Distal Tibial Growth Plate Research Articles

Adult Tillaux-Chaput tubercle fracture of the ankle with rupture of the peroneus tertius muscle: a case report

BackgroundTillaux-Chaput tubercle fractures occur in adolescents, which are often associated with the separation of the distal tibial growth plate. These types of fractures are rare in adults and even rarer when accompanied by a rupture of the peroneus tertius muscle. Given the limited number of reported cases, there is limited clinical awareness, resulting in missed diagnoses and delayed treatment, ultimately affecting ankle function.Case presentationWe report a case of an adult patient who experienced a right ankle injury resulting in swelling and pain after a traffic accident. Initial examination failed to identify the rupture of the peroneus tertius muscle, but the patient was observed to have restricted dorsiflexion and eversion of the foot. Surgical exploration through an anterolateral incision confirmed the rupture and the muscle was then repaired. The patient received four weeks of cast immobilization and then engaged in progressive rehabilitation exercises.Discussion and conclusionThis report shares the diagnostic and therapeutic experiences of an adult with a Tillaux-Chaput tubercle fracture associated with peroneus tertius muscle rupture to improve clinical recognition of such injuries, thus preventing misdiagnosis and treatment delays.

Radiographic study of the development of the pelvis and hip and the femorotibial joints in domestic cats.

The aims of the present study were to monitor, by radiographic examination, the skeletal development of the pelvis and the femorotibial joints of the domestic cat from the first week of life until the closing of the growth plates. Radiographic examinations were collected from 15 domestic cats at weekly intervals during the first month and every 2 weeks from the second to the fourth month of age. After that, examinations were performed monthly until the age of 18 months. The ischiopubic growth plate closed at 2 months of age, followed by the fusion of the iliopubic, ilioischial, proximal femoral, greater trochanter and proximal fibular growth plates. The distal femur and proximal tibial growth plates were the last to close, with fusion occurring at 18 months. The mean time to closure of the iliopubic, ilioischial and distal femoral growth plates was shorter in females. The ossification centers first appeared, in ascending order, beginning with the lesser trochanter, followed by the greater trochanter, proximal fibular epiphysis, tibial tuberosity, patella, ischial tuberosity and lateral sesamoid of the popliteus muscle. The complete closure of the growth plates of domestic cats occurs at approximately 18 months of age. Skeletal maturation at approximately 18 months of age is an important parameter to be considered in radiographic evaluation of certain skeletal changes, evolution of fractures and nutritional imbalance.

Glucosamine and chondroitin sulfate association increases tibial epiphyseal growth plate proliferation and bone formation in ovariectomized rats

OBJECTIVE:The growth plate consists of organized hyaline cartilage and serves as a scaffold for endochondral ossification, a process that mediates longitudinal bone growth. Based on evidence showing that the oral administration of glucosamine sulfate (GS) and/or chondroitin sulfate (CS) is clinically valuable for the treatment of compromised articular cartilage, the current study evaluated the effects of these molecules on the tibial epiphyseal growth plate in female rats.METHOD:The animals were divided into two control groups, including vehicle treatment for 45 days (GC45) and 60 days (GC60) and six ovariectomized (OVX) groups, including vehicle treatment for 45 days (GV45), GS for 45 days (GE45GS), GS+CS for 45 days (GE45GS+CS), vehicle for 60 days (GV60), GS for 60 days (GE60GS) and GS+CS for 60 days (GE60GS+CS). At the end of treatment, the tibias were dissected, decalcified and processed for paraffin embedding. Morphological and morphometric methods were employed for analyzing the distal tibial growth plates using picrosirius red staining and the samples were processed for histochemical hyaluronan detection. Morphometric analyses were performed using the 6.0ProPlus® Image system.RESULTS:Notably, after 60 days of treatment, the number of proliferative chondrocytes increased two-fold, the percentage of remaining cartilage increased four-fold and the percentage of trabecular bone increased three-fold in comparison to the control animals.CONCLUSION:GS and CS treatment drugs led to marked cellular proliferation of the growth plate and bone formation, showing that drug targeting of the tibial epiphyseal growth plate promoted longitudinal bone growth.

