eMedicine Specialties > Orthopedic Surgery > Pediatrics
Growth Plate (Physeal) Fractures: Treatment
Updated: Aug 12, 2008
Treatment
Medical Therapy
Physeal fractures are very commonly treated nonoperatively. Factors that affect treatment decisions include the severity of the injury, the anatomic location of the injury, the classification of the fracture, the plane of the deformity, the age of the patient, and the growth potential of the involved physis. Most SH I and II injuries can be treated with closed reduction and casting or splinting and then reexamination in 7-10 days to evaluate maintenance of the reduction.
Closed reductions through manipulation and traction need to be performed carefully, with the patient (and the patient's involved musculature) as relaxed as possible in order to avoid unnecessary wrestling of the bony components that may lead to grating of the physis on sharp metaphyseal bone fragments and potential damage to the physis. Less than satisfactory reductions are preferred over repeated attempts at reduction that may damage the germinal layer of cells within the physis. To avoid physeal damage, efforts at reduction should focus more on traction and less on forceful manipulation of the bone fragments.
Disruption of the physis may warrant restoration of its congruency in order to ensure proper joint mechanics. Angular deformities may also occur, due to malreduction or partial growth arrest. The location and direction of the deformity need to be considered when planning treatment. In general, greater angular deformity can be tolerated in the upper extremity than in the lower extremity, more valgus deformity can be tolerated than varus, and more flexion deformity can be tolerated than extension. More proximal deformities of the lower extremity (in the hip) are better compensated for than distal deformities (the knee and, least of all, the ankle). Spontaneous correction of angular deformities is greatest when the asymmetry is in the plane of flexion or extension (ie, the plane of joint motion), with function often returning to normal unless the fracture occurs near the end of growth.
The age of the patient at the time of injury is of paramount importance in helping predict clinical outcomes because more correction can be anticipated in younger patients. For instance, injuries to the physes of 14- to 15-year-old girls or 17- to 18-year-old boys are of little consequence due to their limited growth potential. As a result, any growth plate injury is unlikely to be clinically significant. However, injuries in younger children with full growth potential can cause significant problems and a wide range of clinical effects.
Surgical Therapy
More severe injuries involving intra-articular fractures (SH III and IV) typically require anatomic reduction with open reduction and internal fixation that avoids crossing the physis. Smooth pins should parallel the physis in the epiphysis or metaphysis, avoiding the physis. Oblique application of pins across the physis should be considered only when satisfactory internal fixation is unattainable with transverse fixation. Any internal fixation devices should be easily removable yet adequate for internal fixation.
Type V fractures are rarely diagnosed acutely, and unfortunately, treatment is often delayed until the formation of a bony bar across the physis is evident. A high level of clinical suspicion is necessary to detect this complication early. In many cases, "early" may not be until 6 months or more after the injury.
Follow-up
Long-term follow-up is essential to determine whether or not complications will occur. Most physeal injuries (growth plate injuries) should be reevaluated in the short term to ensure maintenance of reduction and proper anatomic relationships. Some physeal fractures (growth plate fractures) are more problematic than others when it comes to risk of growth arrest. Physeal fractures that are considered to be at increased risk for growth arrest include fractures to the following growth plates:
- Distal femur
- Distal tibia
- Distal radius and ulna
- Proximal tibia
- Triradiate cartilage
After initial fracture healing has occurred, physeal fractures require additional follow-up radiographs 6 months and 12 months following injury to assess for growth disturbance. Management of such physeal fractures can thus be divided into 2 phases. The first phase involves ensuring bone healing, and the second phase is monitoring growth.
For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Sprains and Strains.
Complications
Growth acceleration
Growth acceleration is a possible complication of physeal injuries; however, it is uncommon. This complication usually occurs in the first 6-18 months after the initial injury. The rapid healing of the physis enables an increased vascular response that is usually of shorter duration than that for healing of bony fractures. Accelerated growth patterns also may be associated with the use of implants and fixation devices that may stimulate longitudinal growth. The greater growth is rarely significant but may require future assessment by the clinician. Treatment for this acceleration in adolescents may involve an epiphysiodesis of the longer limb to avoid producing disproportionate limbs. If more than 6 cm of correction is desired, this is not a treatment option, and the clinician may consider lengthening procedures for bilateral limb-length equilibration.
Growth arrest
Complete growth retardation or partial growth arrest may result in progressive limb-length discrepancies. Complete growth arrest is uncommon and depends on when the injury to the physis occurs in relation to the remaining skeletal growth potential. The younger the patient, the greater the potential for problems associated with growth.
Premature partial growth arrest is far more common and can appear as peripheral or central closures. These can result in angular deformities and limb-length discrepancies. Premature partial arrests are produced when a bridge of bone (bone bar/bridge) forms, connecting metaphysis to epiphysis, traversing the physis. This bone bar inhibits growth, and the size and location of this bar determines the clinical deformity. For example, if the bar is located medially in the physis of the distal femur, the normal physis continues to grow laterally, producing a varus deformity (genu varum), and vice versa for a genu valgum deformity. Recent investigation into gait analysis for patients with genu valgum deformity revealed improvements in cosmesis and corrected joint kinematics with hemiphyseal stapling. Anterior bone bars in the distal femoral physis allow for normal physeal growth posteriorly but result in a genu recurvatum deformity.
Similarly, central growth arrests result in tented lesions of the physis and epiphysis due to a central osseous tether with the metaphysis, resulting in the characteristic physeal coning. As the physis tries to push the epiphysis away from the metaphysis, the bony bridge hypertrophies in an effort to overcome the increased tension placed on it. Bone tissue under constant tension usually atrophies, but in this instance, a dense reactive cortical bone develops.
Some longitudinal growth continues in patients with growth retardation, though at a much slower rate; thus, a progressive shortening of the limb occurs. Partial growth arrests may be visible on radiographs as early as 3-4 months postinjury or may be delayed as long as 18-24 months. Follow-up checks may be necessary for 1-2 years postinjury to monitor physeal healing and growth response.
Articular problems are also a possibility, particularly in physeal fractures that lead to discontinuities of the articular surface (ie, SH III, SH IV). These lesions can result in intra-articular step-offs and early degenerative joint disease if they are not properly treated and anatomically reduced. Central growth arrest can promote the physeal tenting phenomena and, ultimately, result in a deformed articular surface.
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 Treatment: Growth Plate (Physeal) Fractures |
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Further Reading
Keywords
growth plate fracture, epiphyseal fracture, physeal injury, physeal fracture, epiphyseal plate injury, physis fracture, epiphyseal cartilage, growth plate injury, epiphyses, epiphyseal fracture, bone plate, sprain, strain, ankle fracture, ankle sprain, wrist fracture, wrist sprain, knee fracture, knee sprain, hip fracture, hip sprain
