Growth Plate (Physeal) Fractures Workup

  • Author: Charles T Mehlman, DO, MPH; Chief Editor: Dennis P Grogan, MD   more...
 
Updated: Sep 29, 2010
 

Imaging Studies

  • Many acute physeal injuries are not clearly visible on plain radiographs due to the cartilaginous-osseous nature and irregular contours of the physes.
    • Plain radiographs may depict physeal widening as the only sign of displacement. In order to help delineate the injury, 2 views (anteroposterior and lateral) are necessary. Occasionally, comparison views of the opposite extremity may be helpful. Comparison views can help establish occult separation of the physis, as in an SH I injury.
    • Radiographic stress views (varus and valgus) may be indicated in certain patients. They are not recommended in all instances, as stress maneuvers may cause further physeal damage. However, stress radiographs may be necessary in order to accurately diagnose physeal plate injury. Stress views may prove particularly useful to demonstrate separation between the epiphysis and metaphysis in injuries around the knee and elbow.[10]
  • CT scans are at times necessary to delineate fragmentation and orientation of severely comminuted epiphyseal and metaphyseal fractures.[11]
  • Bone scans are not particularly helpful, as the physes are normally relatively active on nuclear scans.
  • Magnetic resonance imaging (MRI) has proven to be the most accurate evaluation tool for the fracture anatomy when performed in the acute phase of injury (initial 10 d). MRI can depict altered arrest lines and transphyseal bridging abnormalities prior to their being evident on plain radiographs.[12]
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Charles T Mehlman, DO, MPH  Professor of Pediatrics and Pediatric Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Director, Musculoskeletal Outcomes Research, Cincinnati Children's Hospital Medical Center

Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics, American Fracture Association, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society, Ohio State Medical Association, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society

Disclosure: Nothing to disclose.

Coauthor(s)

Matthew E Koepplinger, DO  Assistant Professor, Department of Orthopaedic Surgery, Baylor College of Medicine; Staff Physician, Department of Orthopaedic Surgery, Ben Taub General Hospital, Houston

Matthew E Koepplinger, DO is a member of the following medical societies: American Osteopathic Academy of Orthopedics and American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mininder S Kocher, MD, MPH  Associate Professor of Orthopedic Surgery, Harvard Medical School/Harvard School of Public Health; Associate Director, Division of Sports Medicine, Department of Orthopedic Surgery, Children's Hospital Boston

Mininder S Kocher, MD, MPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the History of Medicine, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, Massachusetts Medical Society, and Pediatric Orthopaedic Society of North America

Disclosure: Smith & Nephew Endoscopy Consulting fee Consulting; EBI Biomet Consulting fee Consulting; OrthoPediatrics Consulting fee Consulting; Pivot Medical Stock Consulting; pediped Consulting fee Consulting; WB Saunders Royalty None; Fixes-4-Kids Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

George H Thompson, MD  Director of Pediatric Orthopedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, and MetroHealth Medical Center; Professor of Orthopedic Surgery and Pediatrics, Case Western Reserve University School of Medicine

George H Thompson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society

Disclosure: OrthoPediatrics None Consulting; Journal of Pediatric Orthopaedics Salary Management position

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Dennis P Grogan, MD  Clinical Professor, Department of Orthopedic Surgery, University of South Florida College of Medicine; Chief of Staff, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

Dennis P Grogan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society

Disclosure: Nothing to disclose.

References

  1. 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. May-June/ 2006;26:322-328.

  2. 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. May-Jun 2006;26(3):322-8. [Medline].

  3. Lee SH, Lee DH, Baek JR. Proximal humerus Salter type III physeal injury with posterior dislocation. Arch Orthop Trauma Surg. Feb 2007;127(2):143-6. [Medline].

  4. Havranek P, Pesl T. Salter (Rang) type 6 physeal injury. Eur J Pediatr Surg. May 2010;20(3):174-7. [Medline].

  5. Rang M, ed. The Growth Plate and Its Disorders. Baltimore: Williams & Wilkins; 1969.

  6. Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop. Nov-Dec 1990;10(6):713-6. [Medline].

  7. Neer CS, Horowitz BS. Fractures of the proximal humeral epiphyseal plate. Clin Orthop Rel Res. 1965;41:24-31. [Medline].

