Physeal fractures: Part 1. Epidemiology in Olmsted County, Minnesota, 1979-1988

Risk Factor Analysis for Growth Arrest in Paediatric Physeal Fractures-A Prospective Study

Background: Fractures through the physis account for 18-30% of all paediatric fractures, leading to growth arrest in up to 5.5% of cases. We have limited knowledge to predict which physeal fractures result in growth arrest and subsequent deformity or limb length discrepancy. The purpose of this study is to identify factors associated with physeal growth arrest to improve patient outcomes. Methods: This prospective cohort study was designed to develop a clinical prediction model for growth arrest after physeal injury. Patients ≤ 18 years old presenting within four weeks of injury were enrolled if they had open physes and sustained a physeal fracture of the humerus, radius, ulna, femur, tibia or fibula. Patients with prior history of same-site fracture or a condition known to alter bone growth or healing were excluded. Demographic data, potential prognostic indicators, and radiographic data were collected at baseline, during healing, and at one- and two-years post-injury. Results: A total of 332 patients had at least six months of follow-up or a diagnosis of growth arrest within six months of injury. In a comparison analysis, patients who developed growth arrest were more likely to be older (12.8 years vs. 9.4 years) and injured on the right side (53.0% vs. 45.7%). Initial displacement and angulation rates were higher in the growth arrest group (59.0% vs. 47.8% and 47.0% vs. 38.8%, respectively), but the amount of angulation was similar (27.0° vs. 28.4°). Rates of growth arrest were highest in distal femoral fractures (86%). Conclusions: The incidence of growth arrest in this patient population appears higher than the past literature reports at 30.1%. However, there may be variances in diagnostic criteria for growth arrest, and the true incidence may be lower. A number of patients were approaching skeletal maturity, and any growth arrest is likely to have less clinical significance in these cases. Further prospective long-term follow-up is required to determine risk factors, incidence, and true clinical impact of growth arrest when it does occur.

Functional Walker Boots are Preferred to Synthetic Casts by Patients and Carers in the Management of Pediatric Stable Ankle Injuries

INTRODUCTION

Traditionally children who presented with a stable ankle injury have been managed in a below-knee synthetic cast. No previous study has investigated patient and parents/carer preference between synthetic casts and walker boots.

METHODS

Children aged between 6 and 16 years who presented with stable ankle injuries (ankle sprains, small fragment avulsions, and fibular Salter-Harris 1 injuries) were randomized to receive treatment with either a synthetic cast or a walker boot. A tailored, study-specific questionnaire was designed and completed at 4 weeks from injury to evaluate both patient and parents/carer preference. An analysis of costs associated with both treatments was performed.

RESULTS

Ninety-one patients were available for final analysis. Forty-seven received synthetic cast treatment and 44 walker boot treatment. Patient demographics and injury types were matched between groups.Statistical significance was found in favor of the walker boot with regard to comfort, reduction in activity during treatment, and patient-reported problems at the end of treatment. There was a strong and significant preference toward treatment with the walker boot, both from patients and parents/carers. There was no difference between groups with regard to walking ability, analgesia requirement, and patient-reported pain scores.Unplanned attendances to the hospital during the treatment period were higher in the synthetic cast group. The overall treatment cost per patient was lower with the walker boot.

CONCLUSIONS

In children who present with stable ankle injuries, treatment in a walker boot is preferred by both patients and parents/carers. It results in fewer unplanned attendances to the hospital, is less expensive, and we recommend it as the treatment of choice in stable pediatric ankle injuries.

LEVEL OF EVIDENCE

Level II.

Youth soccer players: patterns of injury involving the primary growth plates of epiphyses

Youth soccer (football) is immensely popular internationally. Earlier participation, sport sub-specialization, and year-around practice have led to an increased incidence of injury from both acute trauma and repetitive overuse. The growth plates (physes) of the immature skeleton are particularly vulnerable to injury and delayed diagnosis can lead to future growth disturbance and long-term morbidity. Familiarity with the various components of the growth plate complex necessary for ensuring normal endochondral ossification is fundamental in understanding the various patterns of imaging findings following injury. This review discusses the zonal columnar arrangement of the growth plate proper and the contrasting function of the vasculature within the subjacent epiphysis and metaphysis. This is followed by an evidence-based discussion of the common patterns of injury involving the epiphyseal primary growth plate observed among youth soccer players: subcategorized into physeal fractures (direct injury) and physeal stress injuries (indirect insult to subjacent metaphysis). In this section, the role of imaging and characteristic imaging features will be discussed. While the normal physiologic and pathophysiologic mechanisms can be applied to other growth plates, such as primary growth plates underlying the apophyses and secondary growth plates surrounding the secondary ossificiation centers, which also undergo endochondral ossification, the current review is focused on injuries involving the primary growth plates underlying epiphyses.

Physeal Bar Formation After Pediatric Medial Malleolus Fractures

Pediatric medial malleolus fractures are commonly Salter-Harris (SH) type III or IV fractures of the distal tibia and are associated with a risk of physeal bar formation and subsequent growth disturbance. The purpose of this study was to determine the incidence of physeal bar formation following pediatric medial malleolus fracture and evaluate for patient and fracture characteristics predictive of physeal bar formation. Seventy-eight consecutive pediatric patients during a 6-year period who had either an isolated medial malleolar or a bimalleolar ankle fracture were retrospectively reviewed. Forty-one of 78 patients had greater than 3 months of radiographic follow-up and comprised the study population. Medical records were reviewed for demographic information, mechanism of injury, treatment, and need for further surgery. Radiographs were reviewed to assess for initial fracture displacement, adequacy of fracture reduction, SH type, percentage of the physeal disruption from the fracture, and physeal bar formation. Twenty-two of 41 patients (53.7%) developed a physeal bar. The mean time to diagnosis of physeal bar was 4.9 months (range, 1.6-11.8 months). Twenty-seven percent (6 of 22) of bars were diagnosed at greater than 6 months from injury. Adequacy of reduction was predictive of physeal bar formation, although all patients were reduced to within 2 mm. The mean residual displacement of patients with a bar was 1.2 mm compared with 0.8 mm for those without a bar (P=.03). Because the bar formation rate is greater than 50% on radiographs, routine radiographic assessment of all pediatric medial malleolar fractures should continue for at least 12 months after injury. [Orthopedics. 2024;47(1):e33-e37.].

Pediatric cartilaginous lateral femoral condyle Hoffa fracture: a case report and review of the literature

INTRODUCTION

Hoffa fractures are challenging coronally-oriented articular injuries of the femoral condyle. These fractures are rare in adults and extremely rare in the skeletally immature, with few cases reported in literature. To prevent mal- or non-union, Hoffa fractures require prompt surgical stabilisation with anatomic reduction and internal fixation.

CASE REPORT

We discuss the case of a lateral distal femoral condyle cartilaginous Hoffa fracture in a ten-year-old male patient. The patient presented after a football non-contact "twist and pop" injury with radiographic imaging described as an osteochondritis dissecans lesion. An MRI was obtained which demonstrated a lateral distal femoral condyle osteochondral fracture. An operative plan was formulated to perform arthroscopic reduction and bio-compression screw fixation to minimize damage to the physis and surrounding tissues. Hyperflexion of the knee allowed for anatomic fracture reduction with the placement of 2 bio-compression screws serving as maintenance of fixation. The patient did well postoperatively and returned to full activity after 6 months.

CONCLUSION

Hoffa fractures in the pediatric population are rare and can occur not only through bone but also through the thick chondral layer in younger patients. These are extremely difficult to diagnose through X-Ray alone. The prompt use of MRI imaging allows for operative fixation in a timely fashion, while an arthroscopic-only approach allows for minimal tissue damage. With an appropriate fracture type, hyper-flexion reduces and stabilizes the fracture, permitting the placement of minimally invasive bio-compression fixation.

Variations in the Management of Closed Salter-Harris II Distal Tibia Fractures

BACKGROUND

There are no formal practice guidelines for the surgical management of closed, Salter-Harris (SH) II distal tibia fractures. The purpose of this study was to survey the indications for operative and nonoperative management of this injury across pediatric tertiary care centers.

METHODS

We surveyed pediatric orthopedic surgeons at 20 tertiary care level-1 pediatric trauma centers. Surgeons were provided with 16 clinical scenarios that varied based on patient age and sex, and highlighted the following surgical indications: translation <3 mm, translation ≥3 mm, sagittal plane angulation >5 degrees, and coronal plane angulation >5 degrees. Each case's scenario and radiographs after closed reduction were presented in a randomized manner. Consensus was defined as 80% agreement, and descriptive statistics were used to summarize the results.

RESULTS

In total, 33 of 37 surgeons completed the survey (89% response rate). All surgeons took trauma call at a level-1 pediatric trauma center and had an average of 8.8 years (SD: 6.5 y) of experience. Consensus was reached in 4 of 16 scenarios. Specifically, nonoperative management was recommended for all scenarios showing <3 mm of translation after closed reduction. The majority of surgeons recommended operative management in scenarios showing coronal plane angulation after closed reduction, but none of these scenarios reached consensus. There was a near-equal split in operative and nonoperative management in 8 of 16 scenarios. These scenarios showed ≥3 mm translation after closed reduction and sagittal plane angulation after closed reduction. Surgeons with 6 to 10 years in practice were the most likely to recommend surgery, especially in the case of >5 degrees coronal plane angulation postreduction ( P <0.05).

