyseal plate (physis)

Epiphyseal plate fractures, or physeal special problems in relation to both diagnosis and treatment. They also carry the risk of becoming complicated by serious disturbance of local growth and consequent development of progressive bony deformity during the remaining years of skeletal growth. Although the term physis is a relatively recent and acceptable synonym for the epiphyseal plate, the latter term still more widely used in many countries.(3,4) The following classification, which the author developed with W. Robert Harris, is based on the mechanism of injury as well as the relationship of the fracture line to the growing cells of the epiphyseal plate. It is correlated as well with the method of treatment and the prognosis of the injury concerning growth disturbance.(4)

FIGURE 3 : Salter Harris classification of physeal fractures Type A (Salter-Harris types I & II) The fracture line does not involve the germinal zone of the physeal plate. If a proper reduction is carried out, no growth disturbance is to be anticipated, although exceptions exist.(3,4)

Type B (Salter-Harris types III & IV) The fracture line crosses the epiphysis and the germinal zone of the physeal plate. An absolutely accurate, watertight reduction must be achieved, otherwise partial closure, with resultant eccentric growth disturbance, is to be anticipated. In addition, these injuries involve the articular surface and malunion can produce later joint degeneration. At the distal femur, ligamentous avulsion of an osteochondral block spanning the edge of the physis may occur: growth arrest is likely unless perfect reduction is achieved. Open abrasive injury of the periphery of the physis, resulting in destruction of the zone of Ranvier, usually results in local growth arrest.(3,4)

Type C (Salter-Harris type V) Compression of the physeal cartilage with impaction of epiphyseal bone into the metaphysis
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results in severe damage to the growth area and partial, or complete, closure of the epiphyseal plate with consequent growth disturbance is to be anticipated. Ogden has proposed a most detailed and comprehensive classification, but in some ways this is not necessarily prospective, in as much as the assignment of some injuries to certain groups requires the observation of the behaviour of the physis over a period of time after injury. (3,4) Types VI-IX Rare types of Salter-Harris fractures include the following: (4)

Type VI - Injury to the perichondral structures Type VII - Isolated injury to the epiphyseal plate Type VIII - Isolated injury to the metaphysis, with a potential injury related to endochondral ossification

Type IX - Injury to the periosteum that may interfere with membranous growth

Preferred examination
Currently, two radiologic examinations can be performed to further evaluate fractures(4) (1) CT scanning with multiplanar reconstruction whereas CT shows cross-sectional bone detail and tomographic multiplanar information. (2) magnetic resonance imaging (MRI). MRI depicts marrow edema. MRI is not the standard of care.

CT is used more commonly; typically, it is used for planning surgery. The use of point-of-care ultrasonography in the emergency department setting could correctly diagnose Salter-Harris fractures. Findings of periosteal fluid at the level of the metaphysic and widening of the physis allowed for the diagnosis of a fracture.

Radiographic findings vary according to the type of Salter-Harris fracture.

Type I fracture: Initial radiographs may suggest separation of the physis, but this separation may not be apparent. However, soft-tissue swelling is present, and its center typically overlies the physis. Follow-up radiographs obtained 7-10 days after injury help establish the diagnosis. New bone growth (adjacent sclerosis and periosteal reaction) along the epiphyseal plate confirms the diagnosis of a Salter-Harris type I fracture. (4) Type II fracture : The fracture line passes through the metaphysis into the epiphyseal plate, but no fracture is observed in the epiphysis. The metaphyseal fragment is sometimes called the ThurstonHolland fragment.(4)

FIGURE 4 : Salter-Harris type II fracture of the distal tibia

Type III fracture: Passes through the hypertrophic layer of the physis and extends to split the epiphysis. The fracture crosses the physis and extends into the articular surface of the bone.(4)