  8. Bright RW. Physeal injuries. In: Fractures: Fractures in Children. 3rd ed. Lippincott-Raven;1991: 87-186.

  9. Langenskiold A. Role of the ossification groove of Ranvier in normal and pathologic bone growth: a review. J Pediatr Orthop. Mar-Apr 1998;18(2):173-7. [Medline].

  10. Shrader MW. Pediatric supracondylar fractures and pediatric physeal elbow fractures. Orthop Clin North Am. Apr 2008;39(2):163-71, v. [Medline].

  11. Cutler L, Molloy A, Dhukuram V, Bass A. Do CT scans aid assessment of distal tibial physeal fractures?. J Bone Joint Surg Br. Mar 2004;86(2):239-43. [Medline].

  12. Boutis K, Narayanan UG, Dong FF, Mackenzie H, Yan H, Chew D, et al. Magnetic resonance imaging of clinically suspected Salter-Harris I fracture of the distal fibula. Injury. May 20 2010;[Medline].

  13. Basener CJ, Mehlman CT, DiPasquale TG. Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis. J Orthop Trauma. Oct 2009;23(9):663-7. [Medline].

  14. 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. Jun 2009;29(4):356-61. [Medline].

  15. Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. Sep 2007;27(6):703-8. [Medline].

  16. Riseborough EJ, Barrett IR, Shapiro F. Growth disturbances following distal femoral physeal fracture separations. J Bone Joint Surg Am. Sep 1983;65(7):885-93. [Medline].

  17. Kling TF Jr, Bright RW, Hensinger RN. Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am. Jun 1984;66(5):647-57. [Medline].

  18. Barmada A, Gaynor T, Mubarak SJ. Premature Physeal Closure Following Distal Tibia Physeal Fractures - A New Radiographic Predictor. J Pediatr Orthop. Nov-Dec/ 2003;23:733-739.

  19. Nietosvaara Y, Hasler C, Helenius I, Cundy P. Marked initial displacement predicts complications in physeal fractures of the distal radius: an analysis of fracture characteristics, primary treatment and complications in 109 patients. Acta Orthop. Dec 2005;76(6):873-7. [Medline].

  20. Lee BS, Esterhai JL Jr, Das M. Fracture of the distal radial epiphysis. Characteristics and surgical treatment of premature, post-traumatic epiphyseal closure. Clin Orthop. May 1984;(185):90-6. [Medline].

  21. Moore MS, Mackenzie WG. Fracture of the proximal tibial epiphysis. Clinical Case Presentation: Alfred I. Dupont Institute. April 4, 1996.

  22. Bucholz RW, Ezaki M, Ogden JA. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am. Apr 1982;64(4):600-9. [Medline].

  23. Pinckney LE, Currarino G, Kennedy LA. The stubbed great toe: a cause of occult compound fracture and infection. Radiology. Feb 1981;138(2):375-7. [Medline].

  24. Seymour N. Juxta-epiphysial fracture of the terminal phalanx of the finger. J Bone Joint Surg Br. May 1966;48(2):347-9. [Medline].

  25. Leboy P, Grasso-Knight G, D'Angelo M. Smad-Runx interactions during chondrocyte maturation. J Bone Joint Surg Am. 2001;83-A Suppl 1(Pt 1):S15-22. [Medline].

  26. Buxton P, Edwards C, Archer CW. Growth/differentiation factor-5 (GDF-5) and skeletal development. J Bone Joint Surg Am. 2001;83-A Suppl 1(Pt 1):S23-30. [Medline].

  27. Ahn JJ, Rho JY, Canale T. Mesenchymal stem cells therapy in growth plate cartilage injury. POSNA Annual Meeting Bulletin. 2002;81.

  28. Aizawa T, Kokubun S, Kawamata T. c-Myc protein in the rabbit growth plate. Changes in immunolocalisation with age and possible roles from proliferation to apoptosis. J Bone Joint Surg Br. Sep 1999;81(5):921-5. [Medline].

  29. Balogh K Jr, Kunin AS. The effect of cortisone on the metabolism of epiphyseal cartilage. A histochemical study. Clin Orthop. Oct 1971;80:208-15. [Medline].

  30. Beecroft M, Sherman SC. Posterior displacement of a proximal epiphyseal clavicle fracture. J Emerg Med. Oct 2007;33(3):245-8. [Medline].

  31. Boyan BD, Lohmann CH, Romero J. Bone and cartilage tissue engineering. Clin Plast Surg. Oct 1999;26(4):629-45, ix. [Medline].

