Physeal Arrest Research Articles

Three-dimensional MR imaging in the assessment of physeal growth arrest.

The purpose of this study is to describe an imaging method for identifying and characterising physeal growth arrest following physeal plate aggression. The authors describe the use of three-dimensional MRI performed with fat-suppressed three-dimensional spoiled gradient-recalled echo sequences followed by manual image reconstruction to create a 3D model of the physeal plate. This retrospective series reports the analysis of 33 bony physeal bridges in 28 children (mean age 10.5 years) with the use of fat-suppressed three-dimensional spoiled gradient-recalled echo imaging and 3D reconstructions from the source images. 3D reconstructions were obtained after the outlining was done manually on each source image. Files of all patients were reviewed for clinical data at the time of MRI, type of injury, age at MRI and bone bridge characteristics on reconstructions. Twenty-one (63%) of the 33 bridges were post-traumatic and were mostly situated in the lower extremities (19/21). The distal tibia was involved in 66% (14/21) of the cases. Bridges due to causes other than trauma were located in the lower extremities in 10/12 cases, and the distal femur represented 60% of these cases. Of the 28 patients, five presented with two bridges involving two different growth plates making a total of 33 physeal bone bars. The location and shape of each bridge was accurately identified in each patient, and in post-traumatic cases, 89% of bone bars were of Ogden type III (central) or I (peripheral). Reconstructions were obtained in 15 min and are easy to interpret. Volumes of the physeal bone bridge(s) and of the remaining normal physis were calculated. The bone bridging represented less than 1% to 47% of the total physeal plate volume. The precise shape and location of the bridge can be visualised on the 3D reconstructions. This information is useful in the surgical management of these deformities; as for the eight patients who underwent bone bar resection, an excellent correspondence was found by the treating surgeon between the MRI 3D model and the per-operative findings. Accurate 3D mapping obtained after manual reconstruction can also visualise very small physeal plates and bridges such as in cases of finger physeal disorders. MR imaging with fat-suppressed three-dimensional spoiled gradient-recalled echo sequences can be used to identify patterns of physeal growth arrest. 3D reconstructions can be obtained from the manual outlining of source images to provide an accurate representation of the bony bridge that can be a guide during surgical management.

Leg Length Inequality and Epiphysiodesis: Review of 96 Cases

A retrospective analysis of 96 patients who underwent an epiphysiodesis procedure for leg length discrepancy was performed. Forty patients were identified who had an open Phemister-type epiphysiodesis. Fifty-six patients underwent a percutaneous epiphysiodesis procedure. All patients' medical records and radiographs were reviewed for complications. No angular deformities or epiphysiodesis failures occurred in the open group; however, one deep infection requiring intravenous antibiotics and serial surgical debridement was successfully treated. Five complications occurred in the percutaneous group. The complications included two superficial infections, two failures of physeal arrest, and one postoperative angular deformity. The occurrence of complications in the two groups was not statistically significant. Regular follow-up and radiographic evaluation of patients who have undergone a percutaneous epiphysiodesis is essential. Failure of physeal arrest and angular deformities are rare in this patient population, but they can occur.

Physeal arrest of the ankle secondary to extravasation in a neonate and its treatment by the Gruca operation: a modern application of an old technique

We report a case of physeal arrest secondary to extravasation of an intravenous infusion in a neonate. The ankle was reconstructed according to the Gruca operation followed by callus distraction lengthening.

Physeal arrest of the ankle secondary to extravasation in a neonate and its treatment by the Gruca operation: a modern application of an old technique

Physeal arrest of the ankle secondary to extravasation in a neonate and its treatment by the Gruca operation: a modern application of an old technique

Calf Mass in an 11-Year-Old Girl

Calf Mass in an 11-Year-Old Girl

Anterior cruciate ligament injury in paediatric and adolescent patients: a review of basic science and clinical research.

