Growth Plate Injuries

1
Growth Plate Injuries
Joshua Klatt, MD Revised October, 2011 Created
March 2011 by Steven I. Rabin, MD
2
What Should You Know?

• As in Real Estate
• The Most important things to know about growth
  plate injuries
• Location, Location, Location!
• And
• Timing is Everything

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Terminology

• Epiphyseal Plate Growth Plate Physis
• Epiphysis
• Secondary Ossification Center
• Epiphysis and growth plate are NOT synonyms
• The epiphysis is the bone located between the
  articular surface and the physis
• Metaphysis
• Bone adjacent to the physis on the opposite side
  of the epiphysis.
• Diaphysis
• The shaft of the bone

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Growth Plate Injuries

• Occur by various mechanisms
• Fracture Frostbite
• Disuse Chronic Stress
• Radiation Iatrogenic injury
• Infection Neural involvement
• Tumor Electrical Injuries
• Vascular impairment Burns
• Metabolic abnormality

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Growth Plate Injuries

• When entire physis is arrested
• Bone length is retarded
• If bone ends are arrested, longitudinal bone
  growth ceases completely
• When only part of physis is damaged
• Length retardation can be accompanied by angular
  deformity

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Growth Plate Histology

• Zones of the Physis
• Reserve/Resting Zone
• Adjacent to epiphysis
• Irregularly scattered chondrocytes, low activity
• Proliferative Zone
• Mid-zone
• Columns of chondrocytes.
• Active cell division results in longitudinal
  growth
• Hypertrophic Zone
• Adjacent to metaphysis
• Chondrocytes accumulate calcium
• Chondrocytes die and release calcium
• Capillary ingrowth brings in chondroclasts and
  osteoblasts
• No active growth in this layer

Functional Anatomy Biomechanics A ClydeNET
collaborative project http//www.gla.ac.uk/ibls/US
/fab/
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Classification

• Multiple classification systems
• Salter-Harris most commonly used in US (1963)
• Poland earliest scientific approach (1895)
• Bergenfeldt later modified by Salter Harris
  (1933)
• Aitken standard from 1930s until S-H proposed
  (1936)
• Peterson newer and more thorough, but more
  complicated (1994)

Salter R, Harris W. Injuries involving the
epiphyseal plate. J Bone Joint Surg Am.
196345587-622. Peterson H. Physeal fractures
part 3, classification. J Pediatr Orthop.
199414439-48.
8
Classification SystemsSalter-Harris

• Classified by which peri-physeal structures are
  disrupted
• Physis
• Physis and metaphysis
• Metaphyseal fragment Thurston-Holland sign
• Physis and epiphysis
• Metaphysis, physis and epiphysis
• Crush injury to the physis
• Very difficult to diagnose initially
• Peripheral physeal injury

Salter R, Harris W. Injuries involving the
epiphyseal plate. J Bone Joint Surg Am.
196345587-622.
9
Classification SystemsSalter-Harris
Adapted from Peterson H. Physeal fractures part
3, classification. J Pediatr Orthop.
199414439-48.
10
Classification SystemsPeterson
Peterson H. Physeal fractures part 3,
classification. J Pediatr Orthop. 199414439-48.
11
Epidemiology

• 18 to 30 of childrens fractures involve the
  physis
• Male-to-female ratio is about 21
• Most common site is phalanges of the fingers
  (37)
• Next is distal radius (18)

Peterson HA, Madhok R, Benson JT, et al. Physeal
fractures Part 1. epidemiology in Olmsted
County, Minnesota, 1979-1988. J Pediatr Orthop.
199414(4)423-430.
12
Diagnosis

• Adequate Imaging is Imperative

13
Diagnosis Need Adequate Imaging

• Supplement plain x-rays
• High Index of Suspicion
• Comparison Views
• CT scan
• MRI

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Adequate Imaging

• Child with knee pain
• Fracture difficult to see

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Adequate Imaging

• Oblique X-ray
• Easy to see
• Salter III of the distal femur

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Adequate Imaging

• Final after reduction and internal fixation with
  comparison view

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Adequate Imaging

• Child with ankle pain
• Fracture difficult to see

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Adequate Imaging

• CT shows a Salter III (Tilleaux) fracture of
  the distal tibia
• Tilleaux Fractures occur near the end of growth
  as medial portion of distal tibial physis closes
  before the lateral side closes