CONCLUSIONS

There is considerable variation regarding the indications for operative and nonoperative management of closed, SHII distal tibia fractures. Consensus was reached for nonoperative management in patients with <3 mm of translation after closed reduction; however, with greater deformity consensus regarding optimal treatment was unable to be achieved. The variation in the management of distal tibia SHII fractures is significant, suggesting that perhaps clinical equipoise exists between operative and nonoperative management.

LEVEL OF EVIDENCE

V.

A retrospective epidemiological cohort study of ankle fractures in children and teenagers

Background

Ankle fracture is one of the most frequent pediatric lower-limb fractures and may result in serious complications.

Objective

This study aimed to determine the epidemiology of ankle fractures, defining fracture types, treatments, and complications in a pediatric population below 16 years old.

Methods

Medical records of all the ankle fracture patients treated in our hospital during 2004-2020 were retrospectively reviewed. Data regarding age, sex, mechanism of injury, fracture type, treatment modalities, and complications were collected.

Results

We examined records involving 328 children with 331 ankle fractures, with a ratio of 1:2 male per female. Mean annual prevalence was 24.3 per 100,000 children. Mean patient age was 11.2 ± 4.2 years, with 75.3% of them aged over 10 years. Sports activities accounted for the largest percentage of fractures (162 cases; 49.4%), followed by falls (67; 20.4%) and road traffic accidents (37; 11.3%). Physeal fractures were the most frequent type of lesion (223 cases). Most ankle fractures (60%) were managed using closed reduction and casting; for the remaining 40% of cases, fracture fixation was performed after closed or open reduction to correct the articular step-off and ensure the anatomical restoration of the physis. The main ankle fracture complication was premature growth arrest (12.1% of all physeal fractures).

Conclusion

Pediatric ankle fractures primarily affect children older than 10 years. Most of these fractures were caused by sports injuries or low-energy trauma. The majority of these fractures are physeal, and the distal tibial physis is affected 10 times more frequently than the distal fibular physis.

Level of evidence

Level III.

Clinical characteristics of 1124 children with epiphyseal fractures

BACKGROUND

In this study, to provide a theoretical basis for understanding the clinical characteristics of epiphyseal fractures in children and improving their management, we explored and analyzed the proportions of different types of epiphyseal fractures in children and evaluated the causes of injury and epidemiological characteristics.

METHODS

We retrospectively analyzed children younger than 18 years with fresh epiphyseal fractures who were admitted to our hospital from July 2015 to February 2020. Demographic information, injury mechanisms, fracture characteristics, fracture classification and surgical information were collected.

RESULTS

A total of 1124 pediatric patients (1147 epiphyseal fractures), including 789 boys and 335 girls, were included in this study. Epiphyseal fractures were classified as Salter-Harris type II (1002 cases), type IV (105 cases), type III (25 cases), Salter-Harris type I (14 cases), and Salter-Harris type V (1 case). The number of fracture sites peaked in the adolescent group (440 cases). The most three common sites of epiphyseal fractures were the distal radius (460 cases) in which Salter-Harris type II fractures were the most common (454 cases) and Salter-Harris type I (3 cases), Salter-Harris type IV (2 cases), Salter-Harris type III was the least common (1 case). Followed by phalanges of fingers (233 cases) in which Salter-Harris type II fractures were the most common (224 cases) and Salter-Harris type IV (4 cases), Salter-Harris type I (3 cases), Salter-Harris type III fractures were the least common (2 cases). Distal humerus (146 cases) in which Salter-Harris type II fractures were the most common (95 cases), followed by Salter-Harris type IV (49 cases), Salter-Harris type I fractures were the least common (2 cases). The most three important causes of fractures were falls (720 patients), car accident injuries (68 patients), and basketball falls (43 patients). Among the 1124 children with epiphyseal fractures, 1058 were treated mainly by surgery and the ratio of open and closed reduction was 1:5.3. Eighty-eight patients showed an interval > 72 h between the injury and the hospital visit. Among these 88 patients, the most common fracture type was distal radial epiphyseal fracture (32 cases), and all fractures were of Salter-Harris type II.

CONCLUSIONS

The epidemiological characteristics of epiphyseal fractures in children indicate the need to strengthen health and safety education and protective measures to prevent the occurrence of these fractures in children. In addition, emergency surgeons and orthopedic surgeons in general hospitals should strengthen their basic knowledge of diagnosing and treating epiphyseal injuries in children to reduce missed diagnoses, misdiagnoses or malpractice.

Epidemiology and risk factors for premature physeal closure in distal femur fractures

BACKGROUND AND PURPOSE

Premature physeal closure (PPC) is a common and concerning complication to distal femoral fractures as the distal growth plate accounts for 70% of the growth of the femur. The literature is not unanimous in determining the risk factors of PPC, and the epidemiological characterization of these fractures is limited. Our aim was to calculate the population-based incidence and investigate risk factors for PPC in these fractures.

PATIENTS AND METHODS

In this register-based study, between 2014 and 2021, 70 children with distal femoral physeal fractures presented to our hospital. Demographic data, and fracture- and treatment-related details were collected using the Kids' Fracture Tool. A directed acyclic graph (DAG) was constructed to determine confounding factors used in the risk analysis.

RESULTS

Physeal fractures of the distal femur occurred with an annual incidence of 6/105 children, and a resulting PPC occurred in 16/70 (23%) with an annual incidence of 1.3/105 children. In multivariable analysis, dislocation exceeding 10 mm was a risk factor for PPC (OR 6.3, CI 1.4-22).

CONCLUSION

One-fourth of distal femoral physeal fractures developed PPC. Greater dislocation and higher injury energy were significant risk factors, whereas choice of fracture treatment was not an independent risk factor. All patients with PPC belonged in the age group 11-16 years.

Epidemiology of Physeal Fractures and Clinically Significant Growth Disturbances Affecting the Distal Tibia, Proximal Tibia, and Distal Femur: A Retrospective Cohort Study

INTRODUCTION

Childhood fractures involving the physis potentially result in premature physeal closure that can lead to growth disturbances. Growth disturbances are challenging to treat with associated complications. Current literature focusing on physeal injuries to lower extremity long bones and risk factors for growth disturbance development is limited. The purpose of this study was to provide a review of growth disturbances among proximal tibial, distal tibial, and distal femoral physeal fractures.

METHODS

Data were retrospectively collected from patients undergoing fracture treatment at a level I pediatric trauma center between 2008 and 2018. The study was limited to patients 0.5 to 18.9 years with a tibial or distal femoral physeal fracture, injury radiograph, and appropriate follow-up for determination of fracture healing. The cumulative incidence of clinically significant growth disturbance (CSGD) (a growth disturbance requiring subsequent physeal bar resection, osteotomy, and/or epiphysiodesis) was estimated, and descriptive statistics were used to summarize demographics and clinical characteristics among patients with and without CSGD.

RESULTS

A total of 1,585 patients met the inclusion criteria. The incidence of CSGD was 5.0% (95% confidence interval, 3.8% to 6.6%). All cases of growth disturbance occurred within 2 years of initial injury. The risk of CSGD peaked at 10.2 years for males and 9.1 years for females. Complex fractures that required surgical treatment, distal femoral and proximal tibial fractures, age, and initial treatment at an outside hospital were significantly associated with an increased risk of a CSGD.

DISCUSSION

All CSGDs occurred within 2 years of injury, indicating that these injuries should be followed for a period of at least 2 years. Patients with distal femoral or proximal tibial physeal fractures that undergo surgical treatment are at highest risk for developing a CSGD.

LEVEL OF EVIDENCE

Level III Retrospective Cohort Study.

Rates and Factors Associated With Hardware Removal in Physeal Ankle Fractures: Analysis of the Pediatric Health Information System

Background

Ankle fractures are among the most common physeal fractures in children. When surgical management is warranted, subsequent hardware removal remains controversial. This study was designed to determine rates of hardware removal in patients with physeal ankle fractures and identify risk factors for removal. Procedure data was utilized to compare rates of subsequent ankle procedures in patients with hardware removed and hardware retained.

Methods

We conducted a retrospective cohort study utilizing data from the Pediatric Health Information System (PHIS) for the years 2015 through 2021. We longitudinally followed patients treated for distal tibia physeal fractures to determine the rates of hardware removal and subsequent ankle procedures. Patients with open fractures or polytrauma were excluded. We used univariate, multivariate, and descriptive statistics to characterize the rates of hardware removal, identify factors associated with removal, and assess the rates of subsequent procedures.

Results

This study included 1008 patients who underwent surgical management of a physeal ankle fracture. The mean age at index surgery was 12.6 years with an SD of 2.2 years, and 60% of patients identified as male. Two hundred forty-two patients (24%) had their hardware removed at an average time of 276 days (range, 21-1435 days) following index surgery. Patients with Salter Harris III (SH-III) or Salter Harris IV (SH-IV) fractures had hardware removed more often than patients with Salter-Harris II (SH-II) fractures (28.9% vs 11.7%, P < .01). Four-year rates of subsequent ankle procedures are similar between patients with hardware removed and hardware retained.

