Physeal Fractures Research Articles

Update on premature physeal closure. Diagnosis and treatment.

Premature Physeal Closure (PPC) is the most common consequence of a mostly posttraumatic, physeal injury. They are of utmost importance because they can significantly alter physeal function and lead to disorders such as limb length discrepancies and angular deformities. The type of physeal fracture has not demonstrated a solid predictive value in the formation of PPC, especially in the knee where almost any type of fracture can produce it. The detection of physeal damage with imaging tests (simple radiology and MRI) is very accurate; however, their predictive capacity to foretell which injury will generate a physeal bridge is still poor. For this reason, it is not advisable to make surgical decisions at the first medical assessment. Direct surgical management of PPC's (resection-interposition technique) has generally shown high unpredictability. Nevertheless, the latest interposition materials (chondrocytes and mesenchymal stem cells) showed promising results. PPC is an often devastating consequence of physeal injury and as such deserves further research. To date little is known about etiopathogenesis, risk factors and natural history among other aspects. Until direct surgery offers more consistent results, acute osteotomies and bone distraction for progressive correction continue to be the most widespread treatments for PPCs.

Functional Impact of Osteosuture in Medial Bilateral Clavicular Physeal Fracture in Teenagers

Functional Impact of Osteosuture in Medial Bilateral Clavicular Physeal Fracture in Teenagers

The midterm outcomes of ankle Dias-Tachdjian pronation-eversion external rotation physeal fracture in children treated by open reduction internal fixation with one-stage medial-lateral combined incision.

The objective of this study was to report the midterm outcomes and complications of ankle Dias-Tachdjian pronation-eversion external rotation (PEER) physeal fracture in children treated by ORIF with combined medial and lateral incision. A total of 21 children with ankle Dias-Tachdjian PEER physeal fracture underwent open reduction internal fixation treatment with combined medial and lateral incision between January 2015 and October 2017. The lateral distal tibia angle (LDTA) was measured to evaluate angular deformity and the X-rays were taken to evaluate the premature physeal arrest. All patients were followed up for an average time of 20.1 months (ranging from 17 to 25 months). Bone healing was achieved in all cases. American Orthopedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) score of the patients improved from median 31 (11, 38) preoperation to median 68 (63, 73) postoperation to median score 91 (87, 96) at last follow-up. LDTA of the patients improved from 70.5 ± 4.9 preoperation to 90.0 ± 1.2 postoperation, to measure 90.6 ± 3.7 at last follow-up. The differences were statistically significant (P < 0.05). There is no premature physeal closure, ankle deformity in 19 cases. They could normally exercise and take part in normal sport activities. The remaining two cases had physeal bone bridge and premature physeal closure but could still carry on daily activities and thus were categorized as good. ORIF with one-stage medial-lateral combined incision for ankle Dias-Tachdjian PEER physeal fracture can decrease the rate of premature physeal closure and should be a treatment choice.

Pitfalls in MRI of the Developing Pediatric Ankle.

Normal skeletal development in the pediatric ankle is dynamic and often produces variable imaging appearances that are subject to misinterpretation. Radiologists must understand the underlying developmental phenomena, such as endochondral and membranous ossification and physeal fusion, and be familiar with their common and uncommon imaging manifestations unique to the pediatric ankle. This is especially true as the use of MRI in the evaluation of musculoskeletal trauma expands among younger populations. The authors focus on MRI evaluation of the skeletally maturing pediatric ankle and present pearls for accurately distinguishing normal findings and imaging pitfalls from true pathologic findings. The normal but often variable imaging findings of preossification, secondary ossification, and multiple ossification centers, as well as the range of bone marrow signal intensities that can be visualized within ossification centers, are described, along with tips to help differentiate these from true pathologic findings such as contusion, fracture, or tumor. The authors also review dynamic periosteal and physeal contributions to bone growth to highlight helpful distinguishing features and avoid misdiagnosis of common subperiosteal and periphyseal abnormalities. For example, the normal trilaminar appearance of the immature cortex and periosteum should not be mistaken for periosteal reaction, traumatic stripping, or subperiosteal hematoma. In addition, the physis can have several confusing but normal appearances, including normal physeal undulations (eg, Kump bump) or focal periphyseal edema, which should not be mistaken for pathologic findings such as physeal fracture, infection, or bar. ©RSNA, 2020.

