Salter Harris Classification

and management of
epiphysiolisis
Dita Anggara K

Zone Of Physis

The blood
supply of
the physis
is from
three
sources:
the
epiphyseal
circulation
, the
metaphys
eal
circulation
, and the
perichondr
ial

Type A,
The epiphysis is nearly entirely
covered by articular cartilage.
Type B,
The epiphysis is only partially covered
by articular cartilage.

Proximal femur
Proximal humerus

Distal femur
Proximal & distal tibia
Distal radius

Zone of Ranvier is a wedge-shaped group

of germinal cells that is continuous with
the physis
Perichondral Ring Of La Croix is a fibrous
structure that is continuous with the
fibroblasts of the zone of Ranvier and the
periosteum of the metaphysis.

Mechanism Of Injury
In infancy and early childhood, when the physis is
relatively thick, shearing or avulsion forces are most
commonly involved.
In older children and adolescents, physeal fractureseparation is most often caused by a combination of
shearing and angular forces.
Near the end of skeletal growth, when part of the physis
has closed, intra-articular shearing forces, with or
without angular forces, may lead to an intra-articular
fracture.

Salter Harris
Classificatio
n

Salter Harris I

injury with
physeal
separation
through the
zone of
hypertrophic
cells.

Salter Harris II
injury is
similar to
type I but
has a
metaphyseal
spike.

Salter Harris III

injury with
physeal
separation and
extension
across the
epiphysis into
the joint.

Salter Harris IV

injury with a
metaphyseal
spike; the physis
and epiphysis are
both involved.

Management of Epiphysiolisis
based on Salter Harris
Classification

Type I
Type I injuries (separation of the epiphysis from the
metaphysis) can usually be treated by closed reduction
and casting because the periosteal sleeve is generally
intact.
At sites where the periosteum is thin (such as the femur
or radius), internal fixation may be required after open
or closed reduction.

Type II
fracture-separation of the epiphysis, fracture of the
metaphysis can usually be managed by closed
reduction by using the intact hinge of periosteum.

Type III and IV

require anatomic reduction, usually involving open
reduction and internal fixation with smooth pins that
avoid the physis.
Foster and co-workers recommended the "anticipatory
Langenskiold" procedure for acute physeal injuries in
which growth arrest is expected.
They suggested that this measure might avoid the
standard surgical procedures, such as osteotomies, that
are used to treat the results of growth arrest.

Type V
Type V (compression) fractures are rarely diagnosed
acutely, and treatment is delayed until the development
of a bony bridge across the physis is apparent.

Undisplaced #

Displaced #

Type 1
Type 2

-splitting in a cast or closed

fitting plaster slab for 2-4
weeks

-closed manipulative reduction

-splinted for 3-6 weeks

Type 3
Type 4

-similar to type 1 / 2
-check xray at 4th and 10th day
so not missed late
displacement

-CMR under GA
then cast for 4-8 weeks or
-immediate open reduction and
internal fixation then splint 4-6
weeks

Type 5

-rarely diagnose early, until the formation of a physeal bar across

the physis 6 month after injuries
-physeal bar resection may be required or other surgical
procedures in order to prevent or to correct deformity

 A cancellous screw
should be placed in the
epiphysis only, parallel to
the physis.
Smooth pins may cross
the physis

Case: Proximal Tibia

Case:
Proximal
Femur

Case: Distal Tibia

Case: Proximal Humerus

Complication
TYPE

COMPLICATION

Type I &
Type II

usually excellent prognosis

if misdiagnosed/remain unreduced
causes malunion/ non union

Type III &

Type IV

premature fusion of part of the growth

plate
asymmetrical growth of the bone end
(varus/ valgus deformity)

Type V

premature fusion
growth retardation

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