Conclusion

The rate of hardware removal in children with physeal ankle fractures is higher than previously reported. Patients of younger age, higher income, and with fractures involving the epiphysis (SH-III and SH-IV) are more likely to undergo hardware removal.

Level of Evidence

Level III, retrospective study.

The effectiveness of physeal bar resection with or without Hemi-Epiphysiodesis to treat partial growth arrest

PURPOSE

To evaluate the outcomes of distal femoral, proximal tibial, and distal tibial physeal bar resection combined with or without the Hemi-Epiphysiodesis procedure and provide a better understanding of the application of physeal bar resection combined with Hemi-Epiphysiodesis procedure in the treatment of physeal bar growth arrest.

METHODS

We retrospectively reviewed the patients who suffered physeal bar and underwent physeal bar resection with or without the Hemi-Epiphysiodesis technique during 2010-2020. All were followed up for at least 2 years or to maturity. A modified mapping method was used to determine the area of a physeal bar by CT data. The aLDFA, aMPTA, aLDTA, MAD, and LLD were measured to assess the deformity of the lower limb.

RESULTS

In total, 19 patients were included in this study. The average age was 8.9 years (range 4.4 to 13.3 years old). During the follow-up, 4 (21.1%) patients had an angular change < 5°; 12 (63.2%) patients had angular deformity improvement > 5° averaging 10.0° (range 5.3° to 23.2°), and 3 (15.8%) patients had improvement of the angular deformity averaging 16.8° (range 7.4° to 27.1°). Eleven patients (57.9%) had significant MAD improvement. After surgery, we found that 7 (36.8%) patients had an LLD change of < 5 mm and were considered unchanged. Only 2 (15%) patients had an LLD improvement > 5 mm averaging 1.0 cm (range 0.7 to 1.3 cm), and 7 (36.8%) patients had increasing of LLD > 5 mm averaging 1.3 cm (range 0.5 to 2.5 cm). There were no postoperative fractures, infections, or intraoperative complications such as neurovascular injury.

CONCLUSION

Physeal bar resection combined with Hemi-epiphysiodesis is helpful for partial epiphysis growth arrest. Without statistically verifying, we still believe that patients with limited growth ability could benefit more from physeal bar resection combined with Hemi-epiphysiodesis.

MRI findings of growth plate fractures of the knee: are there age- and fracture-dependent differences?

OBJECTIVE

To investigate MRI findings in children with physeal fractures of the knee with respect to age, location, and articular involvement.

METHODS

Children with physeal fractures who underwent knee MRI between 2008 and 2021 were included. Two radiologists retrospectively reviewed all examinations to determine articular involvement, findings of physeal instability (perichondral disruption, periosteal entrapment), and internal derangement (cruciate ligament injury, meniscal tear, chondromalacia). Independent samples t, Mann-Whitney U, Pearson's chi-square, and Fisher's exact tests were used to compare findings.

RESULTS

Fifty-six patients (37 boys, 19 girls; mean age: 12.2 ± 2.5 years; 32 distal femur, 24 proximal tibial fractures) included 24(43%) intraarticular fractures. Fractures were more common in the tibia than the femur (67% versus 25%, p = 0.004) and intraarticular fractures were more common in older than younger children (13.1 ± 2.0 versus 11.5 ± 2.7 years, p = 0.01), to associate with chondromalacia (46% versus 12%, p = 0.02) and undergo surgery (33% versus 10%, p = 0.04) when compared to extraarticular fractures. Perichondral disruption (n = 44, 79%) and periosteal entrapment (n = 13, 23%) did not significantly differ based on location or articular involvement (p > 0.05). At a median follow-up of 17.5 months (interquartile range: 1.25-34), 3 patients (2 intraarticular, 1 extraarticular fractures) developed osteoarthritis, osteochondral lesion, and leg-length discrepancy from growth arrest, which required additional surgery.

CONCLUSION

Intraarticular physeal fractures were more common with older children, associate with chondromalacia, and underdo surgical intervention when compared to extraarticular fractures of the knee. While MRI findings of physeal instability were common, no significant differences were found between fractures based on anatomic location or fracture pattern.

The Incidence and Treatment Outcome of Atypical Triplane Fractures in Adolescents

Background

Atypical triplane fractures (ATFs) defined as a triplane fracture that did not involve the weight-bearing articulating surface or as an extra-articular triplane fracture. ATFs are scarcely reported and the incidence may be underestimated. Moreover, there is no consensus on treatment. This study aimed to evaluate ATFs incidence, fracture pattern, and treatment outcome, and propose treatment recommendations.

Methods

Twenty-five ATFs of 46 triplane fractures were retrospectively reviewed between 2011 and 2017. ATFs were classified according to the modified ATF classification. Treatment methods were analyzed. Radiologic outcomes were measured based on fracture displacement. Clinical outcomes included the American Orthopedic Foot and Ankle Society score, visual analogue scale, ankle range of motion, and complications at final follow-up period.

Results

A total of 11 type IV, 11 type III, and three type II ATFs were identified. All type II ATFs (intra-articular fracture) were treated with operative treatment. Nine patients were treated with operative treatment and 18 patients were treated with non-operative treatment in type III or IV ATFs (extra-articular fracture). Good radiologic and clinical outcomes were observed in all patients. The residual displacement after initial trial of closed reduction was between 4 and 5 mm in ten cases of type III or IV ATFs; however, no complications were observed, and all cases had good clinical results after non-operative treatment.

Conclusions

ATFs may be under-recognized. Operative treatment and non-operative treatment showed good outcome. Non-operative closed reduction and cast immobilization can be recommended for extra-articular ATF with displacement < 4 mm.

Level of Evidence

Level IV, case series.

Circular External Fixation for Distal Femoral Physeal Injury: A Case Report

Background:

Distal femoral physeal injuries are a challenging clinical scenario because the injuries have a high risk of growth disturbance. The selected treatments include closed reduction and cast immobilization, percutaneous pin fixation, and cannulated screws or internal fixation, but these treatments have some complications. Circular external fixation enables rigid immobilization and walking with full weight bearing. To the best of our knowledge, there is no article on the results of using circular external fixation for distal femoral physeal injury. This case is the first in which circular external fixation for distal femoral physeal injury is used.

Case Presentation:

A 9-year-old boy was injured in a skiing accident, and his injury was a Salter-Harris type II fracture of the distal femoral epiphysis. We immediately performed percutaneous pin fixation with circular external fixation under general anesthesia. After surgery, he was allowed to walk with full weight bearing. One year after surgery, he had no pain, and his knee regained full extension and 140°flexion.

Conclusion:

We consider circular external fixation to be an effective treatment option because of its rigid immobilization without injury to the plate. However, we and patients must fully acknowledge its difficulties (i.e., pin-site problems, neurologic injury, vascular injury, joint stiffness, and pain, and difficulty sleeping).

Analysis of Physeal Fractures from the United States National Trauma Data Bank

Background: Pediatric long-bone physeal fractures can lead to growth deformities. Previous studies have reported that physeal fractures make up 18–30% of total fractures. This study aimed to characterize physeal fractures with respect to sex, age, anatomic location, and Salter–Harris (SH) classification from a current multicenter national database. Methods: A retrospective cohort study was performed using the 2016 United States National Trauma Data Bank (NTDB). Patients ≤ 18 years of age with a fracture of the humerus, radius, ulna, femur, tibia, or fibula were included. Results: The NTDB captured 132,018 patients and 58,015 total fractures. Physeal fractures made up 5.7% (3291) of all long-bone fractures, with males accounting for 71.0% (2338). Lower extremity physeal injuries comprised 58.6% (1929) of all physeal fractures. The most common site of physeal injury was the tibia comprising 31.8% (1047), 73.9% (774) of which were distal tibia fractures. Physeal fractures were greatest at 11 years of age for females and 14 years of age for males. Most fractures were SH Type II fractures. Discussion and Conclusions: Our analysis indicates that 5.7% of pediatric long-bone fractures involved the physis, with the distal tibia being the most common. These findings suggest a lower incidence of physeal fractures than previous studies and warrant further investigation.

Fracture-Separation of the Medial Humeral Epicondyle Caused by Arm Wrestling: A Systematic Review

Background:

Arm wrestling is a popular sport in which various injuries have occurred, even in children.

Purpose:

To analyze reported fracture-separation of the medial humeral epicondyle (MHE) caused by arm wrestling to determine its mechanism and provide a current overview.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

The PubMed and Web of Science databases were searched using the terms “arm wrestling” and “humeral fracture” or “medial humeral epicondyle fracture”; and “sports” and “humeral fracture” or “medial humeral epicondyle fracture,” following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The inclusion criteria were English full-text articles on arm wrestling–induced MHE fracture that described patient characteristics and presented appropriate images. Studies with a lack of appropriate images or detailed description of the injury situation were excluded. The patient characteristics were evaluated, and the ratios of treatment selection and outcomes were evaluated using the chi-square test.

