Distal Femoral Physeal Fx - Pediatric

Author: Chris Souder

Topic updated on 05/19/13 4:53pm

Introduction

Most commonly seen as a Salter-Harris II fracture
Mechanism
- often a varus or valgus force on the knee
- physis fails under traumatic force before ligaments in children
- disruption occurs thru multiple zones of the growth plate
Physeal arrest
- high incidence of physeal arrest that often leads to growth disturbance and deformity
  - be sure to counsel parents of poor prognosis associated with this fracture pattern
  - an increased incidence of complications have been associated with
    - Salter-Harris classification type
    - fracture displacement
    - surgical hardware invading the physis

Presentation

Symptoms
- unable to bear weight
Physical exam
- pain and swelling
- tenderness along the physis in the presence of a knee effusion
- may see varus or valgus knee instability on exam

Imaging

Imaging
- MRI or ultrasound is now the diagnositic modality of choice when confirmation of a physeal fracture is needed
- follow up radiographs after 2-3 weeks of casting can be used as treatment if physeal injury is likely but not identifiable on injury films
- stress radiographs to look for opening of the physis were indicated in the past if there was suspicion of physeal injury

Treatment

Nonoperative
- long leg casting
  - indications
    - stable nondisplaced fractures
  - close clinical followup is mandatory
Operative
- closed reduction and percutaneous pinning followed by casting
  - indications
    - displaced Salter-Harris I or II fractures
    - displaced fractures successfully reduced with closed methods should still be pinned (undulating physis makes unstable following reduction)
  - technique
    - avoid multiple attempts at reduction
    - avoid physis with hardware if possible
      - if physis must be crossed (SH I and SH II with small Thurston-Holland fragments), use smooth k-wires
  - SH II fracture, if possible, should be fixed with lag screws across the metaphyseal segment avoiding the physis
  - postoperatively follow closely to monitor for deformity
- ORIF
  - indications
    - Salter-Harris III and IV in order to anatomically reduce articular surface
    - irreducible SHI and SHII fractures
      - reduction often blocked by periosteum infolding into fracture site
  - techniques
    - If anatomic reduction cannot be obtained via closed techniques, incision over the displaced physis to remove interposed periosteum is necessary.

Complications

Deformity (most common)
- results from physeal arrest and can produce limb length discrepancy and/or angular deformity
- occurs in 30-50% of displaced fractures
- prevent with
  - anatomic physeal alignment (critical)
  - close follow up following nonoperative or operative treatment
- treatment
  - physeal bridge excision
    - indicated when deformity is present with a physeal bar of <50% and at least 2 years or 2 cm of growth remaining
Popliteal Artery injury
- rare and more common with anterior displacement of epiphysis

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Qbank (5 Questions)

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(OBQ12.59) A 10-year-old female presents after being struck by a car while riding her bicycle. Her right leg shows significant swelling and deformity around the knee. An injury radiograph is shown in Figure A. Further radiographic work-up confirms the diagnosis of a Salter-Harris II fracture, without any other significant bony injury. The patient is treated definitively with open reduction and internal fixation with lag screws in the metaphysis. While all of the following have been studied with respect to this injury, which of the following is least predictive of the outcome? Topic

Review Topic

FIGURES: A

1. The Salter-Harris classification of the injury
2. Presence or absence of displacement
3. Violation of the physis by hardware with surgical treatment
4. Direction of fracture displacement
5. Presence of an open fracture

PREFERRED RESPONSE ▶

DISCUSSION: When predicting complications associated with displaced physeal fractures of the distal femur, the direction and amount of displacement does not statistically correlate with outcome.

Distal femoral physeal fractures are uncommon but have a high incidence rate of complications. These should, in general, be treated with internal fixation unless the fracture is truly nondisplaced. Repeated reduction attempts should also be avoided, as this can lead to increased physeal damage. Overall, the most common complication is growth arrest. Salter-Harris II fractures, specifically, should be treated with open reduction and internal fixation with lag screws in the metaphysis and crossing of the physis with hardware should be avoided if possible.

Arkader et al. retrospectively reviewed the medical charts and images of 73 patients who sustained a distal femoral physeal fracture. The outcomes they evaluated included growth arrest, leg length discrepency, and angular deformity. The SH classification significantly correlated with the incidence of complications, and there was also a significantly higher incidence rate of complications among displaced fractures. However, the amount and direction of displacement did not correlate with the outcome. The group treated conservatively had a lower incidence rate of complications than did the surgical group, however this was felt to be due to selection bias because the most severe fractures were treated surgically. Among the surgical group, a higher incidence rate of complications occurred when the physis was violated by hardware.

Figure A is a lateral radiograph of the distal femur which shows anterior displacement of the distal femoral epiphysis from the main portion of the femur.

Incorrect Answers:
Answer 1,2,3,5: All of these are predictive of outcomes with physeal injury of the distal femur.

