Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
“Injuries Involving the Epiphyseal Plate” by Drs. Salter and Harris, published more than a half-century ago, has had a lasting impact on the field of orthopaedic surgery and on the practice of medicine in general. Every surgeon in our specialty—and almost every radiologist, pediatrician, and emergency physician—has at least a passing knowledge of the “Salter fractures.” This most enduring orthopaedic schema lives on in our practices because of its clarity of presentation, its guidance of our understanding, and its implications for treatment. It has outlasted many classifications developed before and since.
In addition to presenting the fracture classification in this classic and beautifully illustrated JBJS Instructional Course Lecture, the authors laid the groundwork with basic principles of mechanical failure and vascularity of the physis. The authors then use these principles to help explain how physeal damage may arise from misalignment, crushing, or vascular interruption. The authors elucidate these concepts further by presenting experimental studies of growth arrest, with resulting histology, and the effects of interpositional surgery. Salter and Harris then describe the famous five types of physeal injury and the clinical implications for treatment and prognosis.
Not content with generalities, the authors conclude with an extensive section describing the variations of physeal fractures in each long bone. The article is fun and inspiring to read because of the obvious fascination that the authors had in exploring the topic so completely. Rarely has experimental and clinical thought been so nicely interwoven. We don’t write that way now, and rarely if ever will we see a 36-page article in one of today’s orthopaedic journals; in many ways we are poorer for that.
Classification systems are highly cited and influential; they figure prominently in lists of top-cited orthopaedic articles. Those at the top earn this rank by their utility. This is just one of three monumental contributions by the late Dr. Salter of Toronto (along with introducing us to surgical reorientation of the acetabulum and to continuous passive motion). Please share your reactions to this classic article and its impact on you and your practice.
Paul Sponseller, MD
JBJS Deputy Editor for Pediatrics
It may not be common knowledge that this seminal paper was written by the 2 authors early in their careers in Canadian hospitals: Robert B Salter was 38 (b. 15 Dec 1924), W Robert Harris was 41.
This paper which was listed as most cited Paediatric Orthopaedic paper (764 in 2013) (Ref 1) and 18th most cited (670 in 2010) Classic Orthopaedic paper (Ref 2) remains the most influential paper in recent modern history.
Was it Level 1 evidence?
Was it Level 2 evidence?
Was it even a research article with a clearly coherent hypothesis with a well run trial, a case-control or cohort study?
The answer to all is NO.
The paper involved is an AAOS Instructional Course published in JBJS [Am] in 5 years before possibly the earliest known (I am aware of) English Language Randomised Control Trial (RCT) paper on Early weight bearing after internal fixation of transcervical fracture of the femur in JBJS (Br) 1968.
Salter and Harris listed 7 papers that discussed epiphyseal injuries before their own paper, but offered no explanation to how they had formulated their own classification nor any coherent evidence of long term research data to validate their offering of classification.
Perhaps, the micrographs of histological images aided in popularising their opinion paper. Robert Salter wrote in Robert Harris’ obituary:
“Bob Harris and I collaborated on a combined research project on injuries involving the epiphyseal plate. He insisted that since his part of the project (basic research) was smaller than mine (clinical research) his name should appear second on the title, hence the Salter-Harris classification of injuries involving the epiphyseal plate. Both he and I were quite young when the classification was published (1963). Indeed, sometimes when being introduced to a foreign orthopaedic surgeon, the statement was made to one, or both of us that “In our country we use the classification that was created by your father(s)”.” (Ref 4)
Nevertheless, it is surely the simplicity (and even perhaps the SALTER mnemonic popularised by later authors: see Wikipedia entry on Salter-Harris fracture) of the classification that made the ease of acceptance so much widespread and completely integrated in contemporary orthopaedic literature; many clinicians may never get (or need) to know what previous authors’ classification of growth plate injuries were.
In spite of their effect and influence on orthopaedic thinking, I suspect in the current climate of medical publishing, that their same work would not have been published in many of the mainstream journals, including JBJS, their paper would at best be rated as a very poorly reference article, with little case studies and too much words.
Perhaps then, it is time for editors throughout the world to take a collective deep breath, and reconsider their recent fashionable pursuit for ‘high-quality research’ in the guise of “RCT” or “meta-analysis”, and not offering adequate platform for original thinkers without Level 1 or 2 quality of evidence.
Afterall, we may very well be in the midst of another “tulip fever” in the form of “evidence-based” justification of our work, the cult status of EBM is evident in the thinking of some of our resident and students.
Afterall, there was never a level 1 evidence proving people jumping off tall building will end in their death, but we dont need one.
We just need some evidence of having a common sense most of the time
Reference
1. Kavanagh,RG et al. The 100 Classic Papers of Pediatric Orthopaedic Surgery. JBJS [Am] 2013;95:e134(1-8)
2. Kelly JC et al The 100 classic papers of orthopaedic surgery. JBJS [Br] 2010;92-B:1338-43.
3. Graham J. Early weight bearing after internal fixation of transcervical fracture of the femur. JBJS [Br] 1968;50-B 562-569
4. Salter SB. Obituary: W. Robert Harris (1922-2005). JBJS[Br] 2006 88-B 698
Thank you for your thoughtful comment, Dr. Goh. The Journal values and always seeks high-quality cohort studies and other non-RCT submissions because of the breadth of musculoskeletal disease and injury that our field encounters.
Marc Swiontkowski, JBJS Editor-in-Chief
So, you do not agree about the EBM remark? EBM is important, but ‘looking in the dark’ (C. Moseley) as well.
For the benefit of fellow readers, Dr Oostenbroek is referring to Colin Moseley’s “Evidence-based Medicine: The Dark Side: POSNA 2008 Presidential Guest Lecture” published in Journal of Pediatric Orthopaedics: December 2009 – Volume 29 – Issue 8 – pp 839-843
Moseley’s article is one of my favourite all time article!
I have permanently kept this pdf on file on my desktop and frequently re-read/distributed to residents and students.
Worth even a visit to the local medical library just to get a printed copy…..