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Growth-Plate Injury

  • Injury to the growing portion of children’s bones, the physis, or physeal plate
  • Some growth-plate injuries do not produce growth disturbances; only those causing substantial crushing or malalignment of the growth plate cause such sequelae.
  • The most commonly affected bones are the long bones of the growing child.
  • The 4 most commonly injured growth plates are the distal radius, distal tibia, phalanges, and proximal humerus.
    • When injured, the distal femur and the distal tibia are the sites that most commonly show a growth disturbance.
  • Synonyms: Physeal injuries; Salter-Harris fractures (named after the system for describing growth plate injuries)
General Prevention
  • If growth-plate damage is detected early, adverse effects may be prevented in some cases.
  • The bar of bone that forms in the area of damage may be resected if it is <50% to allow normal growth; otherwise, corrective osteotomy for angulation or lengthening the damaged limb (if it is >4 cm short) can be done.
  • A simple option is to stop the growth in the contralateral growth plate to maintain symmetry.
  • Younger patients have a higher risk of serious sequela of a growth plate fracture because they have more growth remaining.
  • Boys are affected twice as frequently as girls.
  • These injuries account for 15-20% of all pediatric fractures.
  • Growth-plate injuries may occur at any age, but adolescents have a higher incidence of physeal fractures.
These injuries occur most frequently in girls 11-12 years old and in boys 12-14 years old, when growth is most rapid and trauma is most serious.
Risk Factors
Adolescent boys
  • Trauma is the most common cause of growth plate injury.
  • Other causes that damage the physis:
    • Infection
    • Tumors
    • Drugs (e.g., steroids, estrogen, testosterone)
    • Excessive heat or cold
  • The Salter-Harris classification (2):
    • Universally used
    • 5 patterns of growth plate fractures (types III, IV, and V are at high risk for growth plate damage):
      • Type I: Split along and parallel to the physis without involvement of the metaphysis or epiphysis
      • Type II (most common): Split along the physis that exits through the metaphysis
      • Type III: Intra-articular fracture of the epiphysis that exits transversely out of the physeal plate
      • Type IV: Fracture of the epiphysis that exits through the metaphysis
      • Type V: Crush injury to the physis
Associated Conditions
  • Ligamentous injury
  • Chest, abdominal, and head trauma
  • Neurovascular injury
Signs and Symptoms
  • Pain and swelling are the most frequent findings, often accompanied by deformity.
  • Sometimes crepitus can be felt.
Physical Exam
The limb should be evaluated carefully for open wounds and distal neurovascular status.
Pathological Findings
  • The growth plate consists of the zone of growth, cartilage transformation, ossification, and the metaphysis.
  • Physeal fractures usually cleave at the zone of cartilage transformation.
  • Permanent injury occurs when a fracture causes malalignment of the edges of the growth plate, or when fracture or infection causes the death of cells of the growth plate.
  • AP and lateral radiographs of the involved area are required.
  • Occasionally, tomograms or CT scans may be needed to evaluate more complicated fracture patterns.
  • MRI is the best method with which to diagnose an established injury to the growth plate.
    • It shows the cartilage line of the growth plate as distinct from bone.
    • Order a gradient echo sequence of the growth plate. (This should be discussed with the radiologist in advance to select the best settings.)
Differential Diagnosis
  • In the chronic setting, other causes of growth plate injury must be considered.
  • Infection may be especially insidious.
General Measures
  • Immediate care for any fracture includes immobilization and ice.
  • The neurovascular status of the extremity should be evaluated and treated if necessary.
  • Pain medication can be used if compartment syndrome is not a concern.
  • Nondisplaced fractures should be splinted immediately.
  • Displaced fractures should be reduced using conscious sedation, hematoma block, or general anesthesia; the fracture then is splinted, and reduction is checked with repeat radiographs.
  • If a fracture involves the growth plate:
    • Patients should be seen within 3-5 days.
    • Splints usually are maintained for 1-2 weeks and then replaced by a circumferential cast once edema has mostly resolved.
  • The patient is referred to the orthopaedic surgeon for definitive management.
  • Nonweightbearing is indicated for lower extremity fractures, and upper extremity fractures often are protected with a sling.
Pain control is indicated.
  • Anatomic reduction is the best way to minimize growth disturbance in most growth-plate fractures.
  • If closed reduction is not possible, some fractures must be reduced openly in the operating room.
    • These fractures and any other fracture that is not stable after reduction must be pinned percutaneously or internally stabilized.
  • Almost all open fractures require operative irrigation and debridement.
  • Most physeal fractures heal without difficulty.
  • The higher the Salter-Harris classification, the more common is the incidence of growth abnormality.
  • The closer the patient is to skeletal maturity, the less a growth abnormality will affect growth.
  • Anatomic regions:
    • Certain regions (e.g., distal tibia and distal femur) are more prone to growth disturbance.
    • Other regions (e.g., distal radius and proximal humerus) are relatively protected from growth disturbance.
  • Growth arrest (physis stops growing)
  • Malunion
  • Growth disturbance (physis grows abnormally with resultant angulation), a more serious complication than growth acceleration.
  • Growth acceleration from increased blood flow for healing, which may occur in any child <10 years old with a fracture, and which usually amounts to only 5-10 mm
Patient Monitoring
  • Patients with growth-plate injuries and at increased risk of growth disturbance (Salter-Harris types III to V and all distal femur and distal tibial physeal injuries) should be followed for at least 6-12 months to ensure normal growth.
  • At that time, the physician should:
    • Look for equality of limb length and angulation.
    • Look for the presence of a clean open growth-plate line on a radiograph.
    • Look for the growth-arrest line of bone that was formed at the time of injury to be separated from the growth plate by an even layer of normal newly formed bone.
  • 813.42 Fracture of distal radial epiphysis
  • 821.22 Fracture of distal femoral epiphysis
  • 824.4 Fracture of distal tibial epiphysis
Patient Teaching
  • The family must understand:
    • Proper cast care and the possibility of future growth abnormality with physeal injury
    • The need to bring the child for 6-12-month follow-up of Salter-Harris classification III or IV fracture or any fracture of distal femur or proximal tibia
Q: After a growth-plate injury, what is the possibility of a clinically significant deformity developing?
A: It depends on the fracture pattern, age, and region of the bone injured. On the whole, normal growth is more likely than substantial growth disturbance.
Q: Do growth-plate injuries take longer to heal than other fractures?
A: They heal at the same rate.

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