Posttraumatische Komplikationen am kindlichen Sprunggelenk

Ankle sprains are common injuries in childhood and are generally harmless. However, fractures of the ankle joint are rare, but complications (persistent rotational or axial deformity, alteration of growth of the distal tibia or fibula, or joint deformity) can lead to serious problems during growth. The clinical relevance of growth disturbances at the distal tibia or fibula depends on the age at the time of fracture more than on the fracture type, severity of dislocation, or interponated material in the fracture gap. Both stimulation and inhibition of growth are possible. Inhibition of growth at the distal tibial growth plate regularly leads to varus deformity and shortening. This is of clinical importance as this type of growth disturbance is the most common. Valgus deformity is rare, mostly due to persistent axial deviation of an insufficiently reduced fracture. Transitional fractures always occur at the time of growth plate closure; thus, growth disturbances do not play a role. Transitional fractures could be overlooked or treated insufficiently, leading to a step or gap of the joint surface.

Surgical repair of a tibial fracture in a two-week-old grey seal (Halichoerus grypus)

To report the successful management of a suspected infected tibial fracture in a common grey seal. Case report. Female common grey seal (Halichoerus grypus), 2 weeks old, 20 kg. A closed, complete, transverse fracture of the left tibial distal diaphysis was debrided, reduced and stabilized using a string-of-pearls (SOP) locking plate covered with polymethylmethacrylate impregnated with gentamicin. Fracture of the ipsilateral fibula was left untreated. Postoperative radiographs were obtained immediately, and at 10 days, three weeks, and six weeks post-surgery, and a computed tomographic examination was performed 2.5 months post- surgery. A species-specific progressive rehabilitation programme was conducted. Bone healing of both fractures and absence of injury of the distal tibial growth plate were evident on the 2.5 month follow-up examination, and also full range-of-motion of the flipper was preserved and no lameness or difficulty with swimming and hunting were detected. On computed tomography, signs of chronic left coxofemoral and ilial wing trauma were incidentally detected. The seal was released three months postoperatively. A transverse infected distal fracture of the tibia and fibula in a young common grey seal was successfully managed with the combination of single SOP plating of the tibia, local antibiotic release and a specific rehabilitation programme. Surgical treatment of a long-bone fracture in a wild immature grey seal was successful with a combination of techniques adapted to the species.

Severe lateral tibial bowing with short stature in two siblings—A provisionally novel syndrome

In this report, we describe two siblings with short stature and severe lateral tibial bowing. In the younger sibling, the bowing was bilateral, while in the older sib, it was unilateral. However, both showed bilateral abnormalities of the distal tibial epiphyses and growth plates. Pseudoarthrosis of the left distal tibial metaphysis and subsequent spontaneous resolution of the abnormality occurred in the younger sibling. The fibulas of both children were of normal diameter and were straight, except for the distal ends. Surgery has almost completely corrected the lower leg bowing in both patients. The type of tibial bowing seen in these children can be associated with a number of syndromes, such as neurofibromatosis type I, Weismann-Netter syndrome, and a variety of environmental caused disorders, such as vitamin D deficient rickets. However, the severity of the bowing present in our patients and the absence of other clinical features differentiates this condition from those reported in the literature. We posit that the condition in the children presented here represents an as yet undescribed syndrome, which is likely to be of genetic origin.