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Tilleaux Fracture

• Post-operative and final x-rays after hardware
  removal without residual deformity

20
Adequate Imaging

• 10 year old with painful elbow
• Fracture is difficult to see

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Salter IV Radial Head Fracture

• Better X-ray shows a Salter IV Fracture of the
  radial head
• Childhood radial neck fractures usually 8-12y/o
• Fractures of the radial neck are much more common
  than head in children as head is mainly
  cartilagenous
• Closed reduction acceptable if
• lt 4mm translation
• lt 30-60 degrees angulation

Evans MC, Graham HK. Radial neck fractures in
children a management algorithm. J Pediatr
Orthop. 199989399.
22
Radial Head Fracture

• Percutaneous pinning indicated if closed
  treatment unsuccessful
• Open if cant obtain closed
• Beware posterior interosseous nerve
• Never excise the radial head in children!
• Even a dead head can act as a spacer and allow
  more normal elbow development

Evans MC, Graham HK. Radial neck fractures in
children a management algorithm. J Pediatr
Orthop. 199989399.
23
Treatment

• Goal of treatment of all physeal fractures is to
  maintain function and normal growth
• Attainment of these goals is most likely when all
  structures are anatomically reduced
• Therefore goal is to obtain and maintain anatomic
  reduction
• May be done by open or closed means
• All reductions should be gentle to prevent damage
  to the delicate physeal cartilage
• Forceful, repeated manipulations should be
  avoided!

Peterson HA. Physeal Injuries and Growth Arrest.
In Beaty JH, Kasser JR, eds. Fractures in
Children. Philadelphia, PA Lippincott Williams
and Wilkins, 2001 91-130.
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TreatmentSalter-Harris I

• Most common with fractures of the phalanges,
  distal radius and fibula
• All layers of the physis may be involved
• Should be managed by closed reduction if
  possible, as internal fixation would require
  crossing the physis
• In a young child, better to accept an imperfect
  reduction than risk hazards of fixation across
  physis

Peterson HA. Physeal Injuries and Growth Arrest.
In Beaty JH, Kasser JR, eds. Fractures in
Children. Philadelphia, PA Lippincott Williams
and Wilkins, 2001 91-130.
25
TreatmentSalter-Harris II

• Most can be easily reduced with closed reduction
• Important to have good relaxation to prevent
  physeal damage
• Intact periosteum on side of metaphyseal fragment
  imparts further stability to fracture
• ORIF often unnecessary
• Periosteum can become impinged at fracture site,
  especially in distal tibia

Rohmiller MT, Gaynor TP, Pawelek J, Mubarak SJ.
Salter-Harris I and II fractures of the distal
tibia does mechanism of injury relate to
premature physeal closure? J Pediatr Orthop.
200626(3)322-8.
26
TreatmentSalter-Harris II

• If ORIF is necessary
• Internal fixation is best accomplished by pins or
  screws from metaphysis to metaphysis, avoiding
  the physis
• If Thurstan Holland fragment is small, smooth
  pins may be placed across physis
• Growth arrest less likely if
• Pins avoid perichondrial ring
• Are longitudinal as possible
• Remain in place short time (lt 3 wks)

Barmada A, Gaynor T, Mubarak SJ. Premature
physeal closure following distal tibia physeal
fractures a new radiographic predictor. J
Pediatr Orthop. 200323733-739.
27
TreatmentSalter-Harris II

• Prognosis depends greatly on
• Amount of physis involved
• Site of injury
• Degree of displacement
• Patient age
• Site of injury important because
• Irregular and undulating physes produce more
  scraping of irregular surfaces of delicate
  cartilage (e.g. distal femur)

Peterson HA. Physeal Injuries and Growth Arrest.
In Beaty JH, Kasser JR, eds. Fractures in
Children. Philadelphia, PA Lippincott Williams
and Wilkins, 2001 91-130.
28
TreatmentSalter-Harris III

• Cartilage of physis and articular surface are
  both disrupted
• Best result achieved by anatomic reduction of
  joint and physis
• Reduce the likelihood of degenerative arthrosis
• Reduce the likelihood of growth arrest
• Often occur in older children when risk of growth
  arrest is less a problem (but not always!)