Results:

Included were 27 studies with a total of 68 patients, all boys with a mean age of 14.6 ± 1.24 years (based on n = 65, with 3 patients excluded from this calculation as no definitive age was provided). Boys aged 14 to 15 years accounted for 72% (49/68) of the cases. Fracture occurred suddenly during arm wrestling in 63 boys, while the other 5 boys experienced antecedent medial elbow pain. The match status at the time of injury, provided for 46 patients, was varied. In 31 boys with known match details, injury occurred when a participant suddenly added more force to change the match status. Eight patients displayed anterior and/or proximal displacement of the MHE fragment. Treatment was nonoperative in 25 patients and operative in 38 patients (n = 63, excluding 5 unknown patients). In 35 patients followed up for ≥3 months (mean, 17.6 ± 12.3 months), outcomes were not significantly different between the operative and nonoperative groups.

Conclusion:

MHE fracture-separation caused by arm wrestling occurred mostly in boys aged 14 to 15 years regardless of the match status. The likely direct cause is forceful traction of the attached flexor-pronator muscles. A relative mechanical imbalance during adolescence may be an underlying cause. A sudden change from concentric to eccentric contraction of the flexor-pronator muscles increases the likelihood of fracture occurrence.

Lower extremity physeal fractures and post-traumatic surgical deformities; National Trauma Data Bank and institutional cohorts

Background

Pediatric lower extremity physeal fractures carry a risk of developing deformities. Most epidemiological evidence is over 25 years old, single institution, and lacks follow-up, while recent studies report variable results. Understanding their epidemiology and deformity risk is important for patient counseling and follow-up.

Methods

The National Trauma Data Bank (NTDB) from 2016 was queried to describe the modern epidemiology of physeal fractures. This was contrasted with our 10-year experience of surgically treated deformities. Basic descriptive statistics, Chi-square analysis, prevalence ratios and multivariable linear regression were used to interpret results.

Results

The NTDB contained 22,048 non-physeal and 1,929 physeal fractures of the femur, tibia, and fibula. Physeal fracture prevalence rose after 8 years of age but decreased for girls 2 years sooner than boys. Salter Harris (SH) type 2 fractures predominated. Physeal fractures were more commonly associated with lower energy mechanisms of injury. Distal tibia fractures were more prevalent in the NTDB cohort, while distal femur and SH-1 fractures were more prevalent in the operative cohort. Over 10 years, only 52 (5.3%) of the deformity-correcting surgeries at our institution were for physeal fracture sequelae. Age at injury and intraarticular fractures were associated with shorter times from injury to deformity correction.

Conclusion

Lower extremity physeal fractures are uncommon. Fracture pattern prevalence differs from an operative cohort. Proximal tibia physeal fractures appear to be an underappreciated source of deformity. The risk of developing deformity requiring operative intervention appears to be low and is generally treated within 2 years of initial injury.

Does the size of Thurston-Holland fragment have an effect on premature physeal closure occurrence in type 2 distal tibia epiphyseal fractures?

The purpose of this study was to investigate the possible effect of Thurston-Holland fragment (THF) size on the development of premature physeal closure (PPC) in distal tibia type 2 epiphyseal injuries. Fifty-eight fractures in 57 patients with a minimum follow-up period of 12 months were included. For statistical analysis, sex and age of the patient, number of reduction attempts, percentage of THF base relative to physis length on anteroposterior or lateral radiograph, maximal initial and postreduction displacement amount, presence of accompanying fibula fracture and trauma mechanism were evaluated. PPC was observed in 12 fractures (20.7%). An increased amount of initial displacement, increased number of reduction attempts and passing the physis with three Kirschner wires were determined as statistically significant factors for PPC occurrence (P = 0.011, 0.011 and 0.005, respectively). The THF percentage was not found to be an important factor for the occurrence of PPC. In males, THF size was less than 50% more frequently than that in females (P = 0.013). THF size had no significant effect on PPC occurrence after distal tibial epiphyseal fractures.

Salter-Harris I Injury of the Proximal Tibial Physis with Vascular Compromise: A Case Report and Review of Literature

Introduction:

Physeal injuries of proximal tibia are uncommon and constitute only 1% of all physeal injuries. Major vessel injuries are also rare in children and occur in 0.6% trauma cases, out of which, injuries of popliteal artery comprise only 5%. The combination of these is an extremely rare injury pattern but is potentially limb threatening. Most of the cases of physeal injuries of proximal tibia along with popliteal artery compromise, reported in the literature include Salter Harris (SH) type II, III, and IV patterns (type II being most common) with pure type I being extremely rare.

Case Report:

We describe a rare posteriorly displaced pure SH I injury of proximal tibial physis with compromised vascularity of the limb. Immediate closed reduction and stabilization with Kirschner wires (K-wires) restored the vascularity of the limb and the patient went on to have a good functional recovery at the last follow-up of 1 year.

Conclusion:

Vascular injuries occurring in SH 1 proximal tibial physeal fractures are often overlooked or missed due to the relatively benign appearance of slip with no sharp fragments to injure major vessels. Close monitoring of neurovascular status and a low threshold for fixation, for example, with K-wires, are important to prevent limb threatening ischemia in these relatively simple appearing injuries.

Shedding light on incidence and burden of physeal injuries in a youth elite football academy: A 4-season prospective study

INTRODUCTION

Physeal injuries have been overlooked in epidemiological research in youth sports. Our prospective study investigated the incidence, severity, and burden of physeal injuries in a youth elite football academy.

METHODS

In total, 551 youth male football players from under-9 to under-19 were included and observed over four consecutive seasons. Injuries involving the physis were diagnosed and recorded according to type, location, and diagnosis. Injury incidence (II), severity (days lost), and injury burden (IB) were calculated per squad per season (25 players/squad).

RESULTS

There were 307 physeal injuries: 262 apophyseal (85%), 26 physeal (9%), 2 epiphyseal (1%), and 17 other physeal injuries (5%) with 80% (n=245) causing time-loss. The overall mean incidence of time-loss physeal injuries was 6 injuries/squad-season, leading to a total of 157 days lost/squad-season. The U-16s had the highest burden with 444 days lost per squad-season [median: 20 (95% CI: 12-30) days; II: 10 (95% CI: 7.3.1-13.4)]. Apophyseal injuries of the hip-pelvis resulted in the greatest burden [median: 13 (95% CI: 10-17); II: 2.5 (95% CI: 2.1-3.0)]. Peak apophyseal injury incidence per body parts occurred in U-11 for foot-ankle (II: 2.4; 95% CI: 1.0-4.9), U-14 for knee (II: 4.5; 95% CI: 2.7-7.1), and U-17 for hip-pelvis (II: 6.4; 95% CI: 4.2-9.3).

CONCLUSION

Physeal injuries accounted for a quarter of all-time loss with the largest injury burden in U-16. Most physeal injuries involved the lower limb and affected the apophysis. Physeal and apophyseal injuries incidence, burden, and pattern vary substantially depending on age. Hip-pelvic apophyseal injuries accounted for the largest injury burden.

Pseudarthrosis of distal radial growth plate treated with Blount clip: A case report

Introduction and importance

Epiphyseal detachement of distal radius are frequent, the richness of the vascular supply at this level favors rapid consolidation, but with the possibility of long-term complications which vary according to the classification of Salter and Harris. In the literature they are dominated by the epiphysiodesis, however, Pseudarthrosis of the growth plate is exceptional. Through this case presentation, we will explain contributing factors of its occurrence and its care management.

Case presentation

We report a case of a pseudarthrosis of distal radial growth plate (GP) due to an epiphyseal detachement type I of Salter and Harris in a 16-years-old patient who presented with a right wrist trauma at the age of 8, treated by a traditional immobilization (Moroccan Jbira) and who kept a painful deformity of the right wrist in hand ulnar boot. Face and profile radiography of the right wrist found a pseudarthrosis of distal radial growth plate, the patient had surgery to attach pseudarthrosis spot using a Blount clip, and at the same time, creating a partial epiphysiodesis in the lateral side, resulting in the correction of the wrist malalignment. After 5 years, we had a consolidation of the pseudarthrosis spot, without modification of angular deviation.

Clinical discussion

GP's traumas care management is based on an urgent and anatomical reduction because it is a very fragile area and is more affected by mechanical stress, however in our context Patients consult usually after late complications such as deformations and functional abnormalities.

Blount clip was our surgical team choice because it is the best way of osteosynthesis in our case, it allows a solid fixation thanks to its biomechanical characteristics.

Pseudarthrosis of distal radial growth plate is exceptional in the literature that's why we cannot compare our results.

Conclusion

This complication would have been prevented with initial adequate care management, prevention about avoiding traditional traitements.

