Topic
Review Topic
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Evidence
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Cases
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Introduction
  • Description
    • pediatric distal femoral physeal fractures are most commonly Salter-Harris II fractures that result from direct trauma in children with open physes.
      • treatment is usually closed reduction and percutaneous fixation followed by casting.
  • 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
  • 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 q
          • Salter-Harris classification type
          • fracture displacement
          • surgical hardware invading the physis
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 q
      • 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, uncommon
    • may be necessary in fractures with wide displacement and posterior spiked fragments 
Treatment
  • Nonoperative
    • long leg casting q 
      • indications
        • nondisplaced fractures
      • treated for 4-6 weeks
      • close clinical follow up is mandatory 
  • Operative  
    • closed reduction and percutaneous fixation followed by casting q 
      • 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 and 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 q
        • 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
 

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Questions (16)

(OBQ05.200) All of the variables listed are associated with an increased risk of complications with treatment of distal femoral physeal fractures EXCEPT: Review Topic

QID: 1086
1

Articular incongruity

5%

(43/822)

2

Presence of fracture displacement

5%

(40/822)

3

Direction of fracture displacment

57%

(472/822)

4

Surgical treatment

26%

(210/822)

5

Violation of the physis with surgical hardware

4%

(33/822)

ML 4

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PREFERRED RESPONSE 3
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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? Review Topic

QID: 1215
FIGURES:
1

Hinged knee brace and weight bearing as tolerated

0%

(3/2311)

2

Long leg cast and non-weightbearing

2%

(36/2311)

3

Skeletal traction for three weeks followed by cast immobilization

0%

(0/2311)

4

Closed reduction and percutaneous fixation

78%

(1794/2311)

5

Open reduction and internal fixation of the distal femur with plate fixation

20%

(463/2311)

ML 2

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PREFERRED RESPONSE 4
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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? Review Topic

QID: 4419
FIGURES:
1

The Salter-Harris classification of the injury

8%

(326/4265)

2

Presence or absence of displacement

4%

(157/4265)

3

Violation of the physis by hardware with surgical treatment

10%

(436/4265)

4

Direction of fracture displacement

71%

(3044/4265)

5

Presence of an open fracture

7%

(283/4265)

ML 2

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PREFERRED RESPONSE 4

(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? Review Topic

QID: 1173
FIGURES:
1

Hinged knee brace with early motion and weight bearing as tolerated

14%

(118/825)

2

Cast immobilization with close clinical followup

70%

(578/825)

3

Closed reduction and percutaneous pinning

10%

(85/825)

4

Open reduction with pin fixation

4%

(30/825)

5

Open reduction with plate fixation

1%

(6/825)

ML 2

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PREFERRED RESPONSE 2

(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? Review Topic

QID: 137
FIGURES:
1

Observation with repeat radiographs in 1 year

10%

(232/2440)

2

Lateral opening wedge distal femoral osteotomy

2%

(49/2440)

3

Guided growth with temporary hemiephysiodesis of the lateral distal femoral physis

22%

(529/2440)

4

Physeal bridge resection with polymethylmethacrylate interposition

63%

(1539/2440)

5

Distal femoral epiphysiodesis

2%

(59/2440)

ML 3

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PREFERRED RESPONSE 4
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ARTICLES (19)
CASES (2)
Topic COMMENTS (7)
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