summary Distal Femoral Physeal Fractures are common fractures in the pediatric population that result from direct trauma in children with open physes. Diagnosis is confirmed with plain radiographs of the femur and knee. Treatment is usually operative with closed reduction and percutaneous fixation followed by casting. These fractures are at high risk for the development of future growth arrest. Epidemiology Demographics occur in patients with open growth plates must be considered in patients with open physes to avoid misdiagnosis with collateral ligament injury Pathophysiology Mechanism of injury often the result of direct trauma with some degree of rotation most commonly a valgus-type force or a hyperextension force Most commonly Salter-Harris II fracture physis fails on the tension side metaphysis fails on the compression side, creating a Thurston-Holland fragment injury to physis occurs at the zone of hypertrophy Anatomy Osteology formed from a single ossific nucleus that is present at birth and is the first epiphysis in the body to ossify Muscles both heads of the gastrocnemius and plantaris muscles originate just proximal to the physis leads to flexion of the distal fracture fragment when fracture line is distal to muscle insertion Ligament collateral ligaments attach distal to the physis at the level of the epiphysis stress places tension on the collaterals which transfer force to the physis ACL and PCL attach to epiphysis at the intercondylar notch and may be injured Blood Supply femoral artery travels through the adductor canal medially above the metaphysis and courses in the popliteal space popliteal artery is directly posterior to distal femur trifurcates at this level due to poor collateral circulation, popliteal artery injury may result in loss of lower limb viability Physeal considerations of the knee general assumptions leg growth continues until 16 yrs in boys 14 yrs in girls growth contribution leg grows 23 mm/year, with most of that coming from the knee (in contrast to upper extremity where most of growth is away from the elbow) proximal femur - 3 mm / yr (1/8 in) distal femur - 9 mm / yr (3/8 in) proximal tibia - 6 mm / yr (1/4 in) distal tibia - 5 mm / yr (3/16 in) Presentation History history of significant trauma Symptoms pain with inability to bend knee unable to bear weight Physical exam pain and swelling often in flexed position due to hamstring muscle spasm tenderness along the physis in the presence of a knee effusion may see varus or valgus knee instability on exam swelling in the popliteal space may be a sign of vascular injury or disruption Imaging Radiographs recommended views AP lateral oblique stress radiographs to look for physis opening if there was suspicion of physeal injury have fallen out of favor due to risk of physeal damage, patient discomfort, and possible need for sedation MRI or ultrasound have replaced stress radiographs in this setting indications at presentation close follow up with repeat x-rays if inital radiographs not definitive and treating as a possible Salter I fracture findings physeal widening normal 3-5mm direction of displacement suggestive of mechanism of injury anterior displacement due to hyperextension posterior displacement due to hyperflexion medial displacement due to valgus lateral displacement due to varus MRI indications diagnostic modality of choice to confirm physeal fracture Ultrasound indications can help confirm physeal fracture CT may be necessary for evaluation of intra-articular extension and to define fracture fragments to plan fixation Angiography occasionally necessary to evaluate for a vascular injury in the case of abnormal ABI (<0.9) may be necessary in fractures with wide displacement and posterior spiked fragments Treatment Nonoperative long leg casting indications nondisplaced fractures treated for 4-6 weeks close clinical follow up is mandatory Operative closed reduction and percutaneous fixation followed by casting indications majority of cases displaced Salter-Harris I or II fractures displaced fractures successfully reduced with closed methods typically should still be secured with fixation as fracture pattern is unstable some Salter-Harris III or IV injuries if anatomic reduction is achieved postoperatively follow closely to monitor for deformity ORIF indications Salter-Harris III and IV with weight-bearing articular involvement irreducible SHI and SHII fractures irreducible type II fractures are most often due to interposed periosteum on the tension side of fracture Techniques Closed reduction