Peterson HA. Physeal Injuries and Growth Arrest.
In Beaty JH, Kasser JR, eds. Fractures in
Children. Philadelphia, PA Lippincott Williams
and Wilkins, 2001 91-130.
29
TreatmentSalter-Harris III

• Usually require open reduction of joint
• Most desirable internal fixation is epiphysis to
  epiphysis, especially in younger children

Peterson HA. Physeal Injuries and Growth Arrest.
In Beaty JH, Kasser JR, eds. Fractures in
Children. Philadelphia, PA Lippincott Williams
and Wilkins, 2001 91-130.
30
TreatmentSalter-Harris IV

• Anatomic reduction and maintenance of reduction
  are essential to align both physis and articular
  surface
• If any displacement, open reduction usually
  required
• Closed reduction and percutanous fixation may be
  acceptable in some situations (e.g. lateral hum.
  condyle)
• Fixation best accomplished from epiphysis to
  epiphysis and/or metaphysis to metaphysis
• Growth arrest is common!

Peterson HA. Physeal Injuries and Growth Arrest.
In Beaty JH, Kasser JR, eds. Fractures in
Children. Philadelphia, PA Lippincott Williams
and Wilkins, 2001 91-130.
31
Salter-Harris IVTriplane Fracture

• Example Triplane Ankle Fx
• Complex type IV fracture
• Combination of Salter II and III fractures
• Usually near end of growth
• Anterior epiphyseal fracture with large posterior
  medial fragment
• Fibula may also be fractured

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Salter-Harris IVTriplane Fracture

• CT gives 3D visualization of fracture patterns
• Essential for planning

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Salter-Harris IVTriplane Fracture

• Surgical Correction

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TreatmentSalter-Harris V

• Rarely diagnosed at time of injury
• No fracture on radiograph
• Often diagnosed in retrospect after growth arrest
  discovered
• Occasionally seen in severe triradiate acetabular
  injuries
• Rarely require initial treatment as usually
  minimal displacement and/or instability
• But subsequent deformity may require treatment

Bucholz, et al. Injury to the acetabular
triradiate physeal cartilage. J Bone Joint Surg
Am. 198264(4)600-9.
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Prognosis

• Depends on
• (in order of importance)
• Severity of injury
• Displacement
• Comminution
• Open vs. closed
• Patient age
• Which physis injured
• Radiographic type of fracture
• Treatment, therefore, depends on these factors

Basener et al. Growth disturbance after distal
femoral growth plate fractures in children a
meta-analysis. J Orthop Trauma.
200923663. Arkader et al. Predicting the
outcome of physeal fractures of the distal femur.
J Pediatr Orthop. 200727703. Dale et al.
Prognosis of Epiphysial Separation. J Bone Joint
Surg Br. 195840116.
36
PrognosisDistal Femur Fractures

• Meta-analysis of 564 fxs
• Risk of arrest based on type
• I 36
• II 58
• III 49
• IV 65
• Based on displacement
• Non-displaced 31
• Displaced 65
• 22 developed length discrepancy gt 1.5 cm

Arkader et al. Predicting the outcome of physeal
fractures of the distal femur. J Pediatr Orthop.
200727703. (image with permission) Basener
et al. Growth disturbance after distal femoral
growth plate fractures in children a
meta-analysis. J Orthop Trauma. 200923663.
37
PrognosisDistal Tibia Fractures

• Risk of arrest recently reported higher than
  previously though
• Risk of arrest based on type
• I 3 to 5
• II 17 to 36
• III 13 to 50
• IV 13 to 50
• Tillaux low risk
• Triplane 7 to 21

Leary et al. Physeal fractures of the distal
tibia predictive factors of premature physeal
closure and growth arrest. J Pediatr Orthop.
200929356.
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PrognosisDistal Tibia Fractures