Below-Knee Cast Immobilization for Distal Tibial Physeal Fractures

Distal tibial physeal injuries are one of the most commonly reported fractures in children. Traditionally, treatment recommendations consist of utilization of a long leg cast for initial immobilization. The purpose of this study was to evaluate the efficacy of below-knee cast immobilization in the closed treatment of distal tibial physeal fractures. We reviewed all patients with distal tibial physeal fractures treated with below-knee immobilization at our tertiary care facility between January 2002 and September 2015. Radiographs were analyzed for displacement and angulation at the time of injury, after closed reduction and/or casting, and at completion of immobilization to evaluate for loss of reduction. In total, 120 fractures (120 patients) were reviewed with 63 (52.5%) extra-articular fractures and 57 (47.5%) intra-articular fractures. The mean initial displacement was 4 mm (range 0-26 mm) with 34 patients having greater than 2 mm of displacement at presentation. Closed reduction was performed on 33 (27.5%) patients with the remaining 87 (72.5%) receiving immobilization alone without formal reduction. All fractures successfully healed with only 2 (1.67%) patients experiencing a loss of reduction. Both patients that lost reduction had undergone an initial closed reduction. No nondisplaced fractures lost reduction. These findings suggest that below-knee immobilization is an effective alternative in the treatment of both nondisplaced and displaced distal tibial physeal fractures, including those with intra-articular involvement, as well as those undergoing closed reduction. This creates an opportunity to provide increased patient mobility and early knee range of motion.

Suture Stabilization of Open Physeal Fractures of the Great Toe Distal Phalanx (Seymour Fracture).

Open physeal fractures of the distal phalanx of the hallux are analogous to Seymour fractures of the hand. When missed, these injuries can result in long-term sequelae including infection, pain, nail deformity, and physeal arrest. Nevertheless, there is a paucity in the literature regarding optimal surgical treatment for these challenging injuries. We present a novel technique and case series for suture-only stabilization of Seymour fractures of the great toe. Billing records were used to identify all children aged 18 years or younger who underwent operative treatment open distal phalanx fracture of the hallux with an associated nail bed injury. Electronic medical records and plain imaging were reviewed to identify mechanism of injury, surgical technique, results, complications, and follow-up. Five boys with a mean age of 10.3 years (range, 5 to 13 y) met inclusion criteria. Forty percent (2/5) of injuries were missed by the initial treating providers. Only 2 patients presented to our institution primarily; 60% (3/5) patients were transferred from other facilities. The mechanism of injury was variable but generally involved "stubbing" the toe. The mean time from injury to surgical treatment was 2.6 days (range, 0 to 6 d). Median follow-up was 2 months (range, 1 to 96 mo). No patient complications (including infection) or reoperations were reported. On follow-up imaging, no physeal bars were evident on patients treated with suture-only technique. Seymour fracture of the hallux are uncommon, and there is frequently a delay in both presentation and diagnosis. Providers should have increased suspicion for these injuries when a physeal fracture of the great toe is associated with bleeding or nail bed injury. Currently, no consensus exists for treatment of these injuries. Suture-only stabilization represents a simple, reliable alternative to pin fixation. Level IV-retrospective case series.

Outcomes After Surgical Fixation of Posterior Sternoclavicular Physeal Fractures and Dislocations in Children.

