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Discharge from care
0%
4/1853
Left distal femoral epiphysiodesis
57%
1052/1853
Osteotomy and lengthening of the right femur
18%
333/1853
Osteotomy and lengthening of the right tibia
1%
12/1853
Observation
22%
409/1853
Select Answer to see Preferred Response
This child sustained a SH II distal femur fracture, with resultant physeal arrest, with roughly 6 years of growth remaining. His 1 cm leg length discrepancy will worsen over time, making left distal femoral epiphysiodesis the correct answer. Fractures of the distal femur are most commonly complicated with growth disturbance. These fractures are associated with a growth disturbance up to 60% of the time. The best treatment is to perform a contralateral epiphysiodesis to stop the progression of limb length discrepancy. If done at this time, the child is likely to remain asymptomatic. In these injuries, the physis fails on the tension side and the metaphysis fails at the compression side, creating the Thurston-Holland fragment. Disruption occurs through multiple zones of the growth plate. These fractures usually necessitate open reduction as periosteum becomes interposed on the tension side of the fracture. Fixation should avoid the physis. Basener et al. performed a meta-analysis looking at distal femur growth plate fractures. They found that 52% of distal femoral growth plate fractures had some sort of growth disturbance and 22% of patients developed a leg length discrepancy of greater than 1.5 cm. SH I had the lowest incidence of growth disturbance (36%), while SH IV had the highest rate at 64%. Arkader et al. report that both SH classification and displacement of the fracture are significant predictors of the final outcome. They found that the SH classification was significantly correlated with the rate of complications. There was also a significantly higher rate of complications in fractures that were displaced. The amount and direction of displacement did not correlate with outcome, however. They also noted a higher rate of complications if hardware violated the physis. Figure A is a radiograph of a SH II distal femur fracture while Figure B is a fluoroscopic image demonstrating fixation with lag screws. Incorrect Answers: Answer 1: The leg length discrepancy is likely to progress if the patient is discharged from care Answers 3, 4: Lengthening is not indicated as the limb length discrepancy is small and the patient is asymptomatic. With the patient being skeletally immature, the discrepancy has the potential to recur. Answer 5: The leg length discrepancy is likely to progress if the patient is observed
1.3
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