This 2016 review covers the Salter-Harris classification of pediatric physeal fractures, originally described in 1963. It examines the anatomic and histologic basis of all five fracture types, subsequent classification attempts, and the system's known limitations as a prognostic tool. Physeal fractures represent 15–18% of all pediatric fractures.
The Salter-Harris classification gives you the language to describe a physeal injury, but treating it as a management algorithm is where trainees go wrong. When you see a distal femoral physeal fracture, counsel the family that arrest risk approaches 40% regardless of fracture type. Your reduction quality predicts outcome more than the SH designation.
For Types III and IV, anatomic reduction is non-negotiable. Both exit through the epiphysis, threatening the articular surface and the proliferating cell layer's blood supply. A malreduced Type IV can form a transphyseal bony bar, producing asymmetric growth.
At the femoral head and radial head, even a Type I carries real devascularization risk. These epiphyses have no periosteal blood supply — vasculature crosses the physeal rim from the metaphyseal side and is easily torn by shear forces.
When displacement is uncertain on plain film, get advanced imaging. Plain radiographs consistently underestimate physeal displacement, and CT or MRI can change the classification and the operative plan.
This 2016 review covers the Salter-Harris classification of pediatric physeal fractures, originally described in 1963. It examines the anatomic and histologic basis of all five fracture types, subsequent classification attempts, and the system's known limitations as a prognostic tool. Physeal fractures represent 15–18% of all pediatric fractures.
The Salter-Harris classification gives you the language to describe a physeal injury, but treating it as a management algorithm is where trainees go wrong. When you see a distal femoral physeal fracture, counsel the family that arrest risk approaches 40% regardless of fracture type. Your reduction quality predicts outcome more than the SH designation.
For Types III and IV, anatomic reduction is non-negotiable. Both exit through the epiphysis, threatening the articular surface and the proliferating cell layer's blood supply. A malreduced Type IV can form a transphyseal bony bar, producing asymmetric growth.
At the femoral head and radial head, even a Type I carries real devascularization risk. These epiphyses have no periosteal blood supply — vasculature crosses the physeal rim from the metaphyseal side and is easily torn by shear forces.
When displacement is uncertain on plain film, get advanced imaging. Plain radiographs consistently underestimate physeal displacement, and CT or MRI can change the classification and the operative plan.