Anti-VEGF antibody delivered locally reduces bony bar formation following physeal injury in rats

Physeal injuries can result in the formation of a "bony bar" which can lead to bone growth arrest and deformities in children. Vascular endothelial growth factor (VEGF) has been shown to play a role in bony bar formation, making it a potential target to inhibit bony repair tissue after physeal injury. The goal of this study was to investigate whether the local delivery of anti-VEGF antibody (α-VEGF; 7.5 μg) from alginate:chitosan hydrogels to the tibial physeal injury site in rats prevents bony bar formation. We tested the effects of quick or delayed delivery of α-VEGF using both 90:10 and 50:50 ratio alginate:chitosan hydrogels, respectively. Male and female 6-week-old Sprague-Dawley rats received a tibial physeal injury and the injured site injected with alginate-chitosan hydrogels: (1) 90:10 (Quick Release); (2) 90:10 + α-VEGF (Quick Release + α-VEGF); (3) 50:50 (Slow Release); (4) 50:50 +  α-VEGF (Slow Release +  α-VEGF); or (5) Untreated. At 2, 4, and 24 weeks postinjury, animals were euthanized and tibiae assessed for bony bar and vessel formation, repair tissue type, and limb lengthening. Our results indicate that Quick Release + α-VEGF reduced bony bar and vessel formation, while also increasing cartilage repair tissue. Further, the quick release of α-VEGF neither affected limb lengthening nor caused deleterious side-effects in the adjacent, uninjured physis. This α-VEGF treatment, which inhibits bony bar formation without interfering with normal bone elongation, could have positive implications for children suffering from physeal injuries.

Distal Radius Physeal Bar and Ulnar Overgrowth: Indications for Treatment

BACKGROUND

Distal radius physeal bar with associated growth arrest can occur because of fractures, ischemia, infection, radiation, tumor, blood dyscrasias, and repetitive stress injuries. The age of the patient as well as the size, shape, and location of the bony bridge determines the deformity and associated pathology that will develop.

METHODS

A search of the English literature was performed using PubMed and multiple search terms to identify manuscripts dealing with the evaluation and treatment of distal radius physeal bars and ulnar overgrowth. Single case reports and level V studies were excluded.

RESULTS

Manuscripts evaluating distal radial physeal bars and their management were identified. A growth discrepancy between the radius and ulna can lead to distal radioulnar joint instability, ulnar impaction, and degenerative changes in the carpus and triangular fibrocartilage complex. Advanced imaging aids in the evaluation and mapping of a physeal bar. Treatment options for distal radius physeal bars include observation, bar resection±interposition, epiphysiodeses of the ulna±completion epiphysiodesis of the radius, ulnar shortening osteotomy±diagnostic arthroscopy to manage associated triangular fibrocartilage complex pathology, radius osteotomy, and distraction osteogenesis.

CONCLUSIONS

Decision-making when presented with a distal radius physeal bar is multifactorial and should incorporate the age and remaining growth potential of the patient, the size and location of the bar, and patient and family expectations.

Below-Knee Cast Immobilization for Distal Tibial Physeal Fractures

Distal tibial physeal injuries are one of the most commonly reported fractures in children. Traditionally, treatment recommendations consist of utilization of a long leg cast for initial immobilization. The purpose of this study was to evaluate the efficacy of below-knee cast immobilization in the closed treatment of distal tibial physeal fractures. We reviewed all patients with distal tibial physeal fractures treated with below-knee immobilization at our tertiary care facility between January 2002 and September 2015. Radiographs were analyzed for displacement and angulation at the time of injury, after closed reduction and/or casting, and at completion of immobilization to evaluate for loss of reduction. In total, 120 fractures (120 patients) were reviewed with 63 (52.5%) extra-articular fractures and 57 (47.5%) intra-articular fractures. The mean initial displacement was 4 mm (range 0-26 mm) with 34 patients having greater than 2 mm of displacement at presentation. Closed reduction was performed on 33 (27.5%) patients with the remaining 87 (72.5%) receiving immobilization alone without formal reduction. All fractures successfully healed with only 2 (1.67%) patients experiencing a loss of reduction. Both patients that lost reduction had undergone an initial closed reduction. No nondisplaced fractures lost reduction. These findings suggest that below-knee immobilization is an effective alternative in the treatment of both nondisplaced and displaced distal tibial physeal fractures, including those with intra-articular involvement, as well as those undergoing closed reduction. This creates an opportunity to provide increased patient mobility and early knee range of motion.

Ilizarov Gradual Distraction Correction for Distal Tibial Severe Varus Deformity Resulting from Epiphyseal Fracture: Case Report and Literature Review

We present a case of a 13-year-old female with severe varus deformity and limb discrepancy resulting from epiphyseal fracture. The preoperative tibial articular surface angle was 64.1°, and the affected tibia was 14 mm shorter than the contralateral tibia. She underwent a medial open osteotomy and fibular osteotomy with gradual distraction correction using Ilizarov fixator. The deformity was corrected at 3 months, and the external fixator was removed when bony union was achieved 6 months postoperatively. At 9 months after surgery, the patient could play basketball without feeling pain. At the last follow-up, namely 36 months after the operation, the American Orthopaedic Foot and Ankle Society hindfoot-ankle score was improved from 58 to 90, the patient was pain free, and the radiological measurements were nearly normal. Ilizarov fixator gradual distraction correction for distal tibial severe varus deformity is a safe and cost-effective method that can yield excellent radiological and clinical outcomes.

Extensor hallucis longus muscle contracture after distal tibial physeal injury: A report of two cases

Few studies have reported about isolated contracture in the extensor hallucis longus (EHL) muscle, but none of the EHL muscle contracture after distal tibial physeal injury. Two such cases in 16- and 14-year-old boys who underwent surgeries for distal physeal injury of the tibia at a previous hospital are presented. Extension contracture of the hallux appeared 1-2 months post-surgery. Physical examinations revealed that the extension contracture of the first metatarsophalangeal joint was aggravated in plantar flexion of the ankle due to a tenodesis effect, and magnetic resonance imaging showed atrophy and signal changes in the anterior compartment muscles. This was diagnosed as EHL muscle contracture due to anterior compartment syndrome (ACS) after distal tibial physeal injury. The EHL tendon transfers were performed in both cases, with favorable short-term results. Therefore, the EHL tendon transfer might be preferable in case of the EHL muscle contracture due to partial ACS.

Growth Disturbance Following Intra-articular Distal Radius Fractures in the Skeletally Immature Patient

INTRODUCTION

The purpose of this study was to characterize the incidence of growth disturbance following intra-articular distal radius fractures in skeletally immature patients and to assess early radiographic and functional outcomes.

METHODS

A retrospective investigation of pediatric patients with intra-articular distal radius fractures between 1997 and 2012 at a single institution was performed. Pathologic fractures and fractures in patients with closed physes were excluded. In total, 28 patients (24 males, 4 females), with a mean age of 13.8 years and mean follow-up of 31.7 months, met inclusion criteria. Fractures were categorized according to the Salter-Harris classification, and all radiographs were assessed for evidence of physeal disturbance. Information regarding treatment and early clinical results were obtained from a medical record review. Functional outcomes using the Disabilities of the Arm, Shoulder, and Hand (DASH) and Modified Mayo Wrist Score (MMWS) were collected. Fisher exact test was used to compare the incidence of physeal arrest in the study population to previously published rates of physeal arrest in extra-articular fractures involving the distal radius. Because the data were not parametrically distributed, the Mann-Whitney-Wilcoxon test was used to compare those who did and did not develop physeal arrest.

RESULTS

Of the 28 patients, 9 (32%) sustained Salter-Harris III fractures and 19 (68%) sustained Salter-Harris IV fractures. Growth disturbance occurred in 12 (43%) patients, comprised of 3 Salter-Harris III fractures and 9 Salter-Harris IV fractures; 7 of these patients underwent surgical intervention to address deformity. All 4 children age 10 years or younger had growth arrests that underwent subsequent procedures for a skeletal rebalancing of the wrist. No significant differences in DASH or MMWS were seen in the short term between patients who did or did not have physeal arrest.

CONCLUSIONS

Intra-articular distal radius fractures in skeletally immature patients have a considerably higher rate of physeal growth arrest than extra-articular physeal fractures. Following acute management aimed at restoring and preserving anatomic physeal and articular alignment, follow-up radiographs should be obtained to evaluate for physeal arrest in skeletally immature children. Patients and families should be counseled regarding the high rate of growth disturbance and the potential need for deformity correction in the future, particularly in younger children.

LEVEL OF EVIDENCE

IV-case series.

Evaluation of pediatric distal femoral physeal fractures and the factors impacting poor outcome requiring further corrective surgery

Fractures of the distal femur carry a significant risk of physeal arrest and resulting growth complications which often require additional surgeries to correct the deformity. This study examines the risk of needing corrective procedures as a child approaches skeletal maturity. A retrospective analysis of patients treated at a single institution for distal femoral physeal fractures from 2000 to 2015 was performed. Association between sex, age, Salter-Harris (SH) class, and fracture displacement with the risk of physeal arrest were examined. Association between years of growth remaining to skeletal maturity and the risk of needing additional corrective surgery (defined by leg length difference >2 cm or angular deformity (>5°) was examined using a logistic regression model. One hundred one patients were available for review with an average age of 12.6 ± 3.2 years. Twenty-six patients (25.7%) developed a physeal arrest. Seventy-six percent of these required subsequent surgical intervention to address length and angular deformities Sex, age, and SH class were not significantly associated with physeal arrest (P > 0.05). Percent fracture displacement was significantly associated with physeal arrest (P = 0.02). Years of growth remaining to skeletal maturity were significantly associated with an increased risk of requiring corrective surgery for growth complications (odds ratio: 0.758; 95% confidence interval 0.587-0.979; P = 0.03), however, this association failed to persist when accounting for age. Years of growth remaining to skeletal maturity may predict the need for future interventions and should be accounted for when planning treatment of these challenging injuries.

