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Average 4.2 of 45 Ratings
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?
The Salter-Harris classification of the injury
Presence or absence of displacement
Violation of the physis by hardware with surgical treatment
Direction of fracture displacement
Presence of an open fracture
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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 discrepancy, 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.
Answer 1,2,3,5: All of these are predictive of outcomes with physeal injury of the distal femur.
Arkader A, Warner WC, Horn BD, Shaw RN, Wells L
J Pediatr Orthop. 2007 Sep;27(6):703-8. PMID: 17717475 (Link to Abstract)
Arkader, JPO 2007
Please rate question.
Average 3.0 of 21 Ratings
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?
Observation with repeat radiographs in 1 year
Lateral opening wedge distal femoral osteotomy
Guided growth with temporary hemiephysiodesis of the lateral distal femoral physis
Physeal bridge resection with polymethylmethacrylate interposition
Distal femoral epiphysiodesis
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.
Khoshhal KI, Kiefer GN
J Am Acad Orthop Surg. 2005 Jan-Feb;13(1):47-58. PMID: 15712982 (Link to Abstract)
Khoshhal, JAAOS 2005
Average 3.0 of 24 Ratings
All of the variables listed are associated with an increased risk of complications with treatment of distal femoral epiphyseal fractures EXCEPT:
Presence of fracture displacement
Direction of fracture displacment
Violation of the physis with surgical hardware
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.
Thomson JD, Stricker SJ, Williams MM.
J Pediatr Orthop. 1995 Jul-Aug;15(4):474-8. PMID: 7560038 (Link to Abstract)
Thomson, JPO 1995
Lombardo SJ, Harvey JP Jr.
J Bone Joint Surg Am. 1977 Sep;59(6):742-51. PMID: 908697 (Link to Abstract)
Lombardo, JBJS 1977
Average 1.0 of 106 Ratings
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?
Hinged knee brace with early motion and weight bearing as tolerated
Cast immobilization with close clinical followup
Closed reduction and percutaneous pinning
Open reduction with pin fixation
Open reduction with plate fixation
The clinical presentation, physical exam, and radiographs are consistent with a 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.
Average 3.0 of 31 Ratings
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?
Hinged knee brace and weight bearing as tolerated
Long leg cast and non-weightbearing
Skeletal traction for three weeks followed by cast immobilization
Closed reduction and percutaneous fixation
Open reduction and internal fixation of the distal femur with plate fixation
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 closed reduction and percutaneous fixation of this injury compared to 43% displacement with long leg casting. They also report that complications were more frequent in displaced than nondisplaced fractures.
Graham JM, Gross RH.
Clin Orthop Relat Res. 1990 Jun;(255):51-3. PMID: 2347164 (Link to Abstract)
Graham, CORR 1990
Riseborough EJ, Barrett IR, Shapiro F.
J Bone Joint Surg Am. 1983 Sep;65(7):885-93. PMID: 6885868 (Link to Abstract)
Riseborough, JBJS 1983
Average 4.0 of 26 Ratings
HPI - Patient suffered from a trauma 3 months ago. First, the parents went to an alternative medical center. 2 months after the trauma, patient presented to the hospital for assessment.
Would you order a CT-scan?
HPI - Fall on the ground with pain and deformity of the LT knee. Pt. presents with the injury films show. Closed reduction was performed. See closed reduction below.
What would you do for definitive treatment of the distal femur physeal following the closed reduction films below?