Acute sternoclavicular fractures and dislocations (SCFDs) are a rare but important injury in pediatric patients. SCFDs are either true dislocations, or more commonly, physeal fractures in children. The reduction is advised given the proximity to surrounding vascular structures, and some authors advocate for routine fixation given rates of redisplacement after closed reduction. The purpose of the current study was to provide validated long-term functional outcome data following open reduction and surgical fixation of pediatric SCFDs, as well as provide injury and demographic information. This is a retrospective observational study with a subset of patients reporting functional outcomes. Patients under the age of 18 that had surgically managed acute posterior SCFD from 1990 to 2018 were included. A retrospective chart review was performed to obtain demographic, clinical, and surgical details. Patients with a minimum of 6-month follow-up were contacted to assess outcomes. Functional outcomes of interest included QuickDash, Visual Analog Scale pain rating, Single Assessment Numeric Evaluation of shoulder function, and PROMIS Upper Extremity questionnaire. Statistical analysis included descriptive statistics. A total of 37 patients that sustained an acute posterior SCFD during the study period were included. The average age at the time of injury was 15.2±2.1 years and 89% were male. Patient-reported outcomes were obtained for 14 patients with a mean follow-up of 4.5 years. The mean QuickDash score was 5.1/100 with 0 being normal, and the mean Visual Analog Scale pain rating was 0.7/10. The mean Single Assessment Numeric Evaluation score was 96% with 100% being completely normal. The mean PROMIS score was 55 with 50 being the mean of the relevant reference population. Approximately 29% (4/14 patients) stated that their injury negatively affected their ability to participate in sports. There is a paucity of literature on functional outcomes after surgical management of pediatric acute posterior SCFD. Functional outcomes after surgery were satisfactory in this cohort with most patients being able to perform major activities of daily living. Additional future studies with larger cohorts and comparative groups are needed to better understand outcomes in this population. Level IV.

The impact of COVID-19 on shoulder and elbow trauma in a skeletally immature population: an Italian survey

BackgroundThe aim of this study was to evaluate the impact of COVID-19 on the shoulder and elbow trauma in a skeletally immature population in 30 days starting from March 8, 2020, the first day of restrictions in Italy, and to compare it with the same period of 2019.Materials and methodsAll the skeletally immature (younger than 18 years) patients managed in the emergency unit of our hospital between March 8, 2020, and April 8, 2020 (COVID-19 [C19] period), for a shoulder and elbow trauma were retrospectively included and compared with patients with similar ages admitted in the same period of 2019 (no COVID-19 period). Six categories of diagnosis were distinguished: (1) contusions, (2) no physeal fractures, (3) physeal fractures (Salter-Harris), (4) sprains/subluxations, (5) dislocations, and (6) others (tendinitis, wounds, low back pain, and joint inflammation). According to the mechanism of injury, we arbitrarily distinguished 5 subgroups: (1) accidental fall; (2) sport trauma; (3) accident at school; (4) high-energy trauma occurred by car, public transport, and pedestrian investment; and (5) fall from height.ResultsDuring the C19 period, the number of total accesses in our trauma center steeply decreased: two-thirds less. Regardless of the patient age, we performed 65% less first aid shoulder/elbow services. The number of skeletally immature patients treated at our trauma center for all types of injuries was 350 during the no COVID-19 period and 54 during the C19 period; therefore, the influx of pediatric patients during the C19 period decreased by 84.6%. Furthermore, during the C19 period, (1) there were no cases of fractures, physeal fractures, and dislocations of the shoulder; (2) there were no cases of contusion, physeal fractures, and dislocations of the elbow; and (3) we observed the absence of high-energy, sports, and school injuries; and (4) during the pandemic, shoulder and elbow injuries mainly occurred as a result of accidental fall at home.ConclusionsThe pandemic forced us to become aware of the ways and places where skeletally immature subjects report shoulder and elbow traumas; therefore, it would be desirable that more considerable attention be directed toward the prevention of injury in areas at risk.

Pediatric Seymour Fractures of the Toe.

