SALTER HARRIS FRACTURE

A. Definition: fracture that involves the growth plate of a bone

B. Epiphyseal Plate
The growth plate, also known as the epiphyseal plate or physis, is the area of
growing tissue near the ends of the long bones in children and adolescents. Each long
bone has at least two growth plates: one at each end. When growth is complete, the
growth plates close and are replaced by solid bone.

C. Physis Zone
Reserve/resting zone - This zone is immediately adjacent of the epiphysis and
consists of irregularly scattered chondrocytes with low rates of proliferation; this
layer supplies developing cartilage cells and stores necessary materials (lipids,
glycogen, proteoglycan aggregates) for later growth, and injury to this layer
results in cessation of growth
Proliferative zone - Chondrocytes are flattened and stacked upon each other in
well-defined columns; these cells produce necessary matrix and are responsible
for longitudinal growth of the bone via active cell division
Hypertrophic zone - Cells increase in size, accumulate calcium within their
mitochondria, and deteriorate, ultimately leading to cell death, upon which event
calcium is released from matrix vesicles, impregnating the matrix with calcium
salt; no active growth occurs in this layer, and columns of cells extending toward
the metaphysis are at various stages of maturation; this is the weakest portion of
the physis and is commonly a site of fracture or alteration (eg, widening, as in
rickets)

D. Salter Harris Type

Type I
A transverse fracture through the hypertrophic zone of the physis. In this injury, the
width of the physis is increased. The growing zone of the physis usually is not injured,
and growth disturbance is uncommon. On clinical examination, the child has point
tenderness at the epiphyseal plate, which is suggestive of a type I fracture. Cannot
occur if the growth plate is fused

Type II
The most common type of Salter-Harris fracture, a type II fracture. Occurs through the
physis and metaphysis; the epiphysis is not involved in the injury. These fractures may
cause minimal shortening. The injuries rarely result in functional limitations.

Type III
A type III fracture is a fracture through the physis and epiphysis. Passes through the
hypertrophic layer of the physis and extends to split the epiphysis, inevitably damaging
the reproductive layer of the physis. This type of fracture is prone to chronic disability,
because by crossing the physis, the fracture extends into the articular surface of the
bone. Rarely result in significant deformity. The treatment is often surgical.

Type IV
A Type IV involves all 3 elements of the bone, passing through the epiphysis, physis,
and metaphysic. Similar to a type III fracture, a type IV fracture is an intra-articular
fracture; thus, it can result in chronic disability. By interfering with the growing layer of
cartilage cells, these fractures can cause premature focal fusion of the involved bone.
These injuries can cause deformity of the joint.

Type V
A type V injury is a compression or crush injury of the epiphyseal plate. No
associated epiphyseal or metaphyseal fracture. This fracture is associated with growth
disturbances at the physis. In the older teenagers, the diagnosis is particularly difficult
Type V injuries have a poor functional prognosis.

E. Treatment
Factors that affect treatment decisions: severity of the injury, anatomic location of the
injury, classification of the fracture, plane of the deformity, patient age, growth potential
of the involved physis. Most Salter-Harris I and II injuries can be treated with closed
reduction and casting or splinting and then reexamination. To avoid physeal damage,
efforts at reduction should focus more on traction and less on forceful manipulation of
the bone fragments

F. Prognosis
Angular deformities may also occur as a consequence of malreduction or partial growth
arrest. More proximal deformities of the lower extremity (in the hip) are better
compensated for than distal deformities. The age of the patient at the time of injury is of
paramount importance in helping predict clinical outcomes.
 G. Referensi
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0027349/
http://emedicine.medscape.com/article/412956-overview
http://emedicine.medscape.com/article/1260663-treatment
http://radiopaedia.org/articles/salter-harris-classification