FIGURE 5 : Salter-Harris type III fracture of the distal tibia

Type IV : Fracture passes through the epiphysis, physis, and metaphysis. Similar to a type III fracture, a type IV fracture is an intra-articular injury. (4) Type V: injury, initial plain radiographs may not show a fracture line, similar to images of type I fractures. However, soft-tissue swelling at the physis is present. A compression or crush injury of the epiphyseal plate is present without associated epiphyseal or metaphyseal fracture. (4)

Treatment of fractures in children

1. Closed treatment The majority of fractures in children and adolescents will be treated by closed reduction and casting or traction. The only way to splint and hold reduction is by applying a wellmolded cast. Most fractures heal in a few weeks, and since children cannot be relied on to tell the doctor about pain, sensory alteration, circulatory disturbances, or other signs of impending complications, regular and competent clinical observation is required. The cast
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should be applied only when the fracture has been satisfactorily reduced. The well-padded circular cast with three point moulding is the only splintage that is safe enough for the treatment of fractures in children. The circulation and neurological status distal to the fracture must be checked frequently and thoroughly. (5,6)

2. Open treatment Indications for surgical treatment of fractures in children include(5,6) Open fractures. Polytrauma. Patients with head injuries. Femoral fractures in adolescents. Femoral neck fractures. Certain types of forearm fractures. Certain types of physeal injuries. Fractures associated with burns.

Aims of surgical treatment

As in the adult, open fractures are surgical emergencies and must be treated aggressively to prevent infection and possible permanent disability. Tscherne and Gotzen divided the management of open fractures into four priorities(5) 1) life preservation 2) limb preservation 3) avoidance of infection 4) preservation of function. In children, however, all efforts should be made to salvage limbs, unless all of the major nerves to the extremity are irreparably damaged.

Types of fixation
The aim of internal fixation in children is to obtain an anatomical reduction and to maintain it using a minimum amount of metal. External splintage can be used postoperatively without the risk of fracture disease. 3.5 mm cortex screws, 4.0 mm cancellous bone screws
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(exceptionally 6.5mm), and cannulated screws have been used in the treatment of periarticular and articular fractures. K-wire fixation of epiphyseal and metaphyseal fragments is often all that is necessary for internal fixation, as the hard cancellous bone in children affords excellent purchase.(6) Physeal plates may, if necessary, be crossed by K-wires, but never by lag screws unless growth is nearly complete. Transphyseal wires should be non-threaded, inserted by hand and directed, as far as possible, perpendicular to the growth plate. K-wires can be used percutaneously to maintain a reduction that cannot be held by closed methods. Multiple drilling and insertion of several K-wires at the same point must be avoided. K-wires can be left protruding through the skin and removed at 2-3 weeks as the bone heals rapidly. Alternatively, interfragmentary screws can be used parallel to the physeal plate, either in the metaphysis or the epiphysis, or both. This method is recommended in severely displaced epiphyseal fractures (type B) as it produces a so-called watertight reduction.(6) The disadvantage of screw fixation is the necessity for a second operation to remove the metal. On the other hand, the drawback of using percutaneous wires is the increased risk of infection. If growth disturbance occurs as a result of a bony tether across the physis, resection and the interposition of fat, or cold-curing bone cement, may restore normal growth External fixation devices are the preferred method for patients with open fractures, polytrauma, and fractures associated with burns. The size of the child will determine whether the large or the small fixator is used. In the application of the external fixator great care must be exercised not to damage the growth plate.(6)

Treatment and results

Gentle reduction should be attemped initially for Salter Harris I and II fractures, sometimes using conscious sedation protocols. With reduction and immobilization, these fractures will do well without significant amount of growth arrest (except in the distal femur ). Salter Harris III and IV fractures are intra-articular by definition and usually require ORIF. Follow up radiographs are required for all physeal injuries.(7) When fractures are minimally displaced, simple immobilization is sufficient therapy. Type I, II, and III physeal fractures that are displaced are usually treated by closed reduction. Type IV and V physeal fractures with 2 mm or greater displacement at the articular surface require open reduction and internal fixation to prevent joint incongruity and traumatic
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arthropathy. Type VI fractures are, by definition, open fractures, and they require immediate dbridement, irrigation, and appropriate soft tissue closure. Physeal bars always develop after this injury, and reconstructive surgery (ie, excision of the physeal bar, realignment osteotomy, or both) is needed if significant growth remains.(7)