Seymour fractures of the toe are physeal fractures with often occult concomitant nail bed injuries and thus are open fractures. They are uncommon injuries that without proper treatment can result in osteomyelitis. The literature has sparse information regarding the clinical outcomes for these injuries. A single-center retrospective review included juxta-epiphyseal fractures or Salter-Harris I/II fracture of the toe with documented concomitant nail bed injury or laceration. Clinical and radiographic data were recorded for consecutive fractures. The primary outcome was the incidence of osteomyelitis. Secondary outcomes included premature physeal arrest, development of nail dystrophy, and functionality of the toe. Between 2006 and 2019, 19 patients were treated for this injury by the pediatric orthopaedic division. Complications included osteomyelitis (n=6), physeal arrest (n=4), and nail dystrophy (n=1). Days from injury to definitive treatment were significantly greater in patients who developed osteomyelitis compared with those who did not (P<0.01). Patients were significantly more likely to develop osteomyelitis if they did not receive acute definitive treatment (<48 h) (P<0.001; likelihood ratio, 17.9). Prompt definitive treatment of Seymour fractures of the toe was associated with a lower incidence of osteomyelitis. Greater awareness for these seemingly innocuous injuries is needed to provide an early treatment that may reduce the rate of osteomyelitis. Level IV-case series.

Simultaneous bilateral versus unilateral tibial tubercle fractures

PurposeTibial tubercle/tuberosity fractures are rare injuries in young patients accounting for less than one percent of physeal fractures. Bilateral simultaneous fractures are even rarer, with only a few case reports in literature. The purpose of our study was to describe the largest case series of bilateral simultaneous tibial tuberosity avulsion fractures and compare it with unilateral fractures. We also wanted to compare our bilateral fractures case series with all the cases reported in the last 65 years. MethodsIRB approved retrospective study involving patients under age 18 years with tibial tuberosity avulsion fractures. Bilateral simultaneous fractures were compared to a unilateral group including demographic data, mechanism of injury, clinical exam findings, complication rates, and outcomes including return to function. Statistical analysis was performed using Mann-Whitney and Fisher Exact tests to compare the different groups. Results138 patients (131 males, 7 females) from a tertiary children’s hospital between 2012 and 2019 with tibial tuberosity avulsion fractures were included. 11 bilateral simultaneous fractures (BL Group) were identified and compared to age matched cohort from the 127 unilateral fracture patients (UL group). There was no significant difference found in BMI, height, weight, age, sex, mechanism of injury, return to functional range of motion, and return to sports between the groups. 7/11 (63%) of the patients in the BL group who sustained simultaneous fractures had to be home bound and could not attend school for an average of 8.3 weeks. There was a higher rate of complications in the BL group (63.3%) compared to the UL group (21.1%), which was statistically significant. The most common complications in the bilateral group were hardware removal and wound dehiscence. ConclusionThis first case series comparing unilateral versus bilateral simultaneous tibial tuberosity avulsion fractures suggests that the final outcomes of the two groups are similar, however it shows a significantly higher complication rate and hardware removal rate in the BL group. This study is also the first to highlight the significant initial morbidity in the BL fracture group with issues with regards to early mobility and loss of school-days. Keeping in mind the profound initial impact the bilateral injury poses to the patient; surgeons can possibly plan for rigid fixation for early mobilization to better prepare bilateral fracture patients for the early post-operative recovery process.

Tibial tuberosity ossification predicts reoperation for growth disturbance in distal femoral physeal fractures.

