Growth Plate Injuries
Joshua Klatt, 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
Disuse
Radiation
Infection
Tumor
Vascular impairment
Metabolic abnormality
– Frostbite
– Chronic Stress
– Iatrogenic injury
– Neural involvement
– Electrical Injuries
– Burns
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
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–
–
–
–
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
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, 19791988. J Pediatr Orthop. 1994;14(4):423-430.
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
(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
–
–
–
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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
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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
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•
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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