COMPLICATIONS
Complications unique to pediatric fractures include the following:

Complete growth arrest: This may occur with physeal injuries in Salter-Harris fractures. It may result in limb length inequalities necessitating the use of orthotics, prosthetics, or operative procedures including epiphysiodesis or limb lengthening.(8)

Progressive angular or rotational deformities: They may result from physeal injuries with partial growth arrest or malunion. If these result in significant functional disabilities or cosmetic deformity, they may require operative intervention, such as osteotomy, for correction.(8)

Osteonecrosis: May result from disruption of tenuous vascular supply in skeletally immature patients in whom vascular development is not complete (e.g., osteonecrosis of the femoral head in cases of slipped capital femoral epiphysis).(8)

Types and prognosis (9)

Type Description I Transverse physis Fractures through the physis, with metaphyseal fragment fractures through the Prognosis Excellent

II

Excellent

III

Fractures through the physis and Good but with the potential for intra-articular epiphysis Fractures through the epiphysis, deformity; may require ORIF Good but unstable; fragment requires ORIF

IV

physis, and metaphysis

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Type Description V VI Crush injury to the physis Injury to the perichondrial ring

Prognosis Poor, with growth arrest Good; may cause angular deformities

ORIF, open reduction with internal fixation

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CHAPTER III
CONCLUSION
The higher incidence of fractures in children is explained by combination of their relatively slender bones and their carefree capers. Some of this injuries, such as crack or hairline fractures, buckle fractures, and greenstick fractures, are not serious.others, such as intra-articular fractures and epiphyseal plate fractures, are very serious indeed. In children not yet walking who have a fracture or joint injury, you must consider the possible but tragic diagnosis of child abuseThere are two special types of fractures that are limited to childhood, namely, fractures that involve the epiphyseal plate and birth fractures. There are five type of Salter-Harris Fracture Type A (Salter-Harris types I & II). The fracture line does not involve the germinal zone of the physeal plate. Type B (Salter-Harris types III & IV) The fracture line crosses the epiphysis and the germinal zone of the physeal plate. Type C (Salter-Harris type V) Compression of the physeal cartilage with impaction of epiphyseal bone into the metaphysic results in severe damage to the growth area and partial, or complete, closure of the epiphyseal plate with consequent growth disturbance is to be anticipated. Currently, two radiologic examinations can be performed to further evaluate fractures which are CT scan and MRI. Treatment depends on the type of fracture. Complications unique to pediatric fractures include Complete growth arrest, Progressive angular or rotational deformities, Osteonecrosis. The prognosis depends on types of fracture, good management and traement and also the complications.

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REFERENCES
1. Robert BS, Text book of Disorders and Injuries of the Muskuloskeletal System 3rd Ed. 2008. Chapter 15 2. Koval, Kenneth, joseph D. Handbook of Fractures. 3rd ed. Lippincott William 2008 3. Mary J.C, Denise R, What do you need to know about Salter-Harris fractures, article. ED insider 4. http://emedicine.medscape.com/article/412956-overview#923. 5. Ruedi TP, Murphy WM. AO Principles of Fracture Management. AO Publishing : 680-2 6. David W, Selvadurai N; Apleys System of Orthopaedics and Fractures. 9th ed. UK company 2010 7. Walter B.G, Netters Orthopaedics 1st ed. Elsevier 2006 8. Robert BS, Text book of Disorders and Injuries of the Muskuloskeletal System 3rd Ed. 2008. Chapter 15 9. Miller M.D, Review of Orthopaedics 5th ed. Elsevier 2008 10. Aydin A, Topal M, salter harris type III and type IV combined fracture of the distal femoral epiphysis, Case report in medicine. Vol 2012. Hindawi publishing 2012

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