Growth Plate Fractures (Physeal Fractures) Differential Diagnoses

Updated: Dec 13, 2021
  • Author: Steven I Rabin, MD, FAAOS; Chief Editor: Jeffrey D Thomson, MD  more...
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DDx

Diagnostic Considerations

A high index of suspicion is required to diagnose many growth plate injuries. If initial images are normal but clinical examination reveals tenderness over a physis, additional images including oblique images, comparison views of the opposite side, computed tomography (CT), or magnetic resonance imaging (MRI) may be indicated.  Misdiagnosis of a physeal injury as a sprain can result in long-term complications from growth deformity including growth arrest and arthritis.

An example is provided by the case of a child with knee pain and tenderness over the physis in whom routine anteroposterior (AP) and lateral imaging do not show the fracture (see the first image below). An inexpensive oblique x-ray easily reveals the Salter-Harris (SH) type III fracture of the distal femur (see the second image below).

Growth plate (physeal) fractures. Anteroposterior Growth plate (physeal) fractures. Anteroposterior and lateral views of distal femur Salter-Harris III fracture where fracture is not well seen.
Growth plate (physeal) fractures. Oblique view of Growth plate (physeal) fractures. Oblique view of distal femur reveals Salter-Harris III fracture of distal femur.

Another example is provided by the case of a patient with ankle pain in whom plain radiographs do not show the Tillaux fracture of the distal tibia (see the first image below) but a CT scan clearly reveals the pathology (see the second image below).

Growth plate (physeal) fractures. Tillaux fracture Growth plate (physeal) fractures. Tillaux fracture of distal tibia epiphysis that is not well seen on anteroposterior radiograph.
Growth plate (physeal) fractures. Tillaux fracture Growth plate (physeal) fractures. Tillaux fracture that was not well seen on plain radiographs is now relatively easy to see on axial CT image.

Differential Diagnoses