Premature Physeal Closure Following Distal Tibia Physeal Fractures

Abstract

The incidence and predictors of premature physeal closure (PPC) after pediatric distal tibial fractures were investigated. PPC was defined as evidence of growth plate disturbance on the injured side compared with the uninjured side. Ninety-two fractures were reviewed with at least 1 year of follow-up, or until physiologic closure of the growth plates. Twenty-five fractures (27.2%) were complicated by PPC, as confirmed by CT scan in most cases. Salter-Harris III and IV (medial malleolar type) fractures resulted in the highest percentage of PPC by fracture type (38%). Salter-Harris I and II fractures resulted in PPC in 36% of cases, followed by triplane fractures (21%) and Tillaux fractures (0%). Initial displacement, number of reduction attempts, or treatment method did not significantly affect the incidence of PPC. More anatomic reductions resulted in a statistically significant decrease in PPC rates. Residual physeal gap (>3 mm) following reduction was determined from radiographs in Salter-Harris I and II fractures. If a residual gap was seen on the radiograph, the incidence of PPC increased to 60%; if no gap was present, the incidence decreased to 17%. Open reduction was performed in five Salter-Harris II fractures that had a residual gap. Periosteum was entrapped in the physis in all of these cases. Residual gaps in the physis following closed reduction may represent entrapped periosteum in Salter-Harris I and II fractures. This can lead to a higher incidence of PPC, suggesting that open reduction and removal of the entrapped periosteum may be beneficial.

Fractures of the Foot and Ankle in Children

“…Recent studies have suggested that Salter-Harris 1 and 2 fractures may have a higher rate of growth arrest than previously thought, perhaps up to 40 % [2,27]. In one study of Salter Harris 1 and 2 fractures, rates of premature physeal closure of 60 % were seen if the residual fracture gap was greater than 3 mm radiographically, and this gap often represented trapped periosteum [2]. Depending on the size and location of the growth arrest, and on the age of the child, premature closure may result in varus or valgus deformity, with or without shortening of the injured side (Figs.…”

“…Damage may occur at the time of initial injury, although anatomical reduction is also vital to prevent arrest secondary to displacement. Recent studies have suggested that Salter-Harris 1 and 2 fractures may have a higher rate of growth arrest than previously thought, perhaps up to 40 % [2,27]. In one study of Salter Harris 1 and 2 fractures, rates of premature physeal closure of 60 % were seen if the residual fracture gap was greater than 3 mm radiographically, and this gap often represented trapped periosteum [2].…”

Pediatric Ankle Fractures

“…Repeated or delayed manipulation of physeal fractures should be avoided, so as to avoid additional damage to the physis with incurrent risks of premature closure. 38, 41 …”

“…12, 38, 41, 49, 50 Fracture type, high energy trauma, higher initial displacement and multiple manipulation attempts are associated with growth arrest. 38 Barmada et al found higher rates of physeal arrest (60% vs. 17%) if a residual gap > 3 mm was seen at the physis for SH-I and II fracture patterns, 41 and recommended open reduction to remove entrapped periosteum in these settings.…”

Preclinical Studies on Mesenchymal Stem Cell-Based Therapy for Growth Plate Cartilage Injury Repair

“…Other types of fractures, types III, IV, and V, however, may/will all result in bony formation at the injured site [13]. It has been estimated that in up to 30% of all children with growth plate-related injuries, undesirable bony repair, and bone bridge at the injury site hinder normal growth of the developing long bone in the affected limb [14, 15], which results in significant orthopaedic problems such as limb length discrepancy and bone angulation deformity [15, 16]. …”