Volume 1, Case 18 Answers

This radiograph shows a tiny fracture of the ulnar styloid. The AP view is otherwise unremarkable. The patient had point tenderness over the dorsum of the radial physis. The lateral view shows a displaced radial epiphysis. On careful inspection, you can see that the radial epiphysis is not centered over the metaphysis. The radial epiphysis is slightly displaced dorsally with respect to the metaphysis. No fractures of the epiphysis or the metaphysis are visible. Since the fracture is strictly through the physis, this is a Salter-Harris type I fracture.

An SH-II fracture occurs through the physis and metaphysis (M).

See SH-II example.

SH-II

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This radiograph shows a fracture of the distal ulna and radius. The radius fracture extends from the metaphysis into the physis. The physis appears to be slightly widened consistent with SH-II.

An SH-III fracture occurs through the physis and epiphysis (E). Since this fracture often involves the articular surface, this injury is more prone to chronic disability if anatomic realignment is not achieved.

See SH-III example.

SH-III

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This radiograph shows a fracture of the distal tibia over the articular surface into the epiphysis and physis.

An SH-IV fracture is a contiguous fracture through the metaphysis, physis, and epiphysis. This fracture often involves the articular surface, making this a high-risk injury for chronic disability as in SH-III injuries.

See SH-IV example.

SH-IV

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This radiograph shows a fracture of the medial malleolus extending from the inferior articular surface of the tibial epiphysis through the physis and extending through the metaphysis.

An SH-V fracture is a crush injury of the physis. This may be radiographically visible as a narrowing of the growth plate lucency; however, it is most often not radiographically visible.

See SH-V example.

SH-V

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This patient fell off a second story balcony onto her feet. The radiographs show several fractures within the body of the calcaneus. A Salter-Harris type V injury of the distal tibia was suspected because of the mechanism of injury. However, this type of injury is rarely visible on initial radiographs. The injury must be suspected clinically. Subsequent growth arrest of this area confirms the presence of the Salter-Harris type V injury.

Comparison views of the non-affected extremity may assist in radiographically diagnosing a SH-V type injury at initial presentation. Based on this comparison view, differences in the width of the growth plates may be evident. A complete obliteration or diminished physeal distance of the affected extremity confirms the diagnosis of a SH-V injury. However, even if there are no obvious differences on the comparison view, or if a comparison view is not obtained, or if both extremities are injured, the patient should be treated as a possible SH-V injury if the mechanism of injury suggests an axial compression along the long axis of the bone, and the patient exhibits tenderness along the physeal region.

References

Bachman D, Santora S. Orthopedic Trauma. In: Fleisher GR, Ludwid S (eds). Textbook of Pediatric Emergency Medicine, third edition. Baltimore, MD, Williams and Wilkins, 1993, pp. 1237-1238.

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 Loren Yamamoto, 
      MD, MPH Associate Professor of Pediatrics University of Hawaii John A. Burns 
      School of Medicine loreny@hawaii.edu