Physeal Injuries of the Coracoid Process Are Closely Associated With Sports Activities: A Systematic Review

Background:

Physeal injuries of the coracoid process are rare but may be increasing because of increased participation of youth in year-round sports.

Purpose:

To analyze reported physeal and apophyseal injuries of the coracoid process.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

PubMed and Scopus were searched using the terms scapula fracture and coracoid fracture. The inclusion criteria were English full-text articles describing coracoid fracture as well as articles that described patient characteristics and presented appropriate images. The exclusion criteria were descriptive cases without images as well as those lacking appropriate images. Citation tracking was conducted to find additional articles and full-text articles written in other languages. Articles were included if they reported physeal injury or judged to involve physeal injury based on the provided images.

Results:

Overall, 22 studies including 32 patients (29 males, 3 females) were identified. All but 2 patients were younger than 18 years of age, and 66% (21/32) had sustained injuries during or as a result of participation in sporting activities. The affected site was the physis at the base in 18 patients, an intra-articular fracture in the primary coracoid ossification center combined with the subcoracoid ossification center to form an intra-articular fracture in 5, the apophysis of the tip in 3, the apophysis of the angle in 5, and uncertain in 1. Eleven patients had concurrent acromioclavicular injuries. The injury was acute in 23 patients, chronic in 6, and traumatic nonunion in 3. Among 21 cases in which treatment methods and outcomes were described, 21% of the acute cases (4/19), and 2 of the 3 nonunions were surgically treated. Only 1 study used a widely accepted evaluation method. Follow-up periods ranged from 6 weeks to 2 years. Outcomes were generally excellent for nonoperative and operative treatment and without any serious complications.

Conclusion:

Coracoid physeal injuries occurred most commonly in patients aged 13 to 15 years of age (71%) and were usually sustained during or as a result of sports activities (66%). The most common injury site was the physis at its base. The cause of these injuries is probably severe or repeated traction of the attached muscles and ligaments. The majority of these injuries can be successfully treated nonoperatively.

[Update: transitional fractures : Osseous injuries in growing up adolescents-correct nomenclature, radiological diagnostics and treatment]

Transitional fractures are special forms of epiphyseal injuries in adolescents in whom the growth plate is already partially closed. Due to the partial ossification specific stereotypical fracture patterns can develop, which can be differentiated into twoplane, triplane I and triplane II fractures, depending on the involvement of the metaphysis and the number of fragments. At the beginning of the diagnostics conventional projection radiography in two planes is used; however, due to the complex fracture patterns computed tomography (CT) is often indicated, also for preoperative planning. The treatment depends on the extent of the fracture dislocation, which should be an integral part of the radiological findings, as dislocation of fragments less than 2 mm in size are usually treated conservatively. Prognostically relevant is above all the reconstruction of the joint surfaces, as early arthrosis can be a threat if the incongruity remains-relevant growth disturbances in the case of growth joint closure that has already begun are usually no longer expected.

The feature assessment of the bone fractures in 1020 children and review of the literature

OBJECTIVE:

This study aims to collect data, which is a risk factor on bone fractures in children.

METHODS:

The study group consisted of 1020 children (n=282; 28% girls and n=738; 72% boys, with a mean age of 8.3 years) with a bone fracture. The age, gender, the month and the time of the day the fracture was sustained, mechanism of injury, feature of the fracture, the presence of coexisting injuries, and the method of treatment were recorded.

RESULTS:

Boys had approximately three times more fractures than girls. The fractures were found to be more prevalent in upper extremities (76.6%) and on its left side (56.0%), and the most commonly fractured bone was isolated radius (n=304; 32.1%); most frequently distal radius). The most prevalent lower-extremity fractures were to the femur (n=92; 31.7%). It was found that fractures occurred most frequently between the ages 3 and 6 (23.6%), and fractures in boys were most common among 13 to 15-year-old patients (n=216; 23.9%), whereas girls aged 3–6 years suffered the most fractures (n=103; 30.8%). The fractures were more common in spring (n=384; 31.0%) and summer (n=365; 29.5%). The time slot bone fractures occurred the most was from 12:00 pm to 5:00 pm (n=824; 66.6%). The most common reasons for fractures were outdoor falls (n=705; 57.0%), and indoor falls (n=239; 19.3%), respectively. Bone fractures co-occurred with head trauma the most (n=30; 42.3%). Fifty-nine patients (5.8%) had epiphysis fracture. 51 patients (5.0%) had open fractures. Five hundred ninety-two patients (58.0%) were given outpatient treatment.

CONCLUSION:

Child bone fractures are most frequently seen in the left upper extremity in 10–15-year-old boys, occurring as a result of outdoor falls in the afternoon in the spring and summer months. Bones located in the wrist, hand, and elbow have been found to be much more vulnerable to fractures. Many of the fractures were treated by conservative methods. Creating a safe environment for children is the most effective method of injury control. Necessary arrangements should be made for the safety of children in the environment and at home. Continuing education and legal regulations play an active role in injury control.

Feasibility of pre- and postoperative arthroscopic assessments with internal fixation for growth plate injury of the distal tibia: three case reports and a literature review

BACKGROUND

Inappropriate treatment of growth plate injury may cause complications such as malunion or early arrest of the growth plate. Identification of intra-articular lesions is mandatory in patients with a growth plate injury of the distal tibia. Arthroscopic assessment is useful in identifying intra-articular injury. We report three cases of intra-articular growth plate injury of the distal tibia that were treated via internal fixation with arthroscopic assessment in our hospital.

MATERIALS AND METHODS

All three cases were performed pre- and postoperative arthroscopic assessment and open reduction and internal fixation with a cannulated cancellous screw (CCS; Meira, Japan). All patients were then examined for postoperative complications, functional recovery, at the end of the final follow-up consultation.

RESULTS

Intraoperatively, a small cartilage injury was found in the non-fracture area in two cases; the remaining case had a reversed cartilage fragment at the talus, which was arthroscopically removed.

CONCLUSIONS

Arthroscopic assessment followed by internal fixation is a useful minimally invasive method for the identification of intra-articular lesions such as osteochondral injury or free bodies.

Acute Fractures and Dislocations of the Ankle and Foot in Children

Distinct biologic and mechanical attributes of the pediatric skeleton translate into fracture patterns, complications, and treatment dilemmas that differ from those of adults. In children, increasing participation in competitive sports activities has led to an increased incidence of acute injuries that affect the foot and ankle. These injuries represent approximately 13% of all pediatric osseous injuries. Important posttraumatic complications include premature physeal arrest, three-dimensional deformities and consequent articular incongruity, compartment syndrome, and infection. The authors describe normal developmental phenomena and injury mechanisms of the ankle and foot and associated imaging findings; mimics and complications of acute fractures; and dislocations that affect the pediatric ankle and foot. Treatment strategies, whether conservative or surgical, are aimed at restoring articular congruency and functional alignment and, for pediatric patients specifically, protecting the physis. The different types of ankle and foot fractures are described, and the American College of Radiology guidelines used to determine appropriate imaging recommendations for patients who meet the Ottawa ankle and foot rules are discussed. The systems used to classify clinically important fractures, including the Salter-Harris, Dias-Tachdjian, Rapariz, and Hawkins systems, are described, with illustrations that reinforce key concepts. These classification systems aid in diagnosis and treatment planning, facilitate communication, and help standardize documentation and research. This information is intended to supplement radiologists' understanding of developmental phenomena, anatomic variants, fracture patterns, and associated complications that affect the pediatric foot and ankle. In addition, the role of imaging in ensuring appropriate treatment, follow-up, and patient and parent counseling is highlighted. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

An Anatomic and Radiographic Study of the Distal Tibial Epiphysis

BACKGROUND

Although the undulating shape of the distal tibial epiphysis is well recognized, its anatomic features have not been well quantified in the literature. To guide the placement of surgical implants about the distal tibial physis, we investigated the topographical anatomy of the distal tibial epiphysis and explored the ability of standard radiographs to visualize the physis.

METHODS

We studied 30 cadaveric distal tibial epiphyses in specimens 3 to 14 years of age. Anteroposterior (AP) and lateral radiographs were obtained of each specimen and then repeated after flexible radiopaque markers were placed on the major undulations. All radiographs were analyzed to determine the height or depth of each landmark, and measurements with and without markers for each landmark were compared using intraclass correlation coefficients (ICC). In 9 specimens, similar measurements were obtained on high-resolution 3-dimensional (3D) surface scans.

RESULTS

There were 4 distinct physeal undulations usually present: an anteromedial peak (Kump's bump), a posterolateral peak, an anterior central valley, and a posterior central valley. On the 3D scans, Kump's bump averaged 5.0 mm (range, 3.0 to 6.4 mm), the posterolateral peak 2.4 mm (range, 1.2 to 5.0 mm), the anterior valley 1.3 mm (range, 0 to 3.6 mm), and the posterior valley 0.77 mm (range, 0 to 2.7 mm). Lateral radiographs with markers correlated with measurements from 3D scans better than those without markers (ICC=0.61 vs. 0.24). For AP radiographs, correlation was good to excellent regardless of marker use (ICC=0.76 vs. 0.66).

