Growth Plate Fractures of the Distal Femur

Abstract

Growth plate fractures of the distal femur are challenging to treat, with complications that require a secondary surgery 40% to 60% of the time. These fractures often necessitate operative intervention, even in the youngest patients and even with minimal apparent displacement. Treatment varies with the Salter-Harris (SH) classification and with the extent of initial displacement, ranging from simple casting for nondisplaced SH I fractures to open reduction and internal fixation for almost all SH III and IV fractures. Poor outcomes have been associated with pediatric fracture care of SH III and IV in 29% to 32% of cases. There are many pitfalls that have to be avoided in the treatment of these fractures to prevent malunion, growth arrest, and posttraumatic arthritis. CLASSIFICATIONThe standard Salter-Harris (SH) classification works well for these fractures, especially with regard to treatment and risk of growth arrest. The risk of growth arrest is reported to be between 40% and 52% for all distal femur growth plate fractures. 1,2 In a meta-analysis of 564 fractures, growth disturbance occurred in 36% of SH 1 fractures, in 58% of SH 2 fractures, in 49% of SH 3, and in 64% of SH 4 fractures. 1 High-energy distal femur growth plate fractures (eg, motor vehicle accident) have a 31% rate of growth disturbance compared with only a 5% rate for low-energy fractures (eg, fall from <10 ft). 2 Displaced fractures have a higher incidence of complications (49%) compared with nondisplaced fractures (27%). 3 In a retrospective review, the authors recommended subdivision of SH II fractures into those with and without metaphyseal comminution and/or initial displacement >3 mm with loss of contact between the 2 fragments. Those with comminution and displacement had a greater risk of growth arrest (75%) compared with those without (38%). 4 SH INondisplaced SH I fractures should be suspected when knee tenderness is localized circumferentially to the distal femur growth plate. With the knee in full extension, the equator of the patella usually overlies the growth plate, which helps to guide the examination. Gentle varus/valgus stress to the knee should elicit pain. Radiographic findings can be subtle in all minimally displaced growth plate fractures of the knee. A slight fleck of bone adjacent to the growth plate, a slight widening of the physis, or other irregularity of the growth plate can give a hint of a fracture. Sometimes, the only indication that a distal femur fracture has occurred may be the appearance of periosteal new bone formation about the metaphysis 3 weeks after injury. Stress views of the knee have fallen out of favor because of the severe pain experienced by the patient and the potential growth plate damage incurred when redisplacing a nondisplaced fracture. 5 Patients who have tenderness over the growth plate and are unable to bear weight should be FIGURE 1. Authors' preferred method of cross pin fixation for displaced Salter I and II fractures with pins exiting the skin proximally. This prevents the pins from passi...

Distal Femoral Physeal Fractures

“…Infants and obese children are more likely to benefit from spica casting. 5,11 Displaced fractures may require closed reduction Type IV 64% Fig. 1 (A, B) A 15-year-old male collided with another player while jumping for a rebound in a basketball game, and landed awkwardly on his right leg, sustaining a Salter-Harris type II fracture.…”

Biomechanical Effects of Four Different Configurations In Salter Harris Type 4 Distal Femoral Epiphyseal Fractures

“…The age of the person, type of fracture, degree of shear, sinuous structure of physis, quality of fracture reduction process and fixation shape [7][8][9][10].Thereis no final proof of evidence or biomechanical research that highlight which factors were effective in the formation of iatrogenic epiphysiodesis (bar formation and consequently growth interruption) in this area [17]. In contrast, in many studies growth retards was related to the fracture fixation of this type of fracture [33].According to our results, it has been found particularly advantageous to use fixation type in parallel screw configuration. The most important point in the treatment of the bone fractures is the elimination of the stress shielding [34].…”

Limb Lengthening and Reconstruction Surgery Case Atlas

“…Distal femoral growth plate injuries can often lead to growth arrest (Wall and May 2012) and an associated injury at the tibial tubercle can be missed (Bowler et al 1990;Fig. 1 Clinical photographs demonstrating the valgus and recurvatum deformity of the knee Domzalski and Mackenzie 2009).…”