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Epiphyseal Injuries, Emergency Medicine

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Epiphyseal Injuries, Emergency Medicine

Basics

Description

All injuries involving the physis should follow-up with a musculoskeletal specialist.

Usually necessary, especially with higher-grade injuries, to monitor limb length:

  • Fractures through the physis accounts for 21-30% of pediatric long bone fractures with 30% of these leading to a growth disturbance:Most frequently seen in the distal radius and ulna, distal tibia and fibula, and the phalangesMore common than ligamentous injury in children:Tensile strength of pediatric bone is less than adjacent ligaments.Physis is the weakest part of pediatric bone.Similar injury in an adult usually causes a sprain.
  • Most common during peak growth:Females: Age 9-12Males: Age 12-15Much less common in infancy and early childhood because epiphysis is not ossified and acts as a shock absorber
  • Twice as common in males because female bones mature earlier
  • Salter-Harris (SH) classification (introduced in 1963, simplest and most commonly used classification system):Type I:Fracture line confined to physisComplete epiphyseal separation from metaphysis through the physisIf periosteum remains intact, epiphysis will not displace.Clinical diagnosis made with focal tenderness over the physisMost common example is SCFE.Growth disturbance is rare.Type II:Accounts for ~80% of physeal fracture patternsFracture propagates along physis, and fragment from metaphysis accompanies the displaced epiphysis (Thurston-Holland sign)Periosteum torn opposite metaphyseal fragmentGrowth is rarely disturbed.Type III:RareFracture through a portion of physis extending through the epiphysisDistal tibia most commonly affectedIf displaced, requires reduction to maintain anatomic alignmentGrowth disturbance may occur despite anatomic reduction because blood supply can be affected.Type IV:Fracture originates at articular surface.Extends through physis and into metaphysisDistal humerus most commonly affectedAlso has Thurston-Holland fragmentAnatomic reduction essential and displaced fractures require ORIFGrowth arrest is common even with optimal treatment.Type V:Results from severe crush injury to physisNo immediately visible radiographic alteration so almost impossible to diagnose initiallyCompression forces lead to physeal injuries and inevitable growth disturbances.Often found in retrospect
  • Ogden modified the SH system to include injuries to the surrounding anatomy-periosteum, perichondrium, and zone of Ranvier:Ogden Type VI: Involves the peripheral perichondrium including the zone of RanvierOgden Type VII: Involves epiphysis only
  • Peterson classification system, 1994:Result of a 10 yr retrospective studyShowed that 16% of physeal injuries could not be classified by the SH systemIncludes 2 different fracture patterns:Peterson Type I-transverse fracture through the metaphysis with 1 or more longitudinal extensions into the physis (this is similar to SH II except most of the energy is transmitted through the metaphysis, leading to a fracture, and not the physis; there is very little growth plate disturbance, this was actually the most common fracture pattern found)Peterson Type VI-a part of the epiphysis, physis, and metaphysis are missing due to an open injury, classically by a lawnmower. Severe growth disturbance.Peterson Types II-V are similar to the SH II-V.
  • Most frequently seen in the distal radius and ulna, distal tibia and fibula, and the phalanges
  • More common than ligamentous injury in children:
  • Tensile strength of pediatric bone is less than adjacent ligaments.
  • Physis is the weakest part of pediatric bone.
  • Similar injury in an adult usually causes a sprain.
  • Females: Age 9-12
  • Males: Age 12-15
  • Much less common in infancy and early childhood because epiphysis is not ossified and acts as a shock absorber
  • Type I:Fracture line confined to physisComplete epiphyseal separation from metaphysis through the physisIf periosteum remains intact, epiphysis will not displace.Clinical diagnosis made with focal tenderness over the physisMost common example is SCFE.Growth disturbance is rare.
  • Type II:Accounts for ~80% of physeal fracture patternsFracture propagates along physis, and fragment from metaphysis accompanies the displaced epiphysis (Thurston-Holland sign)Periosteum torn opposite metaphyseal fragmentGrowth is rarely disturbed.
  • Type III:RareFracture through a portion of physis extending through the epiphysisDistal tibia most commonly affectedIf displaced, requires reduction to maintain anatomic alignmentGrowth disturbance may occur despite anatomic reduction because blood supply can be affected.
  • Type IV:Fracture originates at articular surface.Extends through physis and into metaphysisDistal humerus most commonly affectedAlso has Thurston-Holland fragmentAnatomic reduction essential and displaced fractures require ORIFGrowth arrest is common even with optimal treatment.
  • Type V:Results from severe crush injury to physisNo immediately visible radiographic alteration so almost impossible to diagnose initiallyCompression forces lead to physeal injuries and inevitable growth disturbances.Often found in retrospect
  • Fracture line confined to physis
  • Complete epiphyseal separation from metaphysis through the physis
  • If periosteum remains intact, epiphysis will not displace.
  • Clinical diagnosis made with focal tenderness over the physis
  • Most common example is SCFE.
  • Growth disturbance is rare.
  • Accounts for ~80% of physeal fracture patterns
  • Fracture propagates along physis, and fragment from metaphysis accompanies the displaced epiphysis (Thurston-Holland sign)
  • Periosteum torn opposite metaphyseal fragment
  • Growth is rarely disturbed.
  • Rare
  • Fracture through a portion of physis extending through the epiphysis
  • Distal tibia most commonly affected
  • If displaced, requires reduction to maintain anatomic alignment
  • Growth disturbance may occur despite anatomic reduction because blood supply can be affected.
  • Fracture originates at articular surface.
  • Extends through physis and into metaphysis
  • Distal humerus most commonly affected
  • Also has Thurston-Holland fragment
  • Anatomic reduction essential and displaced fractures require ORIF
  • Growth arrest is common even with optimal treatment.
  • Results from severe crush injury to physis
  • No immediately visible radiographic alteration so almost impossible to diagnose initially
  • Compression forces lead to physeal injuries and inevitable growth disturbances.
  • Often found in retrospect
  • Ogden Type VI: Involves the peripheral perichondrium including the zone of Ranvier
  • Ogden Type VII: Involves epiphysis only
  • Result of a 10 yr retrospective study
  • Showed that 16% of physeal injuries could not be classified by the SH system
  • Includes 2 different fracture patterns:Peterson Type I-transverse fracture through the metaphysis with 1 or more longitudinal extensions into the physis (this is similar to SH II except most of the energy is transmitted through the metaphysis, leading to a fracture, and not the physis; there is very little growth plate disturbance, this was actually the most common fracture pattern found)Peterson Type VI-a part of the epiphysis, physis, and metaphysis are missing due to an open injury, classically by a lawnmower. Severe growth disturbance.Peterson Types II-V are similar to the SH II-V.
  • Peterson Type I-transverse fracture through the metaphysis with 1 or more longitudinal extensions into the physis (this is similar to SH II except most of the energy is transmitted through the metaphysis, leading to a fracture, and not the physis; there is very little growth plate disturbance, this was actually the most common fracture pattern found)
  • Peterson Type VI-a part of the epiphysis, physis, and metaphysis are missing due to an open injury, classically by a lawnmower. Severe growth disturbance.
  • Peterson Types II-V are similar to the SH II-V.