Anterior cruciate ligament (ACL) injuries are recognised with greater frequency in children and adolescents. Non-operative treatment of ACL injuries in children may lead to knee instability and secondary injuries, especially in those who return to sports. ACL reconstruction is controversial in skeletally immature patients because of potential damage to the proximal tibial and distal femoral physes, which may lead to premature arrest and/or leg length discrepancies. This paper reviews studies of ACL injuries in children and adolescents, and examines basic science and clinical studies concerning physeal arrest secondary to ACL reconstruction tunnels. Some animal studies support the conclusion that ACL reconstructions in children have the potential to cause growth disturbances, and there are reports of growth plate complications due to ACL reconstruction in skeletally immature patients. There is evidence that ACL reconstruction can be performed in select skeletally immature patients, but the risk of growth plate complications must be considered.

Treatment of Established and Anticipated Nonunion of the Tibia in Childhood

Nonunion in long bone fractures is rare in the skeletally immature patient. The authors report the outcome of a series of patients treated for tibial bone loss and nonunion at average follow-up of 66 months. Nine children aged 18 months to 17 years were treated. Three patients had established nonunion ranging from 7 months to 6 years, three had bone loss (1-6 cm), and three had fractures in which nonunion was anticipated (one Gustilo IIIb and two Tscherne III). Treatment involved wound excision for open fractures, debridement of devascularized bone, and stabilization with monolateral fixators (two patients) and circular fixators (seven patients). Five patients had unifocal treatment and four had multifocal treatment (three bone transports). Treatment time ranged from 3 to 12 months and was not related to the complexity of treatment. Functional outcome was measured using the Short Musculoskeletal Functional Assessment, a validated outcome assessment tool. At the latest follow-up (average 66 months), the mean knee flexion was 134 degrees and mean ankle range was 12 degrees dorsiflexion, 31 degrees plantar flexion. Physeal arrest was present in three children (limb length discrepancy 2-4 cm), but with no deformity. Functional outcome revealed a "Dysfunction Index" of 0% to 19% (average 7%) and a "Bother Index" of 0% to 16% (average 6%). Good function can be obtained following treatment of these severe injuries.

Intra-articular anterior cruciate ligament reconstruction using patellar tendon allograft in the skeletally immature patient

Purpose: Tears of the anterior cruciate ligament (ACL) are becoming more prevalent in the skeletally immature patient. We report our results with intra-articular transphyseal ACL reconstruction in this patient population. Type of Study: Retrospective analysis. Methods: Ten skeletally immature athletes underwent transphyseal intra-articular ACL reconstruction using patellar tendon allograft. The patients ranged from 9 to 15 years of age. Clinical outcomes were measured using the Lysholm and International Knee Documentation Committee scoring systems, follow-up radiographs, clinical examination, and KT-1000 testing. Results: Mean follow-up was 40 months. The average Lysholm score was 95, and 9 of 10 patients reported normal or nearly normal knee function. There was no clinical or objective evidence of instability, limb-length discrepancy, or early physeal arrest. Nine of 10 patients returned to their preinjury level of athletics. Conclusions: Skeletally immature athletes with symptomatic complete ACL tears who do not want to modify their athletic activity may benefit from intra-articular ACL reconstruction using patellar tendon allografts. Special attention to bone plug and interference screw placement will reduce the risk of early physeal arrest.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 8 (October), 2002: pp 824–828

Aneurysmal bone cyst in 29 children.

The purpose of this study was to review longitudinally the clinical features, method of treatment, and recurrence rates of 40 cases of aneurysmal bone cyst in children treated at one institution. Twenty-nine patients with histologic confirmation of the diagnosis and minimum follow-up of 2 years were included. Thirteen patients were less than 10 years of age, and 16 were in the second decade of life. The most frequent location of the lesion was the tibia (seven cases). Patients were treated with curettage, curettage and bone grafting, or resection. The overall recurrence rate was 27.5%. Five lesions recurred once, and three recurred twice. The average time before recurrence was 18.7 months. Complications occurred in six cases, three of them with physeal arrest. The lesion occurred more commonly in females in the second decade of life and was not associated with a pre-existing tumor. The recurrence rate dropped after the use of a high-speed bur.