  32. Brighton CT. Longitudinal Bone Growth: The growth Plate and Its Dysfunctions. Instructional Course Lectures. 1987;36:3-25.

  33. Brighton CT. Structure and function of the growth plate. Clin Orthop. Oct 1978;(136):22-32. [Medline].

  34. Buckwalter JA, Mower D, Schafer J. Growth-plate-chondrocyte profiles and their orientation. J Bone Joint Surg Am. Jul 1985;67(6):942-55. [Medline].

  35. Caine D, DiFiori J, Maffulli N. Physeal injuries in children's and youth sports: reasons for concern?. Br J Sports Med. Sep 2006;40(9):749-60. [Medline].

  36. Canale ST. Physeal injuries. In: Lampert R, ed. Skeletal Trauma in Children. 2nd ed. WB Saunders Co;1997: 17-58.

  37. Celeste AJ, Iannazzi JA, Taylor RC. Identification of transforming growth factor beta family members present in bone-inductive protein purified from bovine bone. Proc Natl Acad Sci U S A. Dec 1990;87(24):9843-7. [Medline].

  38. Cook SD, Dalton JE, Tan EH. In vivo evaluation of recombinant human osteogenic protein (rhOP-1) implants as a bone graft substitute for spinal fusions. Spine. Aug 1 1994;19(15):1655-63. [Medline].

  39. Cook SD, Rueger DC. Osteogenic protein-1: biology and applications. Clin Orthop. Mar 1996;(324):29-38. [Medline].

  40. Flechtenmacher J, Huch K, Thonar EJ. Recombinant human osteogenic protein 1 is a potent stimulator of the synthesis of cartilage proteoglycans and collagens by human articular chondrocytes. Arthritis Rheum. Nov 1996;39(11):1896-904. [Medline].

  41. Hui JHP, Li L, Goh CH. Chitin as a scaffold for mesenchymal stem cells transfers in the treatment of partial growth arrest. POSNA Annual Meeting Bulletin. 2002;1:82.

  42. Jouve JL, Cottalorda J, Mottet V. Reimplantation of growth plate chondrocyte cultures in central growth plate defects: Part II. Surgical experimentation in rabbits. J Pediatr Orthop B. Apr 1998;7(2):174-8. [Medline].

  43. Jouve JL, Mottet V, Cottalorda J. Reimplantation of growth plate chondrocyte cultures in central growth plate defects: Part I. Characterization of cultures. J Pediatr Orthop B. Apr 1998;7(2):167-73. [Medline].

  44. Mason JM, Breitbart AS, Barcia M. Cartilage and bone regeneration using gene-enhanced tissue engineering. Clin Orthop. Oct 2000;(379 Suppl):S171-8. [Medline].

  45. Mehlman CT, Araghi A, Roy DR. Hyphenated history: the Hueter-Volkmann law. Am J Orthop. Nov 1997;26(11):798-800. [Medline].

  46. Moen CT, Pelker RR. Biomechanical and histological correlations in growth plate failure. J Pediatr Orthop. Mar 1984;4(2):180-4. [Medline].

  47. O'Keefe RJ, Crabb ID, Puzas JF. Effects of transforming growth factor-beta 1 and fibroblast growth factor on DNA synthesis in growth plate chondrocytes are enhanced by insulin-like growth factor-L. J Orthop Res. May, 1994;12 (3):299-310. [Medline].

  48. Oni OO. The microvascular anatomy of the physis as revealed by osteomedullography and correlated histology. Orthopedics. Feb 1999;22(2):239-41. [Medline].

  49. Ozkaynak E, Schnegelsberg PN, Jin DF. Osteogenic protein-2. A new member of the transforming growth factor- beta superfamily expressed early in embryogenesis. J Biol Chem. Dec 15 1992;267(35):25220-7. [Medline].

  50. Pazzaglia UE, Andrini L, Leutner M. The effects of bone resorption inhibitors on the growth plate and proximal tibial metaphysis of rats: clinical implications. Orthopedics. Feb 1998;21(2):195-9. [Medline].

  51. Peterson HA. Physeal & apophyseal injuries. In: Rockwood CA, Wilkins KE, Beaty JH, eds. Fractures in Children. 4th ed. Lippincott-Raven;1996.

  52. Poland J. Traumatic separation of the epiphyses in general. Clin Orthop. 1985;41:7-18.

  53. Porter RW. The effect of tension across a growing epiphysis. J Bone Joint Surg Br. May 1978;60-B(2):252-5. [Medline].