PurposeDistal femoral physeal fractures (DFPF) can cause growth disturbance that requires further surgical intervention. The aim of this study is to determine if Tibial Tuberosity Ossification Stage (TTOS) at the time of injury predicts secondary surgery for growth disturbance in patients who have sustained a DFPF.MethodsWe retrospectively investigated all patients who had operative treatment for a DFPF at a single centre over a 17-year period. Regression analysis was performed investigating associations between secondary surgery to treat growth disturbance and TTOS, age, Salter-Harris fracture classification type, mode of fixation or mechanism of injury.ResultsIn all, 85 consecutive patients were identified. A total of 74 met the inclusion criteria. The mean age at time of injury was 13.1 years (2.0 to 17.1). Following fixation, 30 patients (41%) underwent further surgery to treat growth disturbance. Absence of tibial tuberosity fusion to the metaphysis was significantly associated with the need for further surgery (p < 0.001). Odds of requiring secondary surgery after tibial tuberosity fusion to metaphysis (compared with not fused) were 0.12 (95% confidence interval (CI) 0.04 to 0.34). The estimate of the effect of TTOS on reoperation rates did not vary when adjusted for gender, mechanism, fixation and Salter-Harris type. When accounting for age, the odds of any further operation if the tibial tuberosity is fused to the metaphysis (compared with not fused) were 0.28 (95% CI 0.08 to 0.94).ConclusionTTOS at the time of injury is a predictor of further surgery to treat growth disturbance in paediatric distal femoral fractures.Level of EvidenceDiagnostic Level II

Displaced Physeal and Metaphyseal Fractures of Distal Radius in Children. Can Wire Fixation Achieve Better Outcome at Skeletal Maturity than Cast Alone?

Introduction:Redisplacement following fracture reduction is a known sequela during the casting period in children treated for distal radius fracture. Kirschner wire pinning can be alternatively used to maintain the reduction during fracture healing. This study was conducted to compare the outcomes at skeletal maturity of distal radius fractures in children treated with a cast alone or together with a Kirschner wire transfixation.Material and Methods:This was a retrospective study involving 57 children with metaphyseal and physeal fractures of the distal radius. There were 30 patients with metaphyseal fractures, 19 were casted, and 11 were wire transfixed. There were 27 patients with physeal fractures, 19 were treated with a cast alone, and the remaining eight underwent pinning with Kirschner wires. All were evaluated clinically, and radiologically, and their overall outcome assessed according to the scoring system, at or after skeletal maturity, at the mean follow-up of 6.5 years (3.0 to 9.0 years).Results:In the metaphysis group, patients treated with wire fixation had a restriction in wrist palmar flexion (p=0.04) compared with patients treated with a cast. There was no radiological difference between cast and wire fixation in the metaphysis group. In the physis group, restriction of motion was found in both dorsiflexion (p=0.04) and palmar flexion (p=0.01) in patients treated with wire fixation. There was a statistically significant difference in radial inclination (p=0.01) and dorsal tilt (p=0.03) between cast and wire fixation in physis group with a more increased radial inclination in wire fixation and a more dorsal tilt in patients treated with a cast. All patients were pain-free except one (5.3%) in the physis group who had only mild pain. Overall outcomes at skeletal maturity were excellent and good in all patients. Grip strength showed no statistical difference in all groups. Complications of wire fixation included radial physeal arrests, pin site infection and numbness.Conclusion:Cast and wire fixation showed excellent and good outcomes at skeletal maturity in children with previous distal radius fracture involving both metaphysis and physis. We would recommend that children who are still having at least two years of growth remaining be treated with a cast alone following a reduction unless there is a persistent unacceptable reduction warranting a wire fixation. The site of the fracture and the type of treatment have no influence on the grip strength at skeletal maturity.

Growth Disturbance Following Intra-articular Distal Radius Fractures in the Skeletally Immature Patient.