and percutaneous fixation reduction avoid multiple attempts at reduction reduction maneuver consists of 90% traction and 10% manipulation fixation if physis must be crossed (SH I and SH II with small Thurston-Holland fragments) use smooth K-wires remove 3-6 weeks after surgery SH II fracture with large enough metaphyseal fragment should be fixed with lag screws across the metaphyseal segment Open Reduction Internal Fixation approach incision over the displaced physis to remove interposed periosteum is necessary. fixation should avoid the physis if possible postoperative usually add post-operative immobilization Complications Limb length discrepancy or angular deformity(most common) results from physeal disturbance limb length inequality of >2 cm in one third of cases correlates with fracture pattern 36% of SH 1 fractures 58% in SH 2 fractures 49% in SH 3 fractures 64% in SH 4 fractures minimize with anatomic physeal alignment (critical) close follow up following nonoperative or operative treatment treatment no treatment necessary when predicted final leg length discrepancy <2 cm and no significant angulation indicated for discrepancy between 2-6 cm epiphysiodesis of the contralateral distal femur +/- proximal tibia physeal bridge excision indication physeal bar of <50% and ≥ 2 years or 2.5 cm of growth remaining Septic arthritis Intra-articular pins have a risk of septic arthritis Popliteal artery injury and compartment syndrome rare, most common with anterior displacement of epiphysis or a posterior spike at the fracture site Prognosis Physeal arrest 30-50% rate of physeal arrest that often leads to growth disturbance and deformity counsel parents of poor prognosis associated with this fracture pattern an increased incidence of complications have been associated with 218554Salter-Harris classification type (I and V associated with non-angular deformities) fracture displacement surgical hardware invading the physis
QUESTIONS 1 of 25 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.71) A 9-year-old male sustained the injury shown in Figure A. Which of the following is true with respect to the treatment of this injury? QID: 212967 FIGURES: A Type & Select Correct Answer 1 Anterograde pin fixation has a higher risk of septic arthritis. 1% (16/1954) 2 The size of the Thurston-Holland fragment determines treatment with pins or screws. 41% (793/1954) 3 Interposed periosteum on the compression side of fracture may prevent closed reduction 32% (621/1954) 4 Fully threaded screws are superior to partially threaded screws 3% (56/1954) 5 This physeal injury type has the highest rate of physeal growth arrest 23% (454/1954) L 5 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ17.115) A 12-year-old female is involved in a car collision and suffered the injury demonstrated in Figure A. Subsequent work-up shows this to be an isolated injury. Following surgical fixation to address the injury, what complication would you most expect and what would be the most appropriate treatment? QID: 210202 FIGURES: A Type & Select Correct Answer 1 Avascular necrosis of the medial femoral condyle, prolonged period of nonweightbearing 1% (14/2456) 2 Knee stiffness, immediate use of a continuous passive motion device 1% (35/2456) 3 Physeal growth disturbance, close clinical observation 81% (1980/2456) 4 Physeal growth disturbance, contralateral distal femur epiphysiodesis 15% (362/2456) 5 Physeal growth disturbance, ipsilateral intramedullary limb lengthening 1% (33/2456) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ16SM.17) A 13-year-old boy falls from a trampoline and feels immediate left knee pain. His range of motion is limited from 10-85 degrees with pain over the medial epicondyle of the knee. He has a grade 1A Lachman test and pain with valgus stress testing. Radiographs are read as normal. Selected images of an MRI that demonstrate the only pathology found in the knee are shown in Figures A and B. What is the location of the injury in the patient? QID: 211293 FIGURES: A B Type & Select Correct Answer 1 Femoral attachment of the anterior cruciate ligament (ACL) 2% (20/1229) 2 Meniscocapsular junction of the medial meniscus 6% (77/1229) 3 Cartilage and subchondral bone interface at the posterolateral aspect of the medial femoral condyle 9% (110/1229) 4 At the growth plate zone where chondrocytes are growing in number 13% (159/1229) 5 At the growth plate zone where chondrocytes are growing in size. 70% (856/1229) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ13PE.65) Figure A and B are images