REFERENCES:

1. Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007 Sep;27(6):703-8. PMID:17717475 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Patrick McCulloch MD, Ben Taylor MD,

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(OBQ06.26) An 11-year-old boy underwent surgical intervention for the injury shown in Figure A two years ago. He currently does not complain of knee pain, but the parents have noticed a progressive bow-leg deformity. Physical examination reveals 5 degrees of varus relative to contralateral side. Current radiographs are provided Figure B. Physeal mapping via CT demonstrates a bar involving 25% of the physis. The remainder of the physis is open. Which of the following is the most appropriate management? Topic

Review Topic

FIGURES: A

1. Observation with repeat radiographs in 1 year
2. Lateral opening wedge distal femoral osteotomy
3. Guided growth with temporary hemiephysiodesis of the lateral distal femoral physis
4. Physeal bridge resection with polymethylmethacrylate interposition
5. Distal femoral epiphysiodesis

PREFERRED RESPONSE ▶

DISCUSSION: Physeal bridge excision is a recommmended treatment option for patients with a resulting deformity in which there is at least 2 years or 2 cm of growth remaining and a physeal bridge that is less than or equal to 50% of the physeal area. This procedure can prevent, correct, or improve deformity and limb-length discrepancy by restoring growth potential. Although resection of physeal bridges can be helpful, it remains unpredictable with excellent and good results in most series ranging from 62% to 90%. Physeal bridges are often not clinically evident until years after the injury and therefore long-term follow up is recommended until skeletal maturity. A current indication for osteotomy is correction of angular deformities >20° because they likely will not correct spontaneously after bridge resection. The referenced article is a good review of the physiology and treatment of physeal bars.

REFERENCES:

1. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005 Jan-Feb;13(1):47-58. Review. PMID:15712982 (Link to Abstract)

2. Sponseller et al. Fractures and dislocations about the knee in Rockwood and Wilkin’s Fractures in Children. 982-1076.

Question Authors:

Chris Souder MD, Eric Shirley MD, Eric Shirley MD,

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(OBQ05.200) Distal femoral epiphyseal fractures are uncommon but have a high incidence of complications. In the treatment of these injuries, all of the following variables are associated with an increased incidence of complications EXCEPT: Topic

Review Topic

1. Exactness of fracture reduction
2. Presence of fracture displacement
3. Direction of fracture displacment
4. Surgical treatment
5. Violation of the physis with surgical hardware

PREFERRED RESPONSE ▶

DISCUSSION: All of the variables listed are associated with an increased risk of complications with treatment of distal femoral epiphyseal fractures, EXCEPT for direction of fracture displacement.

Distal femoral physeal fractures are associated with a high incidence of complications including physeal arrest, growth disturbance, and deformity. Several studies have looked at risk factors for complications associated with treatment.

Arkader et al showed that SH classification, presence (but not degree) of fracture displacement, surgical treatment, and violation of the physis with hardware were all associated with an increased incidence of complications. They found the amount and direction of displacement did not correlate with the the incidence of complications (Answer 3).

Lombardo et al reviewed 34 distal femoral physeal fractures and found limb-length discrepancy occurred in 36% and varus or valgus deformity occurred in 33%. They found the development of deformity appears to be related to the degree of initial displacement of the fracture, the exactness of the reduction, and the type of fracture.

Thomason et al reported a retrospective analysis of 30 distal femoral epiphyseal plate fractures. They showed the best results occurred when fractures were anatomically reduced and fixed with pins. The radiograph in Illustration A shows a Salter-Harris II fracture with displacement.

Illustrations: A

REFERENCES:

1. Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007 Sep;27(6):703-8. PMID:17717475 (Link to Abstract)

2. Thomson JD, Stricker SJ, Williams MM. Fractures of the distal femoral epiphyseal plate. J Pediatr Orthop. 1995 Jul-Aug;15(4):474-8. PMID:7560038 (Link to Abstract)

3. Lombardo SJ, Harvey JP Jr. Fractures of the distal femoral epiphyses. Factors influencing prognosis: a review of thirty-four cases. J Bone Joint Surg Am. 1977 Sep;59(6):742-51. PMID:908697 (Link to Abstract)

Question Authors:

Chris Souder MD, Derek Moore, Eric Shirley MD,

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(OBQ04.68) A 10-year-old boy presents to the emergency room after injuring his right knee while playing soccer. He localizes the pain to the distal femur, and is unable to bear weight on the affected leg. On physical exam the patient is tender to palpation only directly over the distal femoral physis. He has swelling about the distal thigh, without any signs of knee effusion. An AP radiograph is shown in Figure A. What is the most appropriate treatment? Topic

Review Topic

FIGURES: A

1. Hinged knee brace with early motion and weight bearing as tolerated
2. Cast immobilization with close clinical followup
3. Closed reduction and percutaneous pinning
4. Open reduction with pin fixation
5. Open reduction with plate fixation

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation, physical exam, and radiographs are consistent with a nondisplaced Salter-Harris Type I fracture of the distal femoral physis. The radiographs show subtle physeal widening, but no displacement. If there is no displacement following the injury, as in this case, then cast immobilization is acceptable treatment. However, these fractures are associated with a high incidence of deformity so close clinical followup is mandatory. If there is evidence of displacement with a SHI or SHII, then closed reduction percutaneous pinning would be indicated. Open reduction is reserved for SHIII and SHIV fractures, or fractures that can not be reduced.