Fluoroscopy-guided retrograde core drilling and cancellous bone grafting in osteochondral defects of the talus

In undetached osteochondral lesions (OCL) of the talus both revitalisation of the subchondral necrosis and cartilage preservation are essential. For these cases, we assess the results of minimally invasive retrograde core drilling and cancellous bone grafting. Forty-one osteochondral lesions of the talus (12x grade I, 22x grade II and 7x grade III according to the Pritsch classification, defect sizes 7-14 mm) in 38 patients (mean age 33.2 years) treated by fluoroscopy-guided retrograde core drilling and autologous cancellous bone grafting were evaluated by clinical scores and MRI. The mean follow-up was 29.0 (±13) months. The AOFAS score increased significantly from 47.3 (±15.3) to 80.8 (±18.6) points. Lesions with intact cartilage (grades I and II) had a tendency to superior results than grade III lesions (83.1 ± 17.3 vs. 69.4 ± 22.2 points, p = 0.07). First-line treatments and open distal tibial growth plates led to significantly better outcomes (each p < 0.05). Age, gender, BMI, time to follow-up, defect localisation or a traumatic origin did not influence the score results. On a visual analogue scale pain intensity reduced from 7.5 (±1.5) to 3.7 (±2.6) while subjective function increased from 4.6 (±2.0) to 8.2 (±2.3) (each p < 0.001). In MRI follow-ups, five of the 41 patients showed a complete bone remodelling. In two cases demarcation was detectable. The technique reported is a highly effective therapeutic option in OCL of the talus with intact cartilage grades I and II. However, second-line treatments and grade III lesions with cracked cartilage surface can not be generally recommended for this procedure.

Continuous Force Measurement in Limb Lengthening

Complications of limb lengthening include stress on soft tissue, premature consolidation, and bone non-union. This study reports on the development and testing of instrumentation that continually measures distraction forces in rabbits with the aim of relating the forces developed to bone growth and muscle physiology. A full bridge strain gage resistor set mounted to a unilateral distractor measured distraction force and stored the data on a self-contained logger attached to a jacket worn by the rabbit. Two rabbits underwent limb lengthening on one hind leg. Lengthening was set at 0.5 mm/ day, twice per day for a total of 12 mm. Tibialis anterior muscle and proximal and distal tibial growth plates from the operated and control legs were harvested after euthanasia for histomorphometric analysis. Radiographs were taken periodically throughout lengthening. Force data show characteristic overall increase in force. Force steadily decays after each lengthening. Peak forces appear to correlate with time between lengthenings. Histologic data show that the operated leg had an increased preponderance of type I muscle fibers, a decrease in type-I and type-II muscle fiber diameters, and a decrease in endogenous bone growth at the distal growth plate. Histomorphometric analysis showed that the lengthening paradigm employed altered distal bone growth and muscle fiber physiology during lengthening.

Growth plate fractures of the distal tibia: is CT imaging necessary?

Comparison of conventional radiographs (CR) of distal tibial growth plate fractures [Salter-Harris (SH) fracture types I-V/triplane fractures I-III] with computed tomography (CT) as the reference standard and assessment of diagnostic benefit of CT imaging in the affected patients. We retrospectively evaluated all growth plate injuries of the distal tibia with complete pre-therapeutic imaging material (CR and CT including MPR) obtained between August 2001 and December 2006. The imaging material was randomised and presented to two radiologists. Fracture of metaphysis, epiphysis and epiphyseal line were noted separately for distal tibia. In case of fracture, involvement of the articular surface, articular dehiscence and ridge formation, subluxation and number of tibial fragments were evaluated. All fractures were classified as SH type I-V or triplane fractures type I-III. Sensitivity, specificity, positive and negative predictive value and overall accuracy of CR were compared to CT. Thirty-three patients (mean age 14 ± 2 years) were evaluated. CR showed significantly less tibial fragments as compared to CT (1.39 ± 0.75 vs. 1.61 ± 1.25; p = 0.023). The overall accuracy of CR was <90% for fracture involving the metaphysis (82%), dehiscence of the articular surface (64%), ridge formation of the articular surface (61%) and subluxation (79%). The CR evaluation showed differing SH classification in CT in 10/33 cases (30%) with the highest misclassification rates in type-III SH fracture. For evaluation of triplane fractures, CR classification was incorrect in five cases (71%) out of seven. No misclassification occurred in types I and II SH fractures. The CR of distal tibial growth plate fractures showed a low overall accuracy for articular surface dehiscence, articular ridge formation and subluxation as compared to CT. CT revealed significantly more fragments. It is difficult to correctly classify type III/IV SH fractures and triplane fractures with CR thus emphasising the necessity of using CT in selected patients.