Etiology

  • Competitive and recreational injuries
  • Traumatic injuries
  • Child abuse
  • Extreme cold
  • Radiation injury
  • Genetic, neurologic, and metabolic disease

Diagnosis

Signs and Symptoms

  • Most commonly occurs after a fall
  • Extreme cold and radiation can injure the physeal plate.
  • Focal tenderness
  • Swelling
  • Limited mobility
  • If lower extremity involved, patient may be nonweight bearing
  • Joint laxity:Can be due to physeal injury and not ligamentous injury
  • Can be due to physeal injury and not ligamentous injury

Essential Workup

  • Radiographs to classify the extent of the injury
  • Assess pulses and capillary filling distal to injury.
  • Evaluate distal motor and sensory function.
  • Verify integrity of skin overlying injury.
  • Address and manage coexisting injuries.

Diagnosis Tests & Interpretation

  • Plain radiography of injured extremity:Type I fractures:Usually normalMay appreciate a slightly separated physis or an associated joint effusionConsider comparison views of contralateral joint to detect small defects.Callus may be present on follow-up films.Types II-IV: Films diagnostic of fractureType V:Initial film often normalSubsequent radiographs may reveal premature bone arrest.
  • Ultrasound can be helpful in infants whose cartilage has not ossified.
  • CT scan: Helpful in assessing orientation of comminuted fragments
  • MRI:Most accurate in the acute phase of injuryCan identify physeal arrest linesRecommended if diagnosis remains equivocal and identification of a specific fracture would alter management
  • Type I fractures:Usually normalMay appreciate a slightly separated physis or an associated joint effusionConsider comparison views of contralateral joint to detect small defects.Callus may be present on follow-up films.
  • Types II-IV: Films diagnostic of fracture
  • Type V:Initial film often normalSubsequent radiographs may reveal premature bone arrest.
  • Usually normal
  • May appreciate a slightly separated physis or an associated joint effusion
  • Consider comparison views of contralateral joint to detect small defects.
  • Callus may be present on follow-up films.
  • Initial film often normal
  • Subsequent radiographs may reveal premature bone arrest.
  • Most accurate in the acute phase of injury
  • Can identify physeal arrest lines
  • Recommended if diagnosis remains equivocal and identification of a specific fracture would alter management

Differential Diagnosis

  • Strain
  • Sprain
  • Contusion

Treatment

Pre-Hospital

  • Immobilize limb in position found if no compromise in vascular status
  • Apply ice or cold packs to injury.
  • Assess injured extremity for neurologic and vascular function.
  • Consider concomitant injuries.

