Salter-Harris fractures


  • The higher the classification, the higher the likelihood of growth abnormalities
  • If physis fracture missed may lead to premature closure and bone growth arrest
  • It was previously taught that ligaments are stronger than bones in kids (and fractures were more likely than sprains), however newer studies (to date in ankles) contradict that assumption[1]


  • S 1 - Slipped (through physis/growth plate)
  • A 2 - Above (physis with metaphysis fracture)
  • L 3 - Lower (physis with epiphysis fracture)
  • T 4 - Through (physis, metaphysis and epiphysis fracture)
  • R 5 - Rammed (growth plate crushed)

Fracture Chart

Type I (Slip) II (Above) III (Below) IV (Through) V (Crush)
Fracture Locationhypertrophic zone of physis (epiphysis separates from metaphysis)Through physis and out through piece of metaphyseal boneIntra-articularStarts at articular surface and extends through epiphysis, physis, metaphysisPhysis compression
PathophysiologyGrowing cells remain on the epiphysis in continuity with blood supplyGrowing cells remain on the epiphysis in continuity with blood supplyfracture extends from epiphysis through physis
EpidemiologyOccurs mostly in infants and todlersMost common type of fractureTypically occurs at knee or ankle
PrognosisGoodGoodModerateModerateHighest chance of growth arrest

Clinical Features

  • Trauma with point tenderness over a non-closed (pediatric) physis

Differential Diagnosis

  • Sprain
  • Contusion
  • Other fracture


Type 1 (Slip)

  • Suspect if point tenderness over a physis
  • X-ray findings are subtle (epiphyseal displacement) or absent (clinical diagnosis)

Type 2 (Above)

  • X-ray shows triangular fragment of metaphysis with out injury to epiphysis

Type 3 (Below)

  • X-ray shows epiphyseal fragment not associated with etaphyseal fracture
  • Greater the displacement greater chance of vascular supply compromise

Type 4 (Both)

  • fracture starts at articular surface and extends through epiphysis, physis, metaphysis

Type 5 (Crush)

  • X-ray shows physis compression fracture
    • May confuse for Type 1 injury
    • X-ray findings may be minimal


General Fracture Management

Type I

  • Most: Splint, ortho follow up
  • Lateral ankle:
    • Removable ankle brace
    • Return to activities as tolerated by pain
    • No ortho followup

Type II

  • Most: Splint, ortho follow up
  • Ankle: Removable ankle brace[2]

Type III-V

  • Splint, ortho consult


  • Outpatient

See Also


  1. Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Joint Surg Am. 2012; 94(13):1234-1244.
  2. . Boutis K, Willan AR, Babyn P, Narayanan UG, Alman B, Schuh S. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007;119(6): e1256-e1263.
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