Growth Plate Injuries. What Should You Know? As in Real Estate: –The Most important things to know about growth plate injuries: Location, Location, Location!

Growth Plate Injuries

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

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


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


• 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

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 & BiomechanicsA ClydeNET collaborative projecthttp://www.gla.ac.uk/ibls/US/fab/

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 1930’s 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. 1963;45:587-622.Peterson H. Physeal fractures: part 3, classification. J Pediatr Orthop. 1994;14:439-48.

Classification SystemsSalter-Harris

Salter R, Harris W. Injuries involving the epiphyseal plate. J Bone Joint Surg Am. 1963;45:587-622.

Classification SystemsSalter-Harris

Adapted from: Peterson H. Physeal fractures: part 3, classification. J Pediatr Orthop. 1994;14:439-48.

Classification SystemsPeterson

Peterson H. Physeal fractures: part 3, classification. J Pediatr Orthop. 1994;14:439-48.

Epidemiology

• 18% to 30% of children’s fractures involve the physis

• Male-to-female ratio is about 2:1

• 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. 1994;14(4):423-430.

Diagnosis

Adequate Imaging is Imperative

Diagnosis: Need Adequate Imaging

• Supplement plain x-rays

• High Index of Suspicion– Comparison

Views– CT scan– MRI

Adequate Imaging

• Child with knee pain

• Fracture difficult to see

Adequate Imaging

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

distal femur

Adequate Imaging• Final after reduction

and internal fixation with comparison view

Adequate Imaging

• Child with ankle pain– Fracture

difficult to see

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

Tilleaux Fracture

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

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

Adequate Imaging

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 – < 4mm translation &– < 30-60 degrees angulation

Evans MC, Graham HK. Radial neck fractures in children: a management algorithm. J Pediatr Orthop. 1999;8:93–99.

Radial Head Fracture

• Percutaneous pinning indicated if closed treatment unsuccessful– Open if can’t 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. 1999;8:93–99.

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.

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


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. 2006;26(3)322-8.


• 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 (< 3 wks)

Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop. 2003;23:733-739.


• 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)


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!)


TreatmentSalter-Harris III

• Usually require open reduction of joint

• Most desirable internal fixation is epiphysis to epiphysis, especially in younger children


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!


• 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

Salter-Harris IVTriplane Fracture

• CT gives 3D visualization of fracture patterns

• Essential for planning


• Surgical Correction


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. 1982;64(4):600-9.

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. 2009;23:663.Arkader et al. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007;27:703.Dale et al. Prognosis of Epiphysial Separation. J Bone Joint Surg Br. 1958;40:116.

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 > 1.5 cm

Arkader et al. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007;27:703. (image with permission)

Basener et al. Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis. J Orthop Trauma. 2009;23:663.

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. 2009;29:356.

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 > 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. 2009;29:356.*Barmada et al. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop. 2003;23:733.

Bibliography• Aitken A. The end result of the fractured distal tibial epiphysis. J Bone Joint Surg. 1936;18:685-91.

• Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007;27:703.

• Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop. 2003;23:733-739.

• Basener CJ, Mehlman CT, DiPasquale TG. Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis. J Orthop Trauma. 2009;23:663.

• Beaty JH. Elbow fractures in children and adolescents. Instr Course Lect. 2003;52:661-5. • Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am.

1982;64(4):600-9.• Dale GG, Harris WR.. Prognosis of Epiphysial Separation. J Bone Joint Surg Br. 1958;40:116.• Evans MC, Graham HK. Radial neck fractures in children: a management algorithm. J Pediatr

Orthop. 1999;8:93–99.• 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. 2003;52:647-59. • Flynn JM, Sarwark JF, Waters PM, Bae DS, Lemke LP. The surgical management of pediatric

fractures of the upper extremity. Instr Course Lect. 2003;52:635-45.• 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. 2009;29:356• Mehlman, C.T. and Koeplinger, M., “Growth Plate Physeal Injuries,”

emedicine.com/orthoped/topic627.htm

Bibliography• Peterson H. Physeal fractures: part 3, classification. J Pediatr Orthop. 1994;14:439-48.

• Peterson HA, Madhok R, Benson JT, et al. Physeal fractures: Part 1. epidemiology in Olmsted County, Minnesota, 1979-1988. J Pediatr Orthop. 1994;14(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, 65:885-93.

• Salter R, Harris W. Injuries involving the epiphyseal plate. J Bone Joint Surg Am. 1963;45:587-622.• Tepper KB, Ireland ML. Fracture patterns and treatment in the skeletally immature knee. Instr Course

Lect. 2003;52:667-76.

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Growth Plate Injuries. What Should You Know? As in Real Estate: –The Most important things to know about growth plate injuries: Location, Location, Location!