Initial Stabilization/Therapy

  • Analgesia
  • Apply sterile dressings to open wounds.
  • Control bleeding of open wounds.

Ed Treatment/Procedures

  • Reduction/alignment required in displaced fractures:Need to achieve anatomic alignment
  • Vascular or neurologic compromise distal to injury requires immediate intervention.
  • Immobilization of all suspected or radiographically confirmed physeal injuries:Splint must immobilize joint proximal and distal to injury in anatomic alignment and neutral position.Limit activity of the injured limb.
  • Open fractures:IV antibiotics for Staphylococcus aureus, group A streptococcus, and potential anaerobes depending on mechanism and after cultures are obtainedCopious irrigation with salineSterile dressingOrthopedic consultation
  • Consultation:Open fracturesType II with displacement and Types III and higher
  • Need to achieve anatomic alignment
  • Splint must immobilize joint proximal and distal to injury in anatomic alignment and neutral position.
  • Limit activity of the injured limb.
  • IV antibiotics for Staphylococcus aureus, group A streptococcus, and potential anaerobes depending on mechanism and after cultures are obtained
  • Copious irrigation with saline
  • Sterile dressing
  • Orthopedic consultation
  • Open fractures
  • Type II with displacement and Types III and higher

Medication

  • Fentanyl: 2-3 μg/kg IV; transmucosal lollipops 5-15 μg/kg, max. 400 mg; contraindicated if <10 kg
  • Morphine: 0.1 mg/kg IV/IM
  • Cefazolin: 25-50 mg/kg/d IV/IM q6-8h
  • Penicillin G: 100,000-300,000 U/kg/24 h IM, or IV in 4-6 div. doses-has better strep and corynebacterium coverage-for farm injuries
  • Gentamicin: 5-7.5 mg/kg/d-for obviously contaminated injuries

Follow-Up

Disposition

  • Open fractures
  • Open surgical reduction required
  • Consider with Type III and IV fractures
  • Low-grade fractures and fractures with higher grade if follow-up is definite
  • Splint
  • Analgesics
  • Ice packs
  • Elevation of affected limb
  • Orthopedic follow-up within 1 wk

Followup Recommendations

  • Involves periodic physical exam and radiographic evaluation

Pearls and Pitfalls

  • Long-term complications:Limb length discrepancy if entire growth plate affectedAngulation if only a part of the physis is affected
  • In patients with suspected SH fracture and negative radiograph, immobilization with follow-up in a few days is appropriate.
  • Limb length discrepancy if entire growth plate affected
  • Angulation if only a part of the physis is affected

Additional Reading

  • Rathjen KE, Birch JG. Physeal injuries andgrowth disturbances. In: Beaty JH,Kasser JR,eds. Rockwood & Wilkins'Fractures in Children. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins;2006:11.
  • Rodr ­guez-Merch ¡n EC. Pediatric skeletal trauma: A review and historical perspective. Clin Orthop Relat Res. 2005;432:8-13.
  • Salter R, Harris W. Injuries involving the epiphyseal plate. J Bone Joint Surg. 1963;45:587-622.
  • Wilkins KE, Aroojis AJ. Incidence of fractures in children. In: Beaty JH, Kasser JR, eds. Rockwood & Wilkins' Fractures in Children. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

Codes

ICD9

  • 812.09 Other closed fracture of upper end of humerus
  • 813.42 Other closed fractures of distal end of radius (alone)
  • 813.43 Closed fracture of distal end of ulna (alone)
  • 824.8 Unspecified fracture of ankle, closed

ICD10

  • S49.009A Unsp physeal fx upper end of humerus, unsp arm, init
  • S59.009A Unsp physeal fracture of lower end of ulna, unsp arm, init
  • S59.209A Unsp physeal fracture of lower end of radius, unsp arm, init
  • S89.309A Unsp physeal fracture of lower end of unsp fibula, init
  • S89.109A Unsp physeal fracture of lower end of unsp tibia, init

SNOMED

  • 208244008 Closed fracture of humerus, upper epiphysis (disorder)
  • 208318005 Closed fracture of ulna, lower epiphysis (disorder)
  • 263199001 Fracture of distal end of radius (disorder)
  • 263242001 Fracture of distal end of fibula (disorder)
  • 240172008 Disorder of epiphysis (disorder)
  • 278537006 Fracture of distal end of tibia (disorder)