Emergency Medicine Hub / Pediatrics & Obstetrics • 3 min read • 2 sections

Pediatric Fractures & Salter-Harris Classification

Comprehensive emergency evaluation and protocolized orthopedic management of pediatric skeletal fractures: unique bone biomechanics (thick periosteum, high porosity, open physis), incomplete fractures (torus/buckle, greenstick, plastic deformation/bowing), the Salter-Harris physeal fracture classification (SALTR mnemonic: Slipped, Above, Lower, Through, Rammed/Ruin), supracondylar humerus fractures (Gartland types I-III, anterior humeral line, teardrop, Volkmann ischemic contracture), and nursemaid's elbow reduction.

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High-Acuity

Salter-Harris SALTR Mnemonic

I: Slipped (physis only), II: Above (metaphysis), III: Lower (epiphysis), IV: Through (meta+physis+epi), V: Rammed (crushed physis)

Salter I Clinical Rule

Normal radiograph + point tenderness directly over growth plate = Salter-Harris Type I fracture until proven otherwise; SPLINT AND IMMOBILIZE

Supracondylar Gartland III

Complete displacement; high risk of brachial artery laceration and Volkmann ischemic contracture; STAT emergent orthopedic consult for OR pinning

Anterior Humeral Line

Lateral elbow X-ray: a line drawn down the anterior cortex of the humerus must pass through the MIDDLE THIRD of the capitellum; if anterior, fracture present

Fat Pad Signs (Elbow)

Posterior fat pad is ALWAYS pathologic (occult intra-articular fracture); elevated anterior fat pad ('sail sign') also indicates effusion/hemarthrosis

Nursemaid's Reduction

Hyperpronation technique has higher first-attempt success than supination-flexion; audible/palpable click confirms annular ligament reduction

Bottom-Line Clinical Pearl

Children's bones have open cartilaginous growth plates (physes) that are mechanically weaker than surrounding tendons and ligaments; an injury that causes a ligament sprain in an adult almost always causes a physeal fracture in a child. Classify physeal fractures using Salter-Harris: Type I (Straight across physis; X-rays often normal, diagnose by point tenderness over physis), Type II (Above physis into Metaphysis; #1 most common [75%], Thurston-Holland fragment), Type III (Lower than physis into Epiphysis), Type IV (Through all three: Metaphysis, Physis, Epiphysis), Type V (Rammed/crush injury; worst prognosis for growth arrest). Supracondylar humerus fractures carry severe neurovascular risk (anterior interosseous nerve [AIN], radial, median nerves, and brachial artery); Gartland III fractures require emergent closed reduction and percutaneous pinning.

1. The Salter-Harris Classification of Physeal Fractures

The epiphyseal growth plate (physis) consists of cartilaginous zones: resting, proliferative, hypertrophic, and calcification. The hypertrophic zone is mechanically the weakest layer, lacking dense collagen and matrix, making it the primary plane of cleavage in pediatric skeletal trauma.

Salter-Harris Type	Anatomical Plane of Fracture	Radiographic Features	Prognosis & Emergency Management
Type I (S = Slipped)	Transverse fracture through the hypertrophic zone of the physis only; epiphysis is separated from metaphysis	Often completely normal plain X-rays (cartilage is radiolucent). May see widening of physis.	Excellent prognosis. If point tenderness is present directly over the physis following trauma, treat as a fracture: immobilize in a splint and follow up in 7–10 days.
Type II (A = Above)	Physis + triangular wedge of Metaphysis (Thurston-Holland fragment); spares epiphysis	Most common (75%). Metaphyseal triangular bone fragment visible on X-ray.	Excellent prognosis. Closed reduction and splint immobilization; rarely causes growth arrest because germinal cells are spared.
Type III (L = Lower)	Physis + intra-articular Epiphysis; spares metaphysis	Intra-articular fracture line extending from joint surface through epiphysis into physis.	Guarded prognosis. Intra-articular step-off mandates anatomic reduction (often ORIF) to prevent joint incongruity and angular deformity.
Type IV (T = Through)	Transverse fracture crossing all three zones: Metaphysis, Physis, and Epiphysis	Vertical fracture line visible extending from metaphysis across physis through epiphysis into joint.	High risk of premature physeal arrest and limb length discrepancy. Requires operative anatomic reduction and internal fixation.
Type V (R = Rammed/Ruin)	Severe axial crush/compression injury to the physis destroying germinal cells	Initial radiographs often normal or subtle physeal narrowing; diagnosis frequently retrospective.	Worst prognosis (100% growth arrest); leads to premature fusion and severe angular deformity or limb shortening.

2. Supracondylar Humerus Fractures & Gartland Staging

Supracondylar fractures of the distal humerus account for 60% of all pediatric elbow fractures (peak age 5–7 years, fall on outstretched hand with elbow in hyperextension):

Gartland Stage	Anatomic Displacement	Radiographic Findings	Emergency Treatment
Type I	Non-displaced	Normal cortex; positive posterior fat pad and/or anterior 'sail sign'; Anterior Humeral Line (AHL) passes normally through middle third of capitellum.	Long-arm posterior splint with elbow at $90^\circ$; orthopedic follow-up in 3–5 days.
Type II	Displaced with intact posterior cortex (angulated)	AHL passes anterior to the middle third of capitellum; posterior cortex remains hinged.	Closed reduction and long-arm splinting vs. percutaneous pinning.
Type III	Completely displaced with total cortical disruption	Complete posterior or posteromedial/posterolateral displacement of distal fragment.	Emergent Surgical Reduction & Pinning (OR). Check radial pulse and median/AIN/radial nerve function before and after splinting.

Critical Pitfall / Contraindication

THE 'PINK, PULSELESS HAND' IN SUPRACONDYLAR FRACTURES: If the radial pulse is absent but the hand is warm, pink, and capillary refill is < 2 seconds, do NOT manipulate the arm with acute flexion. Gentle traction in slight extension often restores the pulse. If the hand is cold, pale, or pulseless, this is a surgical vascular catastrophe (brachial artery entrapment/transection) requiring immediate operative exploration and reduction within 2 hours to avoid Volkmann's ischemic contracture.

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