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

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

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

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

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/

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 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;45:587-622.

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

Classification Systems Peterson 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.

Adequate Imaging is Imperative 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

Adequate Imaging 10 year old with painful elbow Fracture is difficult to see

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.

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; 91-130.

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.

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;23:733-739.

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; 91-130.

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; 91-130.

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; 91-130.

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; 91-130.

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

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

Salter-Harris IV Triplane Fracture Surgical Correction

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.

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.

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.

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.

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.

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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