Fracture involves extensive damage to the soft tissues, including muscle, skin, and neurovascular structures.
Fracture is often accompanied by a high-velocity injury or a severe crushing component.
Special patterns classified as type III:
Open segmental fracture, regardless of the size of the wound Gunshot wounds: high-velocity and short-range shotgun injuries Open fracture with neurovascular injury
Farm injuries, with soil contamination, regardless of size of wound
Open fractures more than 8 hours after injury
Mass casualties (e.g., war, tornado victims)
Adequate soft tissue coverage despite soft tissue laceration or flaps or high-energy trauma, regardless of size of wound; includes segmental fractures or severely comminuted fractures.
Extensive soft tissue lost with periosteal stripping and bony exposure; usually associated with massive contamination.
Fracture with major arterial injury requiring repair for limb salvage.
The epiphysis is separated from the metaphysis along the physis, without an associated fracture through the metaphyseal or epiphyseal bone. The injury goes directly through the cartilaginous physeal plate. These injuries can be displaced or nondisplaced. A nondisplaced Salter-Harris I fracture will have a normal-appearing growth plate on radiographs, but patients will have pain on palpation directly over the growth plate. Stress radiographs or magnetic resonance imaging (MRI) may be necessary to reveal the injury. Displaced type I injuries are typically easy to reduce because the periosteal attachment remains intact. These injuries have an excellent chance of normal healing with full growth of the injured bone. Despite this, growth delay and growth arrest are complications of growth plate injuries, which should be discussed with the patient and family.
The fracture line incompletely extends through the physeal plate and then turns into the metaphysis in an extra-articular fracture pattern. The Salter-Harris II fracture is the most common type of growth plate fracture. The periosteum remains intact on the concave side of the injury, creating a "hinge" and making reduction relatively easy. Prognosis is excellent for future growth when anatomically reduced, with only minor risk of angular deformity.
The fracture line extends incompletely along the physis and then turns through the epiphyseal bone into the joint. Salter-Harris III fractures are intra-articular injuries that imply an increased risk of arthritis, especially if they are not anatomically reduced. Alignment of the joint surface is the top priority, and open reduction is often necessary. Prognosis is good, provided the blood supply to the fracture fragment remains intact.
This intra-articular fracture pattern extends from the epiphy-sis, across the physeal plate, and through a portion of the metaphysis. Open reduction with internal fixation is usually needed to ensure anatomic alignment of the joint surface and perfect alignment and apposition of the physeal plate.
Premature growth arrest and angular deformities can occur with Salter-Harris IV fractures. Prognosis can be good but depends on ability to restore growth plate.
Salter Harris V fractures are crushing injuries in which an axial load compresses the epiphysis into the metaphysis, squeezing the actively growing physis between them. Prognosis for future growth is poor, with a high rate of premature closure of the physis and resultant joint deformity. Fortunately, these are rare injuries.
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