1. Created March 2011 by Steven I. Rabin, MD
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

3. 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

4. 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

5. 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

6. 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

7. 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:
Peterson H. Physeal fractures: part 3, classification. J Pediatr Orthop. 1994;14:

8. Classification Systems Salter-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. 1963;45:

9. Classification Systems Salter-Harris
Adapted from: Peterson H. Physeal fractures: part 3, classification. J Pediatr Orthop. 1994;14:

10. Classification Systems Peterson
Peterson H. Physeal fractures: part 3, classification. J Pediatr Orthop. 1994;14:

11. 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, J Pediatr Orthop. 1994;14(4):

12. Adequate Imaging is Imperative
Diagnosis
Adequate Imaging is Imperative

13. Diagnosis: Need Adequate Imaging
Supplement plain x-rays
High Index of Suspicion
Comparison Views
CT scan
MRI

14. Adequate Imaging
Child with knee pain
Fracture difficult to see

15. Adequate Imaging Oblique X-ray Easy to see
Salter III of the distal femur

16. Adequate Imaging
Final after reduction and internal fixation with comparison view

17. Adequate Imaging
Child with ankle pain
Fracture difficult to see

18. 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

19. 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

21. 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 &
< degrees angulation
Evans MC, Graham HK. Radial neck fractures in children: a management algorithm. J Pediatr Orthop. 1999;8:93–99.

22. 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.

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;

24. Treatment Salter-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;

25. Treatment Salter-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.

26. Treatment Salter-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 (< 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:

27. Treatment Salter-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;

28. Treatment Salter-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;

29. Treatment Salter-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;

30. Treatment Salter-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;

31. Salter-Harris IV Triplane 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

32. Salter-Harris IV Triplane Fracture
CT gives 3D visualization of fracture patterns
Essential for planning

33. Salter-Harris IV Triplane Fracture
Surgical Correction

34. Treatment Salter-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.

35. Prognosis Depends on Treatment, therefore, depends on these factors
(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.

36. Prognosis Distal 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.

37. Prognosis Distal 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.

38. Prognosis Distal 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.

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

40. Bibliography
Peterson H. Physeal fractures: part 3, classification. J Pediatr Orthop. 1994;14:
Peterson HA, Madhok R, Benson JT, et al. Physeal fractures: Part 1. epidemiology in Olmsted County, Minnesota, 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;
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:
Salter R, Harris W. Injuries involving the epiphyseal plate. J Bone Joint Surg Am. 1963;45:
Tepper KB, Ireland ML. Fracture patterns and treatment in the skeletally immature knee. Instr Course Lect. 2003;52:

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