  54. Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg Am. 1963;45-A:587-622.

  55. Stanitski C, Sherman C. How I manage physeal fractures about the knee. Phys Sportsmed. Apr 1997;25(4):108-21. [Medline]. [Full Text].

  56. Stevens PM, MacWilliams BA. Pre and post-operative gait analysis of stapling for genu valgum. POSNA Annual Meeting Bulletin. 2002;1:79.

  57. Sumner DR, Turner TM, Purchio AF. Enhancement of bone ingrowth by transforming growth factor-beta. J Bone Joint Surg Am. Aug 1995;77(8):1135-47. [Medline].

  58. Trippel SB, Wroblewski J, Makower AM. Regulation of growth-plate chondrocytes by insulin-like growth-factor I and basic fibroblast growth factor. J Bone Joint Surg Am. Feb 1993;75(2):177-89. [Medline].

  59. Wang EA, Rosen V, Cordes P. Purification and characterization of other distinct bone-inducing factors. Proc Natl Acad Sci U S A. Dec 1988;85(24):9484-8. [Medline].

  60. Wozney JM. The bone morphogenetic protein family and osteogenesis. Mol Reprod Dev. Jun 1992;32(2):160-7. [Medline].

 
Previous
Next
 
Growth plate (physeal) fractures. John Hunter (1728-1793), the "father of the growth plate."
Growth plate (physeal) fractures. Clinical appearance of the knee of a patient with a minimally displaced Salter-Harris I fracture of the distal femur. Impressive swelling was noted adjacent to the joint, but no evidence of intra-articular swelling was present. The patient was markedly tender to palpation about the distal femoral physis.
Growth plate (physeal) fractures. Anteroposterior radiograph of the knee of the patient in the previous image. Note subtle physeal widening confirming the diagnosis of a Salter-Harris I fracture of the distal femur.
Growth plate (physeal) fractures. Anteroposterior ankle radiograph demonstrating an impressively displaced Salter-Harris II fracture of the distal tibial epiphysis (along with comminuted fracture of distal fibular diaphysis).
Growth plate (physeal) fractures. Displaced Salter-Harris II fracture of the distal femur. The large Thurstan Holland (metaphyseal) fragment may serve an important fixation point for either a Steinmann pin or a lag screw.
Growth plate (physeal) fractures. Multiple computed tomography (CT) scan images depicting a displaced Salter-Harris III fracture of the distal anterolateral tibial epiphysis (ie, Tillaux fracture).
Growth plate (physeal) fractures. Displaced Salter-Harris IV fracture of the proximal tibia. The lateral portion of the epiphysis (with the Thurstan Holland fragment) and the medial portion of the epiphysis are independently displaced (ie, each are free-floating fragments).
Growth plate (physeal) fractures. The Salter-Harris V fracture pattern must be strongly suspected whenever the mechanism of injury includes significant compressive forces. This is the initial injury radiograph of a child's ankle that was subjected to significant compressive and inversion forces. It demonstrates minimally displaced fractures of the tibia and fibula with apparent maintenance of distal tibial physeal architecture.
Growth plate (physeal) fractures. Follow-up radiograph of the ankle of the child in the preceding image. This radiograph depicts growth arrest secondary to the Salter-Harris V nature of the injury. Note the markedly asymmetric Park-Harris growth recovery line, indicating that the lateral portion of the growth plate continues to function and the medial portion does not.
Growth plate (physeal) fractures. Mortise radiograph demonstrating somewhat subtle physeal injury to distal tibia. The Salter-Harris VI pattern may be suspected based upon history and physical examination findings. In this case, the radiograph indicates that it is quite likely that a small portion of the peripheral medial physis (as well as a small amount of adjacent epiphyseal and metaphyseal bone) has been avulsed.
Growth plate (physeal) fractures. Clinical photograph of the patient above with the displaced Salter-Harris II fracture of the distal femur. This mechanism of injury and physical examination findings are consistent with the Salter-Harris VI physeal injury pattern. Some may also refer to this injury type as a Kessel fracture.
Growth plate (physeal) fractures. Radiographic evidence of a pediatric stubbed great toe.
Growth plate (physeal) fractures. Clinical appearance of a pediatric stubbed great toe. Note the subungual hematoma, representative of an open fracture.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.