Classification system
Salter-Harris Classification
Salter-Harris Classification of Physeal Fractures
The Salter-Harris classification grades fractures involving the growth plate into five types, from a fracture through the physis alone (type I) to a crush injury of the physis (type V), according to whether the fracture line also involves the metaphysis, the epiphysis, or both.
What the Salter-Harris category means
Salter-Harris scores run from 1 to 5, where a lower score is better. The bands below are conventional reporting categories, not diagnostic cut-offs.
- Extra-articular (types I–II)1–2
Does not cross the joint surface and spares the germinal layer. Usually closed reduction and immobilisation, with a low but not negligible rate of growth disturbance.
- Intra-articular (types III–IV)3–4
Crosses the articular surface and the germinal layer. Anatomical reduction, usually operative, and follow-up to physeal closure.
- Crush injury (type V)5–5
Highest risk of complete or partial growth arrest, and usually recognised only in retrospect.
Published criteria and reliability
The published cut-offs that define this instrument, and the measured agreement between observers using it. Each is reported with the population it was derived in.
| Type | Value | Subscale | Population | Follow-up | Source |
|---|---|---|---|---|---|
| Criterion | Physeal fractures account for roughly 15–30% of paediatric fractures | — | Children and adolescents, population-based series | — | Peterson HA 1994 |
| Criterion | Growth disturbance after distal femoral physeal fracture in approximately half of children, and common at every Salter-Harris type | — | Distal femoral physeal fractures, meta-analysis | — | Basener CJ 2009 |
| Criterion | Type II is the most common pattern | — | Paediatric physeal fractures, Olmsted County population-based series | — | Peterson HA 1994 |
Criterion is a published cut-off, definition or performance figure belonging to a classification or decision rule — it is not a change score and should not be read as one.
How the score is calculated
Stated in full so the calculation can be independently checked, and reproduced by hand if needed.
The type is read off the path of the fracture line. Type I passes through the physis alone, separating epiphysis from metaphysis with no bony fragment. Type II passes through the physis and exits through the metaphysis, producing a triangular metaphyseal (Thurston Holland) fragment. Type III passes through the physis and exits through the epiphysis into the joint. Type IV crosses metaphysis, physis and epiphysis in a single plane. Type V is an axial crush of the physis with no fracture line. The mnemonic SALTR follows the same order: Slipped, Above, Lower, Through, Rammed. Types I and II are extra-articular; types III and IV are intra-articular and cross the germinal layer, which is why they require anatomical reduction.
Missing data
All three findings must be established before a type can be assigned, with one exception: a crush injury of the physis is type V regardless of the other two answers, and those questions are then not applicable.
Instrument profile
- Developer
- Robert B. Salter and W. Robert Harris
- Institution
- Hospital for Sick Children, University of Toronto, Canada
- First published
- 1963
- Items
- 3
- Response format
- Branching radiographic assessment
- Score range
- 1 to 5
- Direction
- Lower score = better
- Completion time
- About 1 minutes
- Age range
- Skeletally immature children and adolescents, from infancy until physeal closure
- Regions
- Paediatric, General Health
- Conditions
- Physeal fracture, Growth plate injury, Paediatric fracture, Growth arrest, Physeal bar
- Procedures
- Closed reduction and cast immobilisation, Percutaneous pinning, Open reduction and internal fixation, Physeal bar resection
- Validity
- The type predicts growth disturbance only in broad terms. It holds well at sites such as the distal radius, where types I and II do well, and holds poorly at the distal femur, where growth disturbance is common at every type.
- Reliability
- Reliability is limited at the two ends of the scale: a type I injury can be radiographically indistinguishable from a normal physis, and a type V is almost never called prospectively.
- Floor effect
- A physeal injury with no radiographic abnormality cannot be graded at all, and is usually treated as a presumed type I on clinical findings.
Normative values
Reference values from published cohorts, for comparison against the score you calculated.
| Population | Age | Mean | SD |
|---|---|---|---|
| Peak incidence of physeal injury | Around 11–12 in girls and 13–14 in boys | The adolescent growth spurt, when the hypertrophic zone is thickest and the physis is mechanically weakest | — |
| Sex distribution of physeal fractures | — | Boys affected roughly twice as often as girls | — |
| Most frequent sites | — | Distal radius, followed by the phalanges and the distal tibia | — |
When to use the Salter-Harris
Well suited to
- Describing any fracture in a skeletally immature patient where the fracture line reaches the physis.
- Deciding whether anatomical reduction is required — types III and IV are intra-articular and cross the germinal layer.
- Setting the follow-up plan, since every physeal fracture needs review for growth disturbance until the risk period has passed.
Limitations and poor fits
- After physeal closure, where the growth plate is no longer a structural weak point and adult fracture classifications apply.
- As a prognosis on its own — the site of the injury, the energy involved and the adequacy of reduction carry more weight than the type.
- For patterns outside the original five, such as a perichondral ring injury or a physeal fracture combined with epiphyseal osteochondral damage; describe those rather than forcing a type.
Salter-Harris compared with other instruments
Instruments measuring a related construct, with the practical difference between them.
| Instrument | Items | Range | What it adds |
|---|---|---|---|
| Gartland | 2 | 1–4 | The Gartland classification grades extension-type supracondylar humerus fractures in children as type I when non-displaced, type II when angulated with the posterior cortex intact, type III when completely displaced with no cortical contact, and type IV when the fracture is unstable in both flexion and extension — a diagnosis that can only be made under fluoroscopy in theatre. |
| Gustilo-Anderson | 4 | 1–5 | The Gustilo-Anderson classification grades open fractures from type I to type IIIC by wound size, degree of soft tissue damage, contamination and vascular injury, and it is the system that drives antibiotic choice, debridement planning and the decision on soft tissue coverage. |
Copyright and permitted use
Published openly because it is the question every clinician and researcher asks before using an instrument, and almost nobody answers it.
A published radiographic classification system. No licence is required to apply or describe it.
References
- Salter RB, Harris WR. Injuries involving the epiphyseal plate. Journal of Bone and Joint Surgery (American). 1963.
- Rang M. The Growth Plate and Its Disorders. E & S Livingstone, Edinburgh (monograph). 1969.
- Ogden JA. Injury to the growth mechanisms of the immature skeleton. Skeletal Radiology. 1981.
- Peterson HA, Madhok R, Benson JT, Ilstrup DM, Melton LJ 3rd. Physeal fractures: Part 1. Epidemiology in Olmsted County, Minnesota, 1979–1988. Journal of Pediatric Orthopaedics. 1994.
- Basener CJ, Mehlman CT, DiPasquale TG. Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis. Journal of Orthopaedic Trauma. 2009.
Editorial status
This page has not yet been signed off by a named clinical reviewer. The scoring logic is stated in full above so it can be independently verified, and every threshold is traceable to its source. See our editorial methodology.