Note from the Instructor: A primer on Salter-Harris fractures

By Sharme Brodie, RN, CCDS

I’m often asked about Salter-Harris fractures or growth-plate fractures while I’m teaching, so let’s unpack what CDI professionals need to know about these injuries. 

The Salter-Harris Classification is used for Salter-Harris fractures or growth-plate fractures categorized based on the involvement of the physis, metaphysis, and epiphysis. These types of fractures involve the epiphyseal plate or growth plate of long bones, found in children and adolescents. They can occur at any time from birth until the completion of growth.

Once the person reaches adulthood, the plate is replaced by an epiphyseal line (known as epiphyseal closure). Because this type of fracture affects the growth plate, over time it can result in abnormal growth in the length of the bone, resulting in deformity of the bone itself and/or the adjacent joint.

Identifying these types of fractures compared to a simple fracture can affect a patient’s treatment and potential long-term complications. The growth plate holds additional clinical relevancy in that it is often the primary site for infection, metastasis, fractures, and the effects of endocrine bone disorders.

Let’s cover a little bit of anatomy for any of you who, like me, might need a little bit of a refresher regarding the anatomy of long bones. The long bones in a child are divided into four regions:

• The diaphysis (shaft or primary ossification centre): This is the middle section of a long bone and it is composed of compact tissue
• The metaphysis (where the bones flare): This is the part of the bone adjacent to the physis where the growth in length is added to the bone
• The physis (or growth plate): This is a hyaline cartilage plate in the metaphysis of each end of a long bone where new bone growth takes place
• The epiphysis (secondary ossification centre): Each bone has two epiphyses, one located at the proximal end and one at the distal. It is the rounded end of a long bone, composed of spongy bone that contains bone marrow, this is where growth in length occursThe periosteum: This is the dense white fibrous membrane that covers the external surface of the bone

Coding advice

The Salter-Harris Classification, named after Robert Salter and William Harris created the system containing five different types of fractures; the remaining four types were added subsequently, bringing the total to nine, including:

• Type I: This is a transverse fracture through the physis (growth plate) they are fairly rare by themselves but, are usually non-displaced fractures.
• Type II: This is a fracture through the physis and the metaphysis, sparing the epiphysis. These are more likely to be displaced fractures.
• Type III: is a fracture through the growth plate and epiphysis, sparing the metaphysis. The amount of displacement can vary resulting in a higher risk of growth disturbance after healing.
• Type IV: This is a combination of Type II and Type III fractures, the fracture goes through all three elements physis, metaphysis and epiphysis. These usually are rare but, when they occur are complicated fractures with a higher risk of growth disturbance.
• Type V: This is a crush or compression fracture of the growth plate (resulting in a decreased in the perceived space between the epiphysis and metaphysis on x-ray).
• Type VI: This is a rare injury to the peripheral portion of the physis and a resultant bony bridge formation which may produce an angular deformity (is a pathological abnormality in the spatial alignment of any limb).
• Type VII: This is an isolated injury of the growth plate.
• Type VIII: This is an isolated injury of the metaphysis with possible impairment of endochondral ossification (is responsible for the initial bone development from cartilage in utero and infants and the longitudinal growth of long bones in the epiphyseal plate).
• Type IX: This is an injury of the periosteum which may impair intramembranous ossification.

These codes are “S” codes and will require a seventh character extension. In ICD-10-CM, physeal fractures are coded based on site, laterality, Saltar-Harris Classification, episode of care, and whether the care is for routine or delayed healing, or for a nonunion or malunion.

 The fifth character of the code will identify the type of fracture and correspond to the classification. The sixth character indicates laterality. And the seventh character indicates the episode of care. The options for the seventh character are as follows:

A. Initial encounter for closed fracture

D. Subsequent encounter for fracture with routine healing

G. Subsequent encounter for fracture with delayed healing

K. Subsequent encounter for fracture with nonunion

P. Subsequent encounter for fracture with malunion

S. Sequela

There is no seventh character extension for an open physeal fractures; the Salter-Harris Classifications relates only to closed injuries of the physis. Recent advice in AHA Coding Clinic, First Quarter 2018, clarified that the coding of a Salter-Harris fractures takes priority over a simple fracture and that only one code is needed to identify a single physeal fracture. The question said that the Alphabetic Index and Tabular List instructions were confusing and it was not clear if one or two codes were necessary for accurate code assignment. Coding Clinic answered by stating that coding of a Salter-Harris fracture takes priority over a simple fracture because of future implications due to the involvement of the growth plate. Only one code is needed to identify a single physeal fracture.

There are ICD-10-CM codes for unspecified type and unspecified side (laterality), but these codes should rarely be used. Identification of these types of fractures should be possible, and if documentation is lacking specificity, the physician should be queried for additional clarification to ensure that the most accurate code is assigned.

Editor’s Note: Brodie is a CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.