Basics
Description
- 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 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.
- Most common during peak growth:
- 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
- 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 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.
- Type II:
- 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.
- Type III:
- 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.
- Type IV:
- 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.
- Type V:
- 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 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 Ranvier
- Ogden Type VII: Involves epiphysis only
- Peterson classification system, 1994:
- 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.
Etiology
- Competitive and recreational injuries
- Traumatic injuries
- Child abuse
- Extreme cold
- Radiation injury
- Genetic, neurologic, and metabolic disease
Diagnosis
Signs and Symptoms
History
- Most commonly occurs after a fall
- Extreme cold and radiation can injure the physeal plate.
Physical Exam
- 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
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
Imaging
- Plain radiography of injured extremity:
- Type I fractures:
- 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.
- Types II-IV: Films diagnostic of fracture
- Type V:
- Initial film often normal
- Subsequent 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 injury
- Can identify physeal arrest lines
- Recommended if diagnosis remains equivocal and identification of a specific fracture would alter management
Differential Diagnosis
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 obtained
- Copious irrigation with saline
- Sterile dressing
- Orthopedic consultation
- Consultation:
- Open fractures
- Type II with displacement and Types III and higher
Medication
First Line
Pain management:
- 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
If open:
- 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
Admission Criteria
- Open fractures
- Open surgical reduction required
- Consider with Type III and IV fractures
Discharge Criteria
- 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
Issues for Referral
All injuries involving the physis should follow-up with a musculoskeletal specialist.
Followup Recommendations
Usually necessary, especially with higher-grade injuries, to monitor limb length:
- Involves periodic physical exam and radiographic evaluation
Pearls and Pitfalls
- Long-term complications:
- Limb length discrepancy if entire growth plate affected
- Angulation 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.
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)