REFERENCES:

1. Able MF(ed): OKU: Pediatrics 3. Rosemont, IL. American Academy of Orthopaedic Surgeons, 2006.

Question Authors:

Eric Shirley MD, Derek Moore, Ben Taylor MD,

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(OBQ04.110) A 13-year-old boy is unable to bear weight after sustaining a twisting injury during football practice. Physical exam shows swelling and tenderness over the distal femur. Radiographs are shown in Figure A. What is the most appropriate treatment? Topic

Review Topic

FIGURES: A

1. Hinged knee brace and weight bearing as tolerated
2. Long leg cast and non-weightbearing
3. Skeletal traction for three weeks followed by cast immobilization
4. Closed reduction and percutaneous screw fixation
5. Open reduction and internal fixation of the distal femur with plate fixation

PREFERRED RESPONSE ▶

DISCUSSION: The history, physical exam, and radiographs are consistent with a displaced Salter-Harris II fracture of the distal femoral physis. Because the fracture is displaced, closed reduction with percutaneous pinning would be the most appropriate treatment. Open reduction and internal fixation is reserved for SHIII and SHIV fractures and irreducible displaced SH I or II fractures. If anatomic reduction cannot be obtained via closed techniques, incision over the displaced physis to remove interposed periosteum is necessary.

The first referenced article by Graham et al showed a 70% displacement rate with cast treatment of these injuries, and a 90% growth disturbance rate when treated in a closed fashion. They note that initial anatomic reduction with rigid fixation of physeal injuries about the ankle has been demonstrated to decrease the incidence of growth deformity.

The second referenced article by Riseborough et al described the commonly noted growth disturbances of the distal femoral physis when injured, and reported a 56% rate of leg length discrepancy (>2.4cm) with this injury pattern.

The last referenced article by Thomson et al showed no displacement with CRPP of this injury compared to 43% displacement with long leg casting. They also report that complications were more frequent in displaced than nondisplaced fractures.

REFERENCES:

1. Graham JM, Gross RH. Distal Femoral physeal problem fractures. Clin Orthop 1990; 255:51-53. PMID:2347164 (Link to Abstract)

2. Riseborough EJ, Barrett IR, Shapiro F. Growth disturbances following distal femoral physeal fracture-separations. J Bone Joint Surg Am 1983;65:885-93 PMID:6885868 (Link to Abstract)

3. Thomson JD, Stricker SJ, Williams MM. Fractures of the distal femoral epiphyseal plate. J Pediatr Orthop 1995;15:474-78 PMID:7560038 (Link to Abstract)

Question Authors:

Ben Taylor MD, Eric Shirley MD, Michael Hughes MD,

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ABOS II: Distal Femoral Physeal Fx - Pediatric

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007 Sep;27(6):703-8. PMID:17717475 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005 Jan-Feb;13(1):47-58. Review. PMID:15712982 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Able MF(ed): OKU: Pediatrics 3. Rosemont, IL. American Academy of Orthopaedic Surgeons, 2006.
Sponseller et al. Fractures and dislocations about the knee in Rockwood and Wilkin’s Fractures in Children. 982-1076.

Undefined

Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007 Sep;27(6):703-8. PMID:17717475 (Link to Abstract)
Graham JM, Gross RH. Distal Femoral physeal problem fractures. Clin Orthop 1990; 255:51-53. PMID:2347164 (Link to Abstract)
Lombardo SJ, Harvey JP Jr. Fractures of the distal femoral epiphyses. Factors influencing prognosis: a review of thirty-four cases. J Bone Joint Surg Am. 1977 Sep;59(6):742-51. PMID:908697 (Link to Abstract)
Riseborough EJ, Barrett IR, Shapiro F. Growth disturbances following distal femoral physeal fracture-separations. J Bone Joint Surg Am 1983;65:885-93 PMID:6885868 (Link to Abstract)
Thomson JD, Stricker SJ, Williams MM. Fractures of the distal femoral epiphyseal plate. J Pediatr Orthop. 1995 Jul-Aug;15(4):474-8. PMID:7560038 (Link to Abstract)
Thomson JD, Stricker SJ, Williams MM. Fractures of the distal femoral epiphyseal plate. J Pediatr Orthop 1995;15:474-78 PMID:7560038 (Link to Abstract)

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