Orthopaedic Manifestations of Marinesco-Sjögren Syndrome

Two patients with Marinesco-Sjögren syndrome had striking orthopaedic abnormalities that seemed to arise from multiple areas of physeal growth arrest. Major involvement was seen in the distal femora, where bilateral hypoplasia of the lateral condyles resulted in progressive valgus, patellar dislocation, and quadriceps dysfunction. Marinesco-Sjögren syndrome seems to arise from an error in lysosomal handling of lipids. Timely orthopaedic intervention may be helpful in prolonging ambulation in these patients.

Growth Arrest of the Distal Radius following a Metaphyseal Fracture: Case Report and Review of the Literature

We report a 12-year-old girl who developed growth arrest of the distal radius physis 9 months after sustaining a complete fracture of the distal radial and ulnar metaphysis with no involvement of the physis evident at time of injury. The girl sustained a fracture of the metaphysis of her right distal radius and ulna after a fall. Anterior-posterior, lateral and oblique radiographs at injury, and during subsequent healing show no evidence of the fracture involving the physis. She was treated with closed reduction and casting for 6 weeks and healed uneventfully. She returned 4 month later concerned about distal ulnar prominence. Radiographs revealed a loss of radial tilt and with suspicion of a physeal bar. Magnetic resonance imaging confirmed a physeal bar located in the dorsal radial region. A literature search of the Medline database was used to obtain prior case reports for review purpose. The patient underwent an epiphysiodesis of the distal radius and ulna along with an opening wedge osteotomy and bone grafting of the distal radius to restore radial height and inclination. She healed without complication and with restoration of the normal relationship of the distal radius and ulna. A review of the literature reveals five reported case of distal radial metaphyseal fractures not involving the physis leading to growth arrest. By comparison, there are 31 reported cases of distal radius physeal arrest following fractures involving the physis. The physician should be aware that common distal radius metaphyseal fractures may rarely lead to growth arrest.

Effects of a tensioned tendon graft in a bone tunnel across the rabbit physis.

Children who sustain anterior cruciate disruption often are denied the standard reconstructive procedures because of the concern that drilling across the physis of the tibia and femur and compression from a tensioned graft will result in growth plate arrest. To test this concept and to assess whether a tendon placed in the tunnel would function in a manner similar to a fat graft after the resection of a physeal bar, tunnels were made across the proximal tibial physis and distal femoral physis in a group of immature rabbits. Four tunnel diameters were used from 1.95 to 3.97 mm, in three rabbits at each diameter, with patellar tendon autografts being used as the reconstruction of the anterior cruciate ligament in two of the animals. The knees were radiographed every 4 weeks, and the animals were euthanized 4 months after surgery. The surgically treated and control knees were salvaged, and each knee was examined grossly, radiographically, and histologically. Eight of the 11 animals had growth arrest of one or both physes. The larger the drill hole diameter the more marked was the deformity. The proximal tibial physis seemed to be the most vulnerable for growth arrest, occurring in eight of the knees. The insertion of a tendon did not seem to offer any protection to physeal arrest. Because of these findings, it is not recommended that tunnels involving 1% or more of the area of the physis be placed across the tibial and femoral physis to reconstruct the anterior cruciate in very skeletally immature children.

Pediatric ankle fractures: evaluation and treatment.

Pediatric ankle fractures account for approximately 5% of pediatric fractures and 15% of physeal injuries. The biomechanical differences between mature and immature bones, as well as the differing forces applied to those bones, help explain the differences between adult and pediatric fractures. The potential complications associated with pediatric ankle fractures include those seen with adult fractures (such as posttraumatic arthritis, stiffness, and reflex sympathetic dystrophy) as well as those that result from physeal damage (including leg-length discrepancy, angular deformity, or a combination thereof). The goals of treatment are to achieve and maintain a satisfactory reduction and to avoid physeal arrest. A knowledge of common pediatric ankle fracture patterns and the pitfalls associated with their evaluation and treatment will aid the clinician in the effective management of these injuries.