Histomorphometric analysis of an adolescent distal tibial physis prior to growth plate closure

Our current understanding of the rate and pattern of physeal closure is based on roentgenographic, magnetic resonance imaging, and qualitative histological studies. The purpose of this report is to provide a detailed histomorphometric/stereological analysis of a distal tibial human growth plate in the process of physiological epiphysiodesis. A human distal tibial growth plate was sampled in three regions (anterior, central, and posterior), with each region further separated medially, in the middle, and laterally. The regions were assessed for the location and extent of bony bar formation as well as for physeal height. Companion sections from optimally fixed tissue in the distal 100 microm of the hypertrophic zone were analyzed for hypertrophic chondrocytic volumes. Physis closure started in the middle of the central region of the growth plate, with 46% of the volume in this area occupied by trans-physeal bridging bone. The growth plate was also narrowed with the lowest physeal heights evident in the middle of the central and anterior regions of the physis. Disruption of the regular columns of the physis was evident with the cells arranged in clusters with intervening areas of acellularity. The average hypertrophic cell volume was 5,900 microm(3) and did not significantly differ between different areas of the physis. This is the first characterization of closure in a human distal tibial growth plate via optimum fixation and stereological techniques. The studied physis was during the earliest phases of closure and provides stereological support that the distal tibial physis closes in a central to medial direction.

Traumatismes de la cheville sans fracture chez l’enfant. Étude prospective par résonance magnétique de 116 patients

Appropriate assessment of ankle injuries in children and adolescents is a common emergency room problem. Many imaging techniques have been proposed, but with no consensus on the reality of anatomic lesions in ankles free of fractures, complicating the therapeutic decision. We analyzed the lesions observed with magnetic resonance imaging (MRI) in a large number of acute ankles in children. This prospective study was conducted in a pediatric emergency room. The study population included all children aged eight to 15 years who presented an isolated injury of the ankle without fracture on the plain x-ray. History taking and physical examination were standardized. MRI was performed within three days of the initial physical examination. All the radiographic documents were examined by an experienced radiologist blinded to the results of the physical examination. During the study period, 116 patients were included. One hundred two MRI series were examined. Minor ligament injury was noted in 20 patients and ligament tear in five, including three with a closed distal tibial growth plate. Minor bone injury was noted in 42 patients and fracture in seven. None of these fractures were visible on the plain x-ray, even after knowledge of the MRI. Injuries were more frequent in boys. Injuries were more frequent when the pain was localized on the lateral aspect of the ankle and when there was an edema. Despite an abundant literature on ankle sprains, prospective studies are scarce in the pediatric population. We have found that MRI is particularly well-adapted for children because it allows a complete examination of anatomic lesions involving the bone or ligaments without the inconveniences of injections, pain, or radiation. Our clinical and imaging findings show that ankle sprains are real in children. We were however unable to identify any clinical factors predictive of ligament and/or bone injury. Other studies should be conducted to better understand the nosological context of ankle sprain in children and adolescents. Further study will enable a better evidence-based approach to individually adapted therapy.

Morphological alterations in the growth plate cartilage of ovariectomized mice

The effects of ovariectomy on growth and estrogen receptor (ER) expression level in the epiphyseal growth plate in mice have been estimated by histomorphometry and immunohistochemistry. Twelve female ddY mice, 8-9 weeks of age, were subjected to bilateral ovariectomy and 12 others were sham operated. They were then killed 8 weeks later. Ovariectomy significantly increased the total thickness of the distal femoral and proximal tibial growth plate cartilage. Ovariectomy caused a 1.4-fold increase in the thickness of the proliferative layer in the distal growth plate of the femur and a 1.3-fold increase in the thickness of the proliferative layer in the proximal growth plate of the tibia. ERalpha and ERbeta immunoreactivity was detected in chondrocytes of the growth plate and the expression level of ERs in epiphyseal plates was increased in ovariectomized mice compared with controls. These data suggest that ERalpha and ERbeta are coexpressed in the growth plates of the mice and that the cartilage growth and the level of expression of ERs in these tissues are hormonally regulated.