of a 13-year-old male who sustained an injury playing ice hockey. He underwent closed reduction and casting in a rural hospital. The patient and his parents are seeing you in clinic for the first time, 5 weeks after the date injury. Current radiographs of the knee are shown in Figures C and D. What is the most common complication to warn the patient about with this injury and management? QID: 5167 FIGURES: A B C D Type & Select Correct Answer 1 Physeal growth acceleration 12% (383/3218) 2 Recurrent fractures 1% (29/3218) 3 Limb angular deformity 81% (2605/3218) 4 Arterial injury 2% (78/3218) 5 Compartment syndrome 1% (34/3218) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ13.43) An 11-year-old girl sustains the following injury seen in Figure A. Assuming she has complete physeal arrest, which of the following is the closest approximation to the expected limb-length-discrepancy? QID: 4678 FIGURES: A Type & Select Correct Answer 1 1 cm 3% (122/3985) 2 2 cm 11% (421/3985) 3 3 cm 74% (2965/3985) 4 4 cm 7% (275/3985) 5 5 cm 5% (180/3985) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 4419 FIGURES: A Type & Select Correct Answer 1 The Salter-Harris classification of the injury 8% (390/4973) 2 Presence or absence of displacement 3% (174/4973) 3 Violation of the physis by hardware with surgical treatment 10% (500/4973) 4 Direction of fracture displacement 71% (3540/4973) 5 Presence of an open fracture 7% (336/4973) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 137 FIGURES: A B Type & Select Correct Answer 1 Observation with repeat radiographs in 1 year 9% (293/3135) 2 Lateral opening wedge distal femoral osteotomy 2% (70/3135) 3 Guided growth with temporary hemiephysiodesis of the lateral distal femoral physis 22% (692/3135) 4 Physeal bridge resection with polymethylmethacrylate interposition 63% (1963/3135) 5 Distal femoral epiphysiodesis 3% (80/3135) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ05.200) All of the variables listed are associated with an increased risk of complications with treatment of distal femoral physeal fractures EXCEPT: QID: 1086 Type & Select Correct Answer 1 Articular incongruity 5% (73/1614) 2 Presence of fracture displacement 4% (67/1614) 3 Direction of fracture displacement 59% (954/1614) 4 Surgical treatment 26% (427/1614) 5 Violation of the physis with surgical hardware 4% (65/1614) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 1215 FIGURES: A Type & Select Correct Answer 1 Hinged knee brace and weight bearing as tolerated 0% (5/3532) 2 Long leg cast and non-weightbearing 1% (49/3532) 3 Skeletal traction for three weeks followed by cast immobilization 0% (3/3532) 4 Closed reduction and percutaneous fixation 79% (2791/3532) 5 Open reduction and internal fixation of the distal femur with plate fixation 19% (661/3532) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ04.68) A 10-year-old boy presents to the emergency room after injuring his left 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 and lateral radiograph of the affected knee are shown in Figures A and B. An AP and lateral radiograph of the contralateral knee are shown in Figures C and D. What is the most appropriate treatment? QID: 1173 FIGURES: A B C D Type & Select Correct Answer 1 Hinged knee brace with early motion and weight bearing as tolerated 13% (202/1542) 2 Cast immobilization with close clinical followup 71% (1097/1542) 3 Closed reduction and percutaneous pinning 11% (173/1542) 4 Open reduction with pin fixation 3% (49/1542) 5 Open reduction with plate fixation 1% (9/1542) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
All Videos (0) Podcasts (3) Pediatrics | Distal Femoral Physeal Fractures (ft. Dr. Eric Shirley) Team Orthobullets (J) Pediatrics - Distal Femoral Physeal Fractures - Pediatric Listen Now 9:33 min 10/18/2019 62 plays 5.0 (1) Question Session⎪Distal Femoral Physeal Fractures, Glenohumeral Arthritis & TKA Revision Orthobullets Team Pediatrics - Distal Femoral Physeal Fractures - Pediatric Listen Now 27:58 min 11/18/2019 34 plays 4.0 (1) Pediatrics | Distal Femoral Physeal Fractures - Pediatric Pediatrics - Distal Femoral Physeal Fractures - Pediatric Listen Now 23:38 min 3/12/2020 252 plays 5.0 (1)
Neglected epiphysiolysis of the distal femur in a 9M (C2820) Laurens Pool Pediatrics - Distal Femoral Physeal Fractures - Pediatric E 5/23/2017 269 1 2 salter harris fracture distal femur with comminuted upper patellar pole fracture (C2530) DR MICHAEL TS GERGIS Pediatrics - Distal Femoral Physeal Fractures - Pediatric E 3/14/2016 505 3 4