The purpose of this study was to characterize the incidence of growth disturbance following intra-articular distal radius fractures in skeletally immature patients and to assess early radiographic and functional outcomes. A retrospective investigation of pediatric patients with intra-articular distal radius fractures between 1997 and 2012 at a single institution was performed. Pathologic fractures and fractures in patients with closed physes were excluded. In total, 28 patients (24 males, 4 females), with a mean age of 13.8 years and mean follow-up of 31.7 months, met inclusion criteria. Fractures were categorized according to the Salter-Harris classification, and all radiographs were assessed for evidence of physeal disturbance. Information regarding treatment and early clinical results were obtained from a medical record review. Functional outcomes using the Disabilities of the Arm, Shoulder, and Hand (DASH) and Modified Mayo Wrist Score (MMWS) were collected. Fisher exact test was used to compare the incidence of physeal arrest in the study population to previously published rates of physeal arrest in extra-articular fractures involving the distal radius. Because the data were not parametrically distributed, the Mann-Whitney-Wilcoxon test was used to compare those who did and did not develop physeal arrest. Of the 28 patients, 9 (32%) sustained Salter-Harris III fractures and 19 (68%) sustained Salter-Harris IV fractures. Growth disturbance occurred in 12 (43%) patients, comprised of 3 Salter-Harris III fractures and 9 Salter-Harris IV fractures; 7 of these patients underwent surgical intervention to address deformity. All 4 children age 10 years or younger had growth arrests that underwent subsequent procedures for a skeletal rebalancing of the wrist. No significant differences in DASH or MMWS were seen in the short term between patients who did or did not have physeal arrest. Intra-articular distal radius fractures in skeletally immature patients have a considerably higher rate of physeal growth arrest than extra-articular physeal fractures. Following acute management aimed at restoring and preserving anatomic physeal and articular alignment, follow-up radiographs should be obtained to evaluate for physeal arrest in skeletally immature children. Patients and families should be counseled regarding the high rate of growth disturbance and the potential need for deformity correction in the future, particularly in younger children. IV-case series.

Risk of premature physeal closure in fractures of distal tibia.

The reported incidence of premature physeal closure (PPC) in fractures of the distal tibia has varied between 5 and 36%, but there is no consensus on the cause. We wanted to determine incidence and predictors of PPC in distal tibia physeal fractures in a population-based patient cohort. Two hundred forty-one patients (195 Peterson type I-V fractures and 46 transitional fractures) treated for a physeal fracture of the distal tibia during a 5-year period in two tertiary-level teaching hospitals. Odds ratios (OR) for developing PPC for different parameters (Peterson fracture type, associated fibula fracture, primary and postreduction displacement, number of reductions and the method of treatment) were calculated by binary logistic regression analysis. In 195 children with Peterson type I-V fractures PPC was diagnosed in 21 children (11%), of which 11 (6%) had surgery at mean 14 months from the fracture to correct either angular deformity or leg length discrepancy. The incidence of distal tibia PPC is at least 0.05/1000 children. More than one reduction attempt was the most significant risk factor (OR 7.0) for PPC. Peterson fracture type, associated fibula fracture, initial or post-reduction displacement or type of treatment did not correlate with PPC. The incidence of distal tibia PPC is at least 0.05/1000 children. The number of reductions correlates positively with the risk of PPC.

Proximal femoral physeal fractures in children: a rare abusive injury.

Proximal femoral physeal fractures are rare in abused children. Recognition may be hampered due to their rarity and lack of an ossified femoral head. Prompt diagnosis and treatment are essential to preventing coxa vara. To demonstrate the radiographic features of proximal femoral physeal fractures both with unossified and ossified femoral heads. We reviewed our Institutional Review Board-approved 21-year radiology database of 2,206 children who had a skeletal survey as part of their medical evaluation for possible abuse. Cases of proximal femoral physeal fractures were identified. Eight patients, ages 2.5 to 26months, with 10 fractures were found, yielding a prevalence of 0.4% (8/2,206). In all fractures, there was lateral displacement of the proximal femur. In three fractures, the femoral head was not ossified, simulating a hip dislocation. The intra-articular location of the femoral head was verified by ultrasound or abdomen computed tomography. Subperiosteal new bone formation was present in six fractures, all non-weight-bearing patients. The femoral head was ossified in seven cases, all with medial rotation of the femoral head. Metaphyseal irregularity was present in three of four fractures of the weight-bearing patients; two of three also had metaphyseal scalloping resembling osteomyelitis. The three with metaphyseal irregularity developed coxa vara. Proximal femoral physeal fractures are rare in abuse cases. All present with lateral displacement of the proximal femur. With an unossified femoral head, it can simulate hip dislocation, which can be clarified with hip sonogram. Metaphyseal irregularity appears to be a feature in weight-bearing patients.

