Physeal Fractures



  • Fracture of immature skeleton involving cartilaginous primary growth plate (physis)


  • Most fractures detected & managed by radiographs alone

    • Widening or interruption of normally uniform undulating lucent physis

    • Translation &/or angulation of bony fragment adjacent to physis with overlying soft tissue swelling

    • Persistent physeal widening > 3 mm post reduction suggests tissue entrapment requiring open reduction

  • CT: Helps evaluate comminution, displacement, articular surface “step-off,” loose intraarticular fragment(s)

  • MR: Can detect nondisplaced fractures, assess cartilaginous & soft tissue injury or entrapment

Top Differential Diagnoses

  • Incomplete fracture

  • Chronic physeal stress injury

  • Rickets

Clinical Issues

  • Peak age: 11-12 years

  • 6-30% of childhood fractures involve physis

  • Overall complication rate: ∼ 14% (but varies by site)

    • Premature physeal closure with limb shortening or angulation; risk highest in distal femur, tibia

    • Joint incongruity due to intraarticular extension with > 2-mm articular surface gap → degenerative arthritis

    • Osteomyelitis (particularly with nailbed injury)

Diagnostic Checklist

  • Always evaluate involved growth plate for premature closure on follow-up studies

Graphic shows the relationship of the epiphyseal, physeal, & metaphyseal components of the 5 main types of Salter-Harris (SH) fractures.

Lateral (left) & PA (right) radiographs of the wrist in a 9 year old show a SH II fracture of the distal radius with ∼ 60% dorsal translation of the epiphyseal
& metaphyseal
fracture fragments with ∼ 45° apex volar angulation. Note the uncovering of the volar metaphysis
. A nondisplaced ulnar styloid fracture
is noted.

Lateral (left) & AP (right) radiographs of the ankle in a 15 year old show a classic SH IV triplane fracture with sagittal epiphyseal
, horizontal physeal
, & coronal metaphyseal & diaphyseal
components. A fibular fracture
is also present.

Lateral radiograph in a 10 year old after a toe stubbing injury shows a subtle, nondisplaced SH II fracture
of the great toe distal phalanx. If there is a nailbed injury, the patient should be given prophylactic antibiotics to prevent osteomyelitis.



  • Salter-Harris (SH) fractures 1-5 (I-V)


  • Fracture of immature skeleton involving cartilaginous primary growth plate (physis)

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