Physeal Arrest Due to Laser Beam Damage in a Growing Child

A laser beam applied directly to epiphyseal cartilage may damage the cartilage selectively without affecting adjacent bone. The damaged physis is replaced by bone, which forms a bone bridge between the metaphysis and epiphysis, similar to the bone bridges that follow fracture of any long bone. This case report documents damage to two distal phalangeal epiphyseal plates as a sequela of laser beam injury. This resulted in premature partial physeal closure (physeal bars), which in turn caused progressive angular deformity and relative shortening of the digits, requiring multiple osteotomies for correction. This report suggests that special care must be exercised when using laser therapy near physes in growing children.

The Adolescent Pilon Fracture: Management and Outcome

Pilon fractures in the adolescent are complicated by the presence of the adjacent physis. These fractures usually result from high-energy trauma, frequently associated with soft-tissue trauma, further potentiating treatment difficulties. Although rare, such fractures are associated with a high complication rate, including physeal arrest. It was the objective of this review to increase awareness of this fracture pattern in the adolescent, to determine the types of complications in this difficult group, and to develop a treatment plan to improve the outcome of treatment. Seven children, with a total of eight pilon fractures were treated at a major pediatric tertiary referral center over the past 10 years. The average age of the children was 15 years 10 months (range, 13 years 6 months to 17 years 7 months). The average length of follow-up was 16 months (range, 3 months and 3 years 10 months). There were three Reudi type II equivalent fractures and two Reudi type III equivalent injuries. Three fractures did not fit the Reudi classification system as there was an associated ankle dislocation. All fractures were treated with open reduction and internal fixation. There were two cases of posttraumatic osteoarthritis and one physeal arrest. Results were good to excellent in 63% of cases. A new classification system for pediatric pilon fractures has been proposed.

The adolescent pilon fracture: management and outcome.

Pilon fractures in the adolescent are complicated by the presence of the adjacent physis. These fractures usually result from high-energy trauma, frequently associated with soft-tissue trauma, further potentiating treatment difficulties. Although rare, such fractures are associated with a high complication rate, including physeal arrest. It was the objective of this review to increase awareness of this fracture pattern in the adolescent, to determine the types of complications in this difficult group, and to develop a treatment plan to improve the outcome of treatment. Seven children, with a total of eight pilon fractures were treated at a major pediatric tertiary referral center over the past 10 years. The average age of the children was 15 years 10 months (range, 13 years 6 months to 17 years 7 months). The average length of follow-up was 16 months (range, 3 months and 3 years 10 months). There were three Reudi type II equivalent fractures and two Reudi type III equivalent injuries. Three fractures did not fit the Reudi classification system as there was an associated ankle dislocation. All fractures were treated with open reduction and internal fixation. There were two cases of posttraumatic osteoarthritis and one physeal arrest. Results were good to excellent in 63% of cases. A new classification system for pediatric pilon fractures has been proposed.

Free Fat Interpositional Graft in Acute Physeal Injuries: The Anticipatory Langenskiöld Procedure

Free fat graft interposition has been used extensively in management of physeal injuries with established growth disturbances. The use of this technique as part of the management of acute physeal injuries has not been reported. Here we report on its application in acute physeal injuries, where it has prevented the formation of an anticipated physeal arrest.

Test of stability as an aid to decide the need for osteotomy in association with open reduction in developmental dysplasia of the hip.

After open reduction for developmental dysplasia of the hip (DDH), a pelvic or femoral osteotomy may be required to maintain a stable concentric reduction. We report the clinical and radiological outcome in 82 children (95 hips) with DDH treated by open reduction through an anterior approach in which a test of stability was used to assess the need for a concomitant osteotomy. The mean age at the time of surgery was 28 months (9 to 79) and at the latest follow-up, 17 years (12 to 25). All patients have been followed up until closure of the triradiate cartilage with a mean period of 15 years (8 to 23). At the time of open reduction before closure of the joint capsule, the position of maximum stability was assessed. A hip which required flexion with abduction for stability was considered to need an innominate osteotomy. If only internal rotation and abduction were required, an upper femoral derotational and varus osteotomy was carried out. For a 'double-diameter' acetabulum with anterolateral deficiency, a Pemberton-type osteotomy was used. A hip which was stable in the neutral position required no concomitant osteotomy. Overall, 86% of the patients have had a satisfactory radiological outcome (Severin groups I and II) with an incidence of 7% of secondary procedures for persistent dysplasia including one hip which redislocated. The results were better (p = 0.04) in children under the age of two years. Increased leg length on the affected side was associated with poor acetabular development and recurrence of joint dysplasia (p = 0.01). The incidence of postoperative avascular necrosis was 7%. In a further 18%, premature physeal arrest was noted during the adolescent growth spurt (Kalamchi-MacEwen types II and III). Both of these complications were also associated with recurrence of joint dysplasia (p = 0.01). Studies with a shorter follow-up are therefore likely to underestimate the proportion of poor radiological results.