CONCLUSIONS

There are 4 major undulations of the distal tibial physis. Kump's bump is the largest. A centrally placed epiphyseal screw in the medial/lateral direction or screws from anterolateral to posteromedial and anteromedial to posterolateral would tend to avoid both valleys. Particular caution should be taken when placing metaphyseal screws in the anteromedial or posterolateral distal tibia. Physeal undulations were more difficult to visualize on the lateral view.

CLINICAL RELEVANCE

This study provides quantitative data on the topography of the distal tibial physis to aid hardware placement. Lateral views should be interpreted with caution, as the physeal undulations are not as visible, whereas AP views can be interpreted with more confidence.

The incidence and treatment trends of pediatric proximal humerus fractures

BACKGROUND

Proximal humerus fractures comprise approximately 2% of all pediatric fractures. In general, upper extremity fractures have increased in children. However, recent trends of proximal humerus fractures are not analyzed yet. The aim was to study the incidence and treatment trends of proximal humerus fractures in children.

METHODS

All 300 children, aged < 16 years, who suffered from a proximal humerus fracture in the catchment area of Oulu University Hospital, Finland, between 2005 and 2015, were included. Radiographs were reviewed, and patients, injuries, treatments, and outcomes were comprehensively studied. Annual incidence was based on the child population at risk, which changed between 84.500 and 88.100 in the study time.

RESULTS

The annual incidence of childhood proximal humerus fractures was mean 31.4/100,000 and no variation trend was found. The majority (92%) was treated nonoperatively, however, there was an increase of operative fixation from 0 to 16% during the study time (Difference 16, 95% CI 0.3 to 34.9%, P = 0.045). Bayonet displacement increased the risk of surgical fixation up to 16-fold (95% CI 4.8-51.4, P < 0.001) in a multivariate analysis when adjusted with other potential risk factors. Higher age was also associated with operative treatment (P = 0.002). The most usual recreational activities were horse riding, downhill skiing, snowboarding, and trampolining.

CONCLUSION

Contrary to most upper extremity fractures in children, proximal humerus fractures did not increase during the long study period. However, their operative treatment increased compared to nonoperative treatment, but the evidence supporting that trend remains unclear.

[Application of motorized intramedullary lengthening nails in skeletally immature patients : Indications and limitations]

BACKGROUND

Limb lengthening and deformity correction with motorized intramedullary lengthening nails is a more comfortable and equally safe procedure than the use of external fixators. While this treatment is a well-established method in adults, intramedullary nailing for skeletally immature patients remains a challenge and is the focus of current clinical investigations.

OBJECTIVE

Elucidation of the indications for the application of femoral and tibial lengthening nails in skeletally immature patients, presentation of essential characteristics and limitations of the treatment.

MATERIAL AND METHODS

Treatment of skeletally immature patients up to 16 years old who had a lengthening nail inserted was retrospectively clinically and radiologically evaluated (2016-2018).

RESULTS

A total of 60 procedures were performed on 54 patients. Mean age at the time of surgery was 13.6 years and the mean follow-up time was 10 months. Different nailing approaches were used: antegrade femoral (n = 42), retrograde femoral (n = 10) and antegrade tibial (n = 8). The average amount of lengthening was 45 mm. In 58 of the 60 cases (96.7%) the desired amount of lengthening was achieved, while 2 patients experienced complications that required interruption of the treatment. None of the patients developed growth disorders associated with the nailing approach.

CONCLUSION

Different approaches for intramedullary lengthening nails can be used in children and adolescents to correct leg length discrepancy with or without concomitant deformities. The treatment is limited by the size of the available nails, the residual growth and extent of the deformity. Larger trials will be needed to further validate the application of lengthening nails in skeletally immature patients.

Status of growth plates can be monitored by MRI

BACKGROUND

Growth plate injuries and disorders cause premature closure, resulting in shortened or deformed limbs. Quantitative assessment by MRI might monitor the status of the growth plate and may assist in the prediction of these deformations.

PURPOSE

To investigate whether the status of the growth plate can be monitored by quantitative evaluation using MRI of the noninjured region of the growth plate in a physeal injury model.

STUDY TYPE

Prospective, longitudinal.

ANIMAL MODEL

A 3.0-mm drill was used to create an injury to the central region of the right proximal tibial growth plate in 5-week-old male Japanese white rabbits (N = 18). The left tibia served as the control.

FIELD STRENGTH/SEQUENCE

7.04T, T₂ -weighted imaging, diffusion-weighted imaging.

ASSESSMENT

Eight of 18 rabbits underwent MRI, proton density-weighted imaging, and T₂ -weighted and diffusion-weighted imaging. T₂ and apparent diffusion coefficient (ADC) maps were generated for each image. The growth plate height and the T₂ and ADC values of the noninjured region were measured. Two rabbits were sacrificed at 2, 4, 6, 8, and 10 weeks postinjury. Proximal tibial bones were evaluated using microcomputed tomography, histological, and immunohistological methods.

STATISTICAL TESTS

Data were compared using repeated-measures analysis of variance followed by Tukey post-hoc multiple comparison.

RESULTS

Growth plate height decreased at 10 weeks postinjury (P = 0.018) on the injured side. T₂ values were greater at 2 weeks postinjury (P = 0.0478) and decreased at 8 and 10 weeks (P = 0.0226, P = 0.0470, respectively) on the injured side. ADC values increased at 6 weeks on the lateral side (P = 0.0304) and decreased at 8 weeks and 10 weeks postinjury (P < 0.01) on the medial and injured sides, respectively.

DATA CONCLUSION

Quantitative MRI can help monitor the status of the growth plate and capture its changes early.

LEVEL OF EVIDENCE

1 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:133-143.

Distal femoral physeal fractures after neonatal osteomyelitis: A case report

RATIONALE

The physeal separations and septic osteomyelitis in newborns are unusual, which represents a challenging problem in diagnosis and treatment.

PATIENT CONCERNS

A 2-day-old mature male suddenly complained by parents about minimal swelling around the left knee, decreased left extremity motion and no fever.

DIAGNOSIS

Preliminary x-rays of the lower extremities demonstrated a displaced distal femoral physeal, Laboratory investigation indicated infection. Magnetic resonance imaging and ultrasound showed displaced distal femoral physeal. A needle aspiration confirmed the diagnosis.

INTERVENTION

Debridement and ultrasound guide reduction with pinning of physeal separations was performed.

OUTCOME

At 5 years later, his last follow-up showed that there was only 1.6 cm limb-length discrepancy without angular deformity, the child did not report any pain and was perfectly able to perform his daily activities.

LESSONS

Distal femoral physeal fractures after neonatal osteomyelitis requires immediate and reliable decision for management. We point out the important role of the application of sonography, which is helpful to make an early diagnosis and guide reduction and percutaneous pinning of distal femoral physeal fractures.

[Bony knee injuries in childhood and adolescence]

While fractures around the knee are known to be rare, physicians have encountered a rise in the frequency due to the increased participation of children and adolescents in high-impact sports at a younger age. Even if the treatment of fractures in some cases resembles that in adults, the diagnostics and treatment in childhood and adolescence require a hígh level of experience in order avoid possible sequelae and to enable early recognition. Thorough diagnostics using clinical and imaging investigations as well as a precise weighing up of the treatment are essential to minimize differences in leg length and axial malpositioning of the leg. A decision between conservative and operative treatment is made for both the femur and tibia depending on the type of fracture. Decisive is the degree of dislocation of the fracture. In operative treatment, the axis conform reduction and subsequent stress stable treatment are particularly decisive. Avulsion trauma, bony avulsions of the intercondylar eminence and patellar injuries are also treated conservatively with immobilization or surgically with the aid of various fixation techniques, depending on the degree of dislocation.

Comparison of Biomechanical Effects of Different Configurations of Kirschner Wires on the Epiphyseal Plate and Stability in a Salter-Harris Type 2 Distal Femoral Fracture Model

BACKGROUND

We sought to investigate the different configurations of Kirschner wires used in distal femur Salter-Harris (SH) type 2 epiphyseal fracture for stabilization after reduction under axial, rotational, and bending forces and to define the biomechanical effects on the epiphyseal plate and the fracture line and decide which was more advantageous.

METHODS

The SH type 2 fracture was modeled using design software for four different configurations: cross, cross-parallel, parallel medial, and parallel lateral with two Kirschner wires, and computer-aided numerical analyses of the different configurations after reduction were performed using the finite element method. For each configuration, the mesh process, loading condition (axial, bending, and rotational), boundary conditions, and material models were applied in finite element software, and growth cartilage and von Mises stress values occurring around the Kirschner wire groove were calculated.

RESULTS

In growth cartilage, the stresses were highest in the parallel lateral configuration and lowest in the cross configuration. In Kirschner wires, the stresses were highest in the cross configuration and lowest in the cross-parallel and parallel lateral configurations. In the groove between the growth cartilage and the Kirschner wire interface, the stresses were highest in the parallel lateral configuration and lowest in the cross configuration.

CONCLUSIONS

The results showed that the cross configuration is advantageous in fixation. In addition, in the SH type 2 epiphyseal fracture, we believe that the fixation shape should not be applied in the lateral configuration.