• Mechanism of injury likely very important
• MVA 86
• Sports 8
• Falls 6
• Displacement
• Increased risk of 15 with each additional mm of
  displacement
• Residual displacement
• Gap gt 3 mm associated with 60 risk (vs 17)
• Attempts at reduction (not signif.)
• 1 attempt 11
• 2 attempts 24
• 3 attempts 50

Leary et al. Physeal fractures of the distal
tibia predictive factors of premature physeal
closure and growth arrest. J Pediatr Orthop.
200929356. Barmada et al. Premature physeal
closure following distal tibia physeal fractures
a new radiographic predictor. J Pediatr Orthop.
200323733.
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Bibliography

• Aitken A. The end result of the fractured distal
  tibial epiphysis. J Bone Joint Surg.
  193618685-91.
• Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells
  L. Predicting the outcome of physeal fractures of
  the distal femur. J Pediatr Orthop. 200727703.
• Barmada A, Gaynor T, Mubarak SJ. Premature
  physeal closure following distal tibia physeal
  fractures a new radiographic predictor. J
  Pediatr Orthop. 200323733-739.
• Basener CJ, Mehlman CT, DiPasquale TG. Growth
  disturbance after distal femoral growth plate
  fractures in children a meta-analysis. J Orthop
  Trauma. 200923663.
• Beaty JH. Elbow fractures in children and
  adolescents. Instr Course Lect. 200352661-5.
• Bucholz, et al. Injury to the acetabular
  triradiate physeal cartilage. J Bone Joint Surg
  Am. 198264(4)600-9.
• Dale GG, Harris WR.. Prognosis of Epiphysial
  Separation. J Bone Joint Surg Br. 195840116.
• Evans MC, Graham HK. Radial neck fractures in
  children a management algorithm. J Pediatr
  Orthop. 199989399.
• Flynn JM, Skaggs DL, Sponseller PD, Ganley TJ,
  Kay RM, Leitch KK. The surgical management of
  pediatric fractures of the lower extremity.
  Instr Course Lect. 200352647-59.
• Flynn JM, Sarwark JF, Waters PM, Bae DS, Lemke
  LP. The surgical management of pediatric
  fractures of the upper extremity. Instr Course
  Lect. 200352635-45.
• Leary JT, Handling M, Talerico M, Yong L, Bowe
  JA. Physeal fractures of the distal tibia
  predictive factors of premature physeal closure
  and growth arrest. J Pediatr Orthop. 200929356
• Mehlman, C.T. and Koeplinger, M., Growth Plate
  Physeal Injuries, emedicine.com/orthoped/topic627
  .htm

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Bibliography

• Peterson H. Physeal fractures part 3,
  classification. J Pediatr Orthop. 199414439-48.
• Peterson HA, Madhok R, Benson JT, et al. Physeal
  fractures Part 1. epidemiology in Olmsted
  County, Minnesota, 1979-1988. J Pediatr Orthop.
  199414(4)423Y430.
• REVIEW Peterson HA. Physeal Injuries and Growth
  Arrest. In Beaty JH, Kasser JR, eds. Fractures in
  Children. Philadelphia, PA Lippincott Williams
  and Wilkins, 2001 91-130.
• Poland J. Traumatic separation of the epiphyses.
  London Smith, Elder Co, 1898.
• Rabin, S., Naeni, F., and Rabin, H. Ilizarov
  Distraction Osteogenesis A Case Report and
  Review of Basic Principles. Loyola Orthopaedic
  Journal. Volume II, May 1993.
• Rabin, S., Weinstein, L., and Brown, L.
  Epiphyseodesis as an Alternative to Distal Ulna
  Resection for Post-Traumatic Wrist Deformity in
  Children. A review of the literature and report
  of two cases. Loyola Orthopaedic Journal Volume
  III, May 1994.
• Riseborough, EJ, Barrett, IR, Shapiro, F Growth
  disturbances following distal femoral physeal
  separations. JBJS Am 1983, 65885-93.
• Salter R, Harris W. Injuries involving the
  epiphyseal plate. J Bone Joint Surg Am.
  196345587-622.
• Tepper KB, Ireland ML. Fracture patterns and
  treatment in the skeletally immature knee. Instr
  Course Lect. 200352667-76.

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