Rotational injuries of the distal tibial growth plate

Nine rotational injuries of the distal tibial growth plate in combination with spiral fracture of the fibula were treated in our department between 1993 and 2000. The average age of the patients was 12 years. The injury was a result of sudden, forceful external rotation of the ankle and foot. Pain and slight swelling of the ankle and external rotation of the distal tibia of 20°–40° were present. Radiologically, irregularity and widening of the growth plate of the distal tibia were obvious. In all these cases we noted, on lateral views, the characteristic sign of an “open fish mouth,” due to the changes in the shape of the physeal plate. The spiral fracture of the fibula was not obvious in all radiographic views. The treatment in all eight fresh cases was closed reduction and manipulation by reversing the mechanism of injury and long leg cast application in all nine cases (including the one neglected case) for 6–8 weeks. The final results were either excellent or very good in all nine patients after a mean follow-up of 6 years.

Raloxifene acts as an estrogen agonist on the rabbit growth plate.

Estrogen treatment has been used to induce growth plate fusion, thereby reducing the final height in girls expected to achieve extreme tall stature. The treatment is effective, in terms of limiting final height, but concerns have been raised that it might also increase the risk for malignancies later in life. Raloxifene, a selective estrogen receptor modulator, has been shown to act as an estrogen agonist on bone density but as an estrogen antagonist on breast and uterine tissue. The effect of raloxifene treatment on growth plate fusion and final height is unknown. The aim of this study was to determine whether raloxifene would act as an estrogen agonist or antagonist on growth plate cartilage. Ovariectomized immature rabbits were treated for 4 wk with vehicle (controls), estradiol cypionate (E2), or raloxifene. Tibial growth velocity was decreased in both E2- (P < 0.001) and raloxifene-treated animals (P < 0.001), compared with controls. E2 and raloxifene treatment also decreased chondrocyte proliferation and the height of the proximal tibial growth plate. In addition, E2 and raloxifene hastened fusion of the distal tibial growth plate (P < 0.05) and decreased the number of proliferative and hypertrophic chondrocytes per column in the proximal tibial growth plate. As expected, the uterus was enlarged by estrogen, but not raloxifene, treatment. We conclude that raloxifene acts as an estrogen agonist on the growth plate, accelerating growth plate senescence and thus hastening epiphyseal fusion.

Effect of short-term fasting on bone elongation rates: an analysis of catch-up growth in young male rats.

Bone elongation in the postnatal animal is a result of cellular activity during endochondral ossification. Growth plate chondrocytes undergo a differentiation cascade involving stem cell clonal expansion and cellular enlargement during hypertrophy. Nutritional status has a significant effect on rates of bone growth, and a period of accelerated growth will occur if nutritional stunting of growth in early childhood can be corrected. This study focuses on changes in rates of increase in bone length in a model of catch-up growth in 4-wk-old male rats. Animals fasted for 3 d reached a weight approximately 60% of the control littermates. By 28 d postfasting, fasted animals had regained weight to 95% of control levels. A 3-d fast caused an immediate and profound decrease in rate of growth in the proximal tibial growth plate to only 30% of that of control animals, while stopping growth in the distal tibial growth plate. During the rapid initial rate acceleration of bone elongation, growth rate in both growth plates reached that of the control littermates by 7 d postfasting. The proximal tibial growth plate then maintained rates that were 10-15% higher than control over the rest of the experimental period. By 10 d postfasting, the previously fasted animals were on the same weight/rate trajectory as the control littermates. Changes in elongation rates were reflected by dramatic changes in growth plate morphology in all cellular zones. This is the first study to directly correlate weight recovery during catch-up with growth rate responses at the level of the growth plate.