The Role of the Basement Plate in Physeal Bar Formation

BACKGROUND

Physeal fractures and resultant physeal bars can pose significant problems in skeletal development for the injured growing child. Although now well-recognized, only a small body of experimental literature covering this problem is available. The goal of this study was to help further develop an understanding of the different regions of the physis and the way in which each region responds to injury/fracture.

METHODS

This Institutional Animal Care and Use Committee (IACUC)-approved study assessed bar formation using radiologic and histologic methods and measured leg lengths of skeletally immature rats. The right tibia was used as the control to measure leg length discrepancy (LLD), and the left tibia received either a fracture only (F), an epiphyseal scrape (ES), an epiphyseal drilling procedure (ED), or metaphyseal drilling (MD). Radiographs and LLD measurements were obtained at postoperative days 0, 21, and 56.

RESULTS

A significant LLD was present at day 56 in the ED group (P=0.01). Radiographic identification of bars showed significant evidence of bar formation for the ES and ED groups at 21 days and the ED group at 56 days (P<0.05). Histologic examination showed a high incidence of histologic physeal bar formation in the ES, ED, and MD groups at 21 and 56 days.

CONCLUSIONS

Findings showed that the physis was able to continue to grow following an injury to the physis' hypertrophic region. MD produced little effects with few physeal bars and little LLD. By postoperative day 56, ED animals showed greater LLD than ES animals. Penetration of the basement plate was more likely to lead to bar formation/growth retardation than was ablation of the epiphyseal region of the physis (including resting cells).

CLINICAL RELEVANCE

Data presented here provides insight into the importance of different regions of the physis and its repair/continued growth after physeal fracture. We suggest that a better understanding of the physiological cause of physeal arrest after physeal fracture will be important for the development of treatments to prevent physeal arrest or to treat physeal arrest after it occurs.

Focal Periphyseal Edema: Are We Overtreating Physiologic Adolescent Knee Pain?

The goals of this study were to (1) introduce the MRI phenomenon of focal periphyseal edema (FOPE) to the orthopaedic community and (2) describe characteristic features and clinical outcomes of a small series of adolescents with FOPE lesions about the knee. The inclusion criterion was the presence of activity-related knee pain and periphyseal edema on T2-weighted MRI. Exclusion criteria were skeletal maturity, history of traumatic knee injury, and the presence of other knee abnormalities. Participants completed the Short Form 10 and Pediatric International Knee Documentation Committee (pedi-IKDC) outcome assessments. Four patients (average age, 13.7 years) with atraumatic activity-related knee pain and FOPE lesions were retrospectively identified. At follow-up (average, 15.8 months), all patients reported the ability to participate in physical activities at the desired level. The mean pedi-IKDC score was 71.2. With supportive treatment, patients with FOPE were able to return to sport, although they had lower-than-average outcome scores. Increased awareness and understanding of this clinical entity are necessary for provision of effective, cost-efficient care to patients with FOPE.

Imaging of Pediatric Growth Plate Disturbances

The growth plates, or physes, are visible on virtually all images obtained in skeletally immature children. The proper function of these growth plates depends on an intricate balance between chondrocyte proliferation, which requires nourishment from the epiphyseal vessels, and chondrocyte death, which requires the integrity of the metaphyseal vessels. Therefore, injury to the growth plate (ie, direct insult) or vascular compromise on either side of the growth plate (ie, indirect insult) can cause growth plate dysfunction. Direct growth plate insults occur most commonly with Salter-Harris fractures, and injuries that allow the transphyseal communication of vessels are at a higher risk for subsequent transphyseal bone bridge formation. Indirect insults lead to different sequelae that are based on whether the epiphyseal blood supply or metaphyseal blood supply is compromised. Epiphyseal osteonecrosis can result in slowed longitudinal bone growth, with possible growth plate closure, and is often accompanied by an abnormal secondary ossification center. In contrast, the disruption of metaphyseal blood supply alters endochondral ossification and allows the persistence of chondrocytes within the metaphysis, which appear as focal or diffuse growth plate widening. Imaging remains critical for detecting acute injuries and identifying subsequent growth disturbances. Depending on the imaging findings and patient factors, these growth disturbances may be amenable to conservative or surgical treatment. Therefore, an understanding of the anatomy and physiologic features of the normal growth plate and the associated pathophysiologic conditions can increase diagnostic accuracy, enable radiologists to anticipate future growth disturbances, and ensure optimal imaging, with the ultimate goal of timely and appropriate intervention. ^©RSNA, 2017.

What is the best treatment for displaced Salter-Harris II physeal fractures of the distal tibia?

Background and purpose - The optimal treatment of displaced Salter-Harris (SH) II fractures of the distal tibia is controversial. We compared the outcomes of operative and nonoperative treatment of SH II distal tibial fractures with residual gap of >3 mm. Factors that may be associated with the incidence of premature physeal closure (PPC) were analyzed. Patients and methods - We retrospectively reviewed 95 patients who were treated for SH II distal tibial fractures with residual gap of >3 mm after closed reduction. Patients were assigned to 1 of 2 groups: Group 1 included 25 patients with nonoperative treatment, irrespective of size of residual gap (patients treated primarily at other hospitals). Group 2 included 70 patients with operative treatment. All patients were followed for ≥ 12 months after surgery, with a mean follow-up time of 21 months. Logistic regression analyses were performed to identify risk factors for the occurrence of PPC. Results - The incidence of PPC in patients who received nonoperative treatment was 13/52, whereas PPC incidence in patients who received operative treatment was 24/70 (p = 0.1). Multivariable logistic regression analysis determined that significant risk factors for the occurrence of PPC were age at injury, and injury mechanism. The method of treatment, sex, presence of fibular fracture, residual displacement after closed reduction, and implant type were not predictive factors for the occurrence of PPC. Interpretation - Operative treatment for displaced SH II distal tibial fractures did not seem to reduce the incidence of PPC compared with nonoperative treatment. We cannot exclude that surgery may be of value in younger children with pronation-abduction or pronation-external rotation injuries.

Outcomes Following Operative Treatment of Adolescent Mallet Fractures

BACKGROUND

Many surgeons advocate for surgical intervention of adult mallet fractures that involve either subluxation of the distal interphalangeal (DIP) joint or those that involve more than one-third of the articular surface. However, the efficacy of operative treatment and complication rates are unclear regarding the adolescent population.

QUESTIONS/PURPOSES

The goal of this study is to evaluate the clinical outcomes following operative fixation of bony mallet fractures in the adolescent population.

METHODS

Seventeen patients with bony mallet fractures treated surgically were retrospectively reviewed. Twelve patients were treated by closed reduction with extension block pinning. The other patients underwent an open reduction and pin fixation. The average age was 15.2 years (13-18). Most injuries were sport related. The average time from injury to presentation was 17 days and from injury to surgery was 24.5 days. Nine patients had subluxation at the DIP joint and all involved at least one-third of the articular surface.

RESULTS

The average time from surgery to pin removal was 28 days (19-46). All distal phalanx physis were closed or nearly closed. One patient reported pain at the final follow-up. Two patients (11.8%) had major complications. One had an extension contracture postoperatively, did not attend therapy, and re-fractured 5 months later requiring reoperation. The second was treated delayed (32 days) and lost fixation, requiring revision surgery and antibiotics for a superficial infection. Two patients with delayed treatment (32 and 44 days) had an extensor lag (11.8%).

CONCLUSIONS

Operative treatment of mallet fractures with subluxation or involving more than one-third of the articular surface appears effective. Pin removal 4 weeks postoperatively appears adequate. Complications occurred with delayed presentation and non-compliance.

Intra-articular Physeal Fractures of the Distal Femur: A Frequently Missed Diagnosis in Adolescent Athletes

Background:

Intra-articular physeal fractures of the distal femur are an uncommon injury pattern, with only a few small case series reported in the literature.

Purpose:

To pool patients from 3 high-volume pediatric centers to better understand this injury pattern, to determine outcomes of surgical treatment, and to assess risk factors for complications.

Study Design:

Case series; Level of evidence, 4.

Methods:

A multicenter retrospective review of all patients presenting with an intra-articular physeal fracture between 2006 and 2016 was performed. Patient demographic and injury data, surgical data, and postoperative outcomes were documented. Radiographs were evaluated for fracture classification (Salter-Harris), location, and displacement. Differences between patients with and without complications were compared by use of analysis of variance or chi-square tests.

Results:

A total of 49 patients, with a mean age of 13.5 years (range, 7-17 years), met the inclusion criteria. The majority of fractures were Salter-Harris type III fractures (84%) involving the medial femoral condyle (88%). Football was responsible for 50% of the injuries. The initial diagnosis was missed in 39% of cases, and advanced imaging showed greater mean displacement (6 mm) compared with radiographs (3 mm). All patients underwent surgery and returned to sport with “good to excellent” results after 2 years. Complications were more common in patients with wide-open growth plates, patients with fractures involving the lateral femoral condyle, and patients who were casted (P < .05).

Conclusion:

Clinicians evaluating skeletally immature athletes (particularly football players) with acute knee injuries should maintain a high index of suspicion for an intra-articular physeal fracture. These fractures are frequently missed, and advanced imaging may be required to establish the diagnosis. Leg-length discrepancies and angular deformities are not uncommon, and patients should be monitored closely. Surgical outcomes are good when fractures are identified, with high rates of return to sport.