Epihyseal fractures classification
Approximately 10% of long bone injuries in patients under the age of 16 years involve the epiphyseal growth plate (physis). This is important as injuries to the growth plate may result in shortening or deformity of the growing bone.
Anatomy[1]:
Epiphyses consist of the epiphyseal bone plate with the articular surface and the epiphyseal growth plate. Growth of long bones is achieved by division of chondrocytes within the germinal layer of the growth plate, which proliferate towards the metaphyseal side. The cartilaginous matrix hypertrophies, degenerates and mineralises in the zone of transformation after which vascular penetration and osteogenesis begins and this eventually becomes the bony metaphysis. Classification of epiphyseal fractures is based on the degree of involvement of the germinal matrix and allows categorisation according to the radiographic appearances as well as the prognosis. The most commonly used classification is the Salter-Harris classification [2], others have been described (e.g. Aitken classification [3] used in Germany) but are not internationally recognised.
Diagnosis:
Epiphyseal plate injury should be suspected in any child with injuries to joints, be it fracture, dislocation, ligamentous rupture or even simple sprains. Factors affecting the prognosis of epiphyseal plate injuries include the mechanism of this, the age of the child at the time of injury, the blood supply to the epiphysis, the method of reduction and the extent of soft tissue injury (e.g. compound fracture). Significant disturbance of growth occurs in approximately 10% of epiphyseal plate injuries. Minor disturbances, which are not clinically relevant, occur more frequently.
Good quality radiographs are crucial. A minimum of two views obtained at right angles to each other is essential. If doubt exists comparison views of the other limb may be useful. The diagnosis of separation of an epiphysis before its ossification centre has appeared is very difficult, but this may be suspected if there is mal-alignment of the metaphysis and significant soft tissue swelling.
Salter-Harris Type I (Fig. 2)
This amounts to approximately 6% of epiphyseal plate injuries. Type I injuries occur usually below the age of 5 years and may be seen in the context of birth trauma. The epiphysis is completely separated from the metaphysis. This is a result of shearing or avulsion force causing a transverse fracture of the zone of transformation. The germinal matrix is preserved in its entirety on the epiphyseal side. The periosteum is intact and the fracture may reduce immediately and therefore be difficult to spot. If reduction is required, this is usually not difficult due to the continuity of the periost. The prognosis for future growth is excellent unless the epiphysis involved is entirely covered by cartilage (e.g. upper femoral epiphysis). Type I injuries may also be seen in the context of scurvy, rickets, osteomalacia and other endocrine abnormalities.
Salter-Harris Type II (Fig. 3)
This is by far the commonest form of epiphyseal plate injury, amounting to approximately 75%. Peak incidence is at an age between 10 and 16 years.
The fracture line runs across the zone of transformation and extends into the metaphysis removing a triangular metaphyseal fragment (Thurston-Holland’s sign). This is also usually due to shearing or avulsion; however, the periosteum in this case is torn on the convex side of the angulation. Reduction is easy due to the intact ‘periosteal hinge’. The physis itself is again intact remaining attached to the epiphysis with the metaphyseal fragment. Prognosis for growth is therefore excellent assuming that the blood supply remains intact.
Salter-Harris Type III (Fig. 4)
Approximately 8% of epiphyseal plate injuries are type III. Peak incidence is between 10 – 15 years. This is an intra-articular fracture running from the joint surface through the germinal matrix and then extending along the metaphyseal side of the growth plate to the periphery of the bone. The periosteum remains intact, however as the fracture traverses the growth plate accurate reduction is essential and open reduction may be required. If good alignment of the fragments is achieved prognosis regarding growth is reasonably good; bearing in mind that the fracture also involves an articular surface. The commonest sites are the distal tibia, proximal tibia and distal femur.
Salter-Harris Type IV (Fig. 5)
These are approximately 10% of all epiphyseal plate injuries. An oblique intra-articular fracture extends from the joint surface through the epiphysis across the full thickness of the epiphyseal plate into the metaphysis. Accurate reduction is vital to try to preserve normal growth, as well as reconstructing a smooth joint surface. Open reduction and internal fixation is frequently required. There is a relatively high risk of bony re-union occurring across the growth plate, which will prevent normal symmetrical growth in the future. Type IV injuries are most commonly seen at the lateral condyle of the humerus.
Salter-Harris Type V (Fig. 6)
Approximately 1% of epiphyseal plate injuries are type V. Fortunately, this is the rarest of injuries to the growth plate, as it is difficult to diagnose and to treat. It is a consequence of compression trauma to the growth plate resulting in crushing of the germinal matrix and its vascular supply. It usually occurs in joints with a uniplanar range of movement (i.e. knee) submitted to forced ab- or adduction, which squashes the epiphyseal plate. Direct axial trauma may also result in this type of injury. There is no fracture as such and no direct radiographic signs to alert to this type of injury. It is commonest in adolescence and frequently dismissed as sprain. The prognosis of type V injuries is decidedly poor and premature cessation of growth is almost inevitable. There is no specific treatment.
For further reading the excellent chapter in Resnick’s ‘Diagnosis of Bone and Joint Disorders’ is recommended.
Epiphyseal fracture classification
From the provided images, a clear fracture line can be seen in the region of the growth plate (physis). The fracture line traverses the growth plate and extends into the metaphysis, where a small triangular bone fragment is visible at the distal metaphysis. Mild to moderate local soft tissue swelling is observed. The articular surface is essentially intact, with no evident extension of the fracture line into the joint. No significant pathological changes are noted in the bone near the growth plate.
Based on the radiological findings described above and the common characteristics of growth plate injuries in adolescents (usually 10–16 years old), the following types of epiphyseal injuries should be included in the differential diagnosis:
Considering the clear fracture line crossing the growth plate along with a metaphyseal fragment observed in this case, Salter-Harris II is the most likely diagnosis. Other types can be considered but do not fully align with the imaging characteristics or the patient’s age.
Taking into account the patient’s adolescent age range, the radiological features of the fracture line, the triangular metaphyseal fragment (Thurston-Holland sign), and the continuity of the growth plate, the most likely diagnosis is Salter-Harris Type II physeal injury.
Treatment Strategies:
Rehabilitation and Exercise Prescription (FITT-VP Principle):
During the reduction, fixation, and early healing stage, rest and protective weight-bearing are essential. After removing the fixation, gradually restore joint range of motion and muscle strength. For example:
Throughout the rehabilitation process, close monitoring of the growth plate healing and the child’s overall growth and development is crucial. Regular radiological assessments are recommended to rule out premature physeal closure or malunion.
Disclaimer:
This report provides a reference medical analysis and does not replace professional clinical diagnosis or in-person consultations. If you have any doubts or if symptoms worsen, please seek medical attention and follow a specialist’s advice.
Epiphyseal fracture classification
