Bone fractures in children pose particular problems because they often occur at growth plates (legs, ankles, hips, feet, and wrists), where they can significantly affect future growth and function. These breaks also occur in different directions on the long bones and near joints, requiring careful identification to be properly reset. That’s why it’s essential to precisely diagnose the location and direction of the break to determine the necessary treatment and/or referrals.

‍The Salter-Harris Classification

The Salter-Harris classification is the most well-established tool for diagnosing the type and severity of fractures in children. Salter-Harris fractures are graded as Type I through V, with increasing severity and worsening prognosis with each grade level. 

• SH Type I goes through the physis or within the growth plate. This usually occurs due to longitudinal force extending through the physis, which then splits the epiphysis from the metaphysis. Soft tissue swelling may be present, and diagnosing the fracture is based on physical findings like focal point tenderness or swelling around the growth plate. The prognosis is good, but follow-up with an orthopedist is recommended.

• SH Type II goes entirely through the physis and continues into the proximal metaphysis, usually breaking off in a wedge shape. This is the most common type of growth-plate fracture, involved in about 75% of cases, mostly in children over age ten. An orthopedic consult is indicated. With proper treatment, full reunion can be accomplished (without surgery in some cases), and permanent damage is not likely.

• SH Type III cuts through the physis and also vertically into the joint space to produce an intra-articular fracture with a partially displaced fragment. A more severe injury than Type II usually occurs in children over age ten and often has a poor prognosis involving chronic disability. An immediate orthopedic consult should be ordered, and surgery may be necessary.

• SH Type IV fractures are complete intra-articular breaks going from the metaphysis through the physis and epiphysis into the joint space, requiring orthopedic consult and usually surgery to repair the injury. In addition, physical growth may be impaired.

• SH Type V are rare compression fractures resulting from excess axial load pressure on the physis. These injuries are hard to detect on X-ray and are often misdiagnosed, so an orthopedic consult is required for any suspicious fracture without clear delineation. The prognosis is generally poor, even with treatment, and growth inhibition or arrest is likely to occur.

For more information on growth plate fractures, go to The National Institute of Arthritis and Musculoskeletal and Skin Diseases’ website on growth plate injuries.