Test of stability as an aid to decide the need for osteotomy in association with open reduction in developmental dysplasia of the hip

After open reduction for developmental dysplasia of the hip (DDH), a pelvic or femoral osteotomy may be required to maintain a stable concentric reduction. We report the clinical and radiological outcome in 82 children (95 hips) with DDH treated by open reduction through an anterior approach in which a test of stability was used to assess the need for a concomitant osteotomy. The mean age at the time of surgery was 28 months (9 to 79) and at the latest follow-up, 17 years (12 to 25). All patients have been followed up until closure of the triradiate cartilage with a mean period of 15 years (8 to 23). At the time of open reduction before closure of the joint capsule, the position of maximum stability was assessed. A hip which required flexion with abduction for stability was considered to need an innominate osteotomy. If only internal rotation and abduction were required, an upper femoral derotational and varus osteotomy was carried out. For a ‘double-diameter’ acetabulum with anterolateral deficiency, a Pemberton-type osteotomy was used. A hip which was stable in the neutral position required no concomitant osteotomy. Overall, 86% of the patients have had a satisfactory radiological outcome (Severin groups I and II) with an incidence of 7% of secondary procedures for persistent dysplasia including one hip which redislocated. The results were better (p = 0.04) in children under the age of two years. Increased leg length on the affected side was associated with poor acetabular development and recurrence of joint dysplasia (p = 0.01). The incidence of postoperative avascular necrosis was 7%. In a further 18%, premature physeal arrest was noted during the adolescent growth spurt (Kalamchi-MacEwen types II and III). Both of these complications were also associated with recurrence of joint dysplasia (p = 0.01). Studies with a shorter follow-up are therefore likely to underestimate the proportion of poor radiological results.

Juxtaphyseal aneurysmal bone cysts.

Aneurysmal bone cysts are benign primary or secondary lesions that commonly arise in long bones and often before skeletal maturity. Little has been written about aneurysmal bone cysts that abut the physeal plate. The records of 15 patients with juxtaphyseal aneurysmal bone cysts were reviewed. Fourteen of the patients were referred with abnormal radiographs after evaluation for pain in the affected limb. One patient presented with abnormal radiographs after fracture about the aneurysmal bone cyst. None of the patients had evidence of growth plate disruption. The children's ages ranged from 2 to 14 years, with a mean of 9.8 years. There were 10 boys and five girls. Lesion locations included: six in the proximal tibia, three in the distal fibula, two in the distal tibia, two in the proximal femur, one in the distal femur, and one in the distal radius. All of the lesions abutted the physeal plate and fell into one of the types in Campanacci's classification of juxtaphyseal aneurysmal bone cysts. Three lesions were classified as Type 1, eight were Type 2, and four were Type 3. This study included no cases of Type 4 or 5 lesions. Treatment of all lesions consisted of excision, curettage, and bone grafting with care taken to preserve the growth plate. Adjunctive cauterization was performed in two cases. There were no incidences of postoperative physeal plate arrest. Overgrowth of the fibula occurred in one patient. Three patients experienced recurrent lesions. One of the children underwent repeat curettage and bone grafting with no additional recurrence. In the other two children with recurrence, the lesion had grown away from the physeal plate while remaining static in size and asymptomatic. Based on this study, juxtaphyseal aneurysmal bone cysts may be treated satisfactorily with intralesional surgery and bone grafting with expectation of normal physeal growth.