Triplane fracture of the proximal tibia

A triplane fracture occurs in three planes (transverse, sagittal and coronal). It typically occurs in an adolescent who has sustained an injury to the distal tibial growth plate. The fracture crosses through the articular surface, the epiphysis, the physis and the metaphysis. This distinctive injury was described in 1957 by Johnson and Fahl [1] before the term ‘triplane’ was first used in 1972 by Lynn [2] who described two three-dimensional distal tibial fractures. Although a triplane fracture has been described in the distal humerus [3] and distal radius [4] these are rare. There is only one description, in the French literature, by Pietu et al. [5] of a triplane fracture in the proximal tibia. In this report we describe a triplane fracture of the proximal tibia treated by closed reduction and internal fixation.

Reconstruction of part of the distal tibial growth plate with an autologous graft from the iliac crest

We describe the reconstruction of a defect of the medial malleolus which was the result of an accident in a ten-year-old child. A graft from the iliac crest, with the apophyseal cartilage and perichondrium, was used for reconstruction of the medial malleolus, the growth plate and the adjacent metaphyseal defect, respectively. The soft-tissue defect was covered with a free scapular flap with microvascular anastomosis. Three years after the injury stability of the ankle is excellent with adequate growth of the reconstructed epiphyseal plate.

The domain of hypertrophic chondrocytes in growth plates growing at different rates.

In this study, we tested the hypotheses that (a) both the domain volume (volume of the cell and the matrix it has formed) and matrix volume of juxtametaphyseal hypertrophic chondrocytes in the growth plate is tightly controlled, and that (b) the domain volume of juxtametaphyseal hypertrophic chondrocytes is a strong determinant of the rate of bone length growth. We analyzed the rate of bone length growth (oxytetracycline labeling techniques) and nine stereologic and kinetic parameters related to the juxtametaphyseal chondrocytic domain in the proximal and distal radial and tibial growth plates of 21- and 35-day-old rats. The domain volume increased with increasing growth rates, independent of the location of the growth plate and the age of the animal. Within age groups, the matrix volume per cell increased with increasing growth rates, but an identical growth plate had the same matrix volume per cell in 21- and 35-day-old rats. The most suitable regression model (R2 = 0.992) to describe the rate of bone length growth included the mean volume of juxtametaphyseal hypertrophic chondrocytes and the mean rate of cell loss/cell proliferation. This relationship was independent of the location of the growth plate and the age of the animal. The data suggest that the domain volume of juxtametaphyseal hypertrophic chondrocytes, as well as the matrix volume produced per cell, may be tightly regulated. In addition, the volume of juxtametaphyseal hypertrophic chondrocytes and the rate of cell loss/rate of cell proliferation may play the most important role in the determination of the rate of bone length growth.

Linear relationship between the volume of hypertrophic chondrocytes and the rate of longitudinal bone growth in growth plates

In this study, we tested the hypothesis that hypertrophic cell volume varies directly with the rate of longitudinal bone growth. The volume of hypertrophic chondrocytes (using stereological techniques) and longitudinal bone growth per 24 h (using oxytetracycline labeling techniques) were measured in the proximal and distal radial growth plates and the proximal and distal tibial growth plates of 21- and 35-day-old hooded rats and 21- and 35-day-old Yucatan pigs. We demonstrated a high coefficient of correlation (rats 0.98, pigs 0.83) between the final volume of hypertrophic chondrocytes and the rate of longitudinal bone growth over a wide range of growth rates and volumes of hypertrophic chondrocytes. In addition, we demonstrated a positive linear relationship between the rate of longitudinal bone growth and the final volume of hypertrophic chondrocytes. The slope of the regression line was different for rats than for pigs. The relationship was independent of the location of the growth plate in the animal and the age of the animal. The data suggest that mechanisms regulating volume changes in hypertrophic chondrocytes may exist and that chondrocytic volume increase is a major determinant of the rate of longitudinal bone growth. However, the relative contribution of cellular hypertrophy to longitudinal bone growth may be different in rats than in pigs.

Computed tomography of pediatric distal tibial growth plate fractures: A practical guide

Computed tomography of pediatric distal tibial growth plate fractures: A practical guide