Evaluation of pediatric distal femoral physeal fractures and the factors impacting poor outcome requiring further corrective surgery.

Fractures of the distal femur carry a significant risk of physeal arrest and resulting growth complications which often require additional surgeries to correct the deformity. This study examines the risk of needing corrective procedures as a child approaches skeletal maturity. A retrospective analysis of patients treated at a single institution for distal femoral physeal fractures from 2000 to 2015 was performed. Association between sex, age, Salter-Harris (SH) class, and fracture displacement with the risk of physeal arrest were examined. Association between years of growth remaining to skeletal maturity and the risk of needing additional corrective surgery (defined by leg length difference >2 cm or angular deformity (>5°) was examined using a logistic regression model. One hundred one patients were available for review with an average age of 12.6 ± 3.2 years. Twenty-six patients (25.7%) developed a physeal arrest. Seventy-six percent of these required subsequent surgical intervention to address length and angular deformities Sex, age, and SH class were not significantly associated with physeal arrest (P > 0.05). Percent fracture displacement was significantly associated with physeal arrest (P = 0.02). Years of growth remaining to skeletal maturity were significantly associated with an increased risk of requiring corrective surgery for growth complications (odds ratio: 0.758; 95% confidence interval 0.587-0.979; P = 0.03), however, this association failed to persist when accounting for age. Years of growth remaining to skeletal maturity may predict the need for future interventions and should be accounted for when planning treatment of these challenging injuries.

Risk Factors for Adverse Radiographic Outcomes After Elastic Stable Intramedullary Nailing of Unstable Diaphyseal Tibia Fractures in Children.

Elastic stable intramedullary nails (ESIN) are commonly utilized to treat unstable pediatric tibia fractures but have been associated with complications. The purpose of this study was to identify risk factors for adverse radiographic outcomes after ESIN of pediatric tibia fractures. A retrospective review of all patients who underwent diaphyseal tibia fracture stabilization with ESIN between 2010 and 2018 at 3 pediatric level 1 trauma centers was performed. Inclusion criteria were open growth plates, no intra-articular or physeal fracture involvement, and radiographic follow-up until union. Patient demographics, injury mechanism, fracture characteristics, and implant fill relative to the medullary canal were recorded. Radiographic outcome measures included achievement of and time to union, residual angular deformity, and additional procedures. One hundred seventy-two patients met inclusion criteria and were followed for a mean of 1.2 years. Nonunions were observed in 3% of the patient cohort. Another 10% required >6 months to heal, but did not require further surgical intervention. Angular deformities were common with 57% having a residual deformity ≥5 degrees and 14% having a residual deformity ≥10 degrees. Of the patients with a residual deformity between 5 and 10 degrees, 3% were symptomatic, where as 26% of the patients with a residual deformity ≥10 degrees were symptomatic. Greater angular deformities were associated with open fractures, compartment syndrome, and longer time to union. Patient age, weight, tibial comminution, and canal fill were not associated with nonunions or malunions. ESIN of pediatric tibia fractures results in reliable healing for a majority of patients, but poses risks for residual angular deformities and delayed healing. Open fractures and compartment syndrome were associated with adverse radiographic outcomes.

Surgical treatment of distal tibia physeal fractures

Surgical treatment of distal tibia physeal fractures

Colocephalectomy for the Treatment of Capital Physeal Fracture of the Femoral Head in Pony

Background: Femoral capital physeal fractures occur in young animals and are generally associated with trauma. They have a poor prognosis and surgical therapy is the most indicated. There are few studies describing surgical treatment and postoperative results, so the objective of the present report was to present the first case in Brazil of a colocefalectomy for the treatment of femoral capital physeal fracture in a young pony, the post-surgical and the results obtained with the technique employed.Case: An 18-month-old pony, male, not castrated, , weighing 136 kg was referred to the Veterinary Hospital of the Federal University of Paraná (HV-UFPR) with a history of trauma for 4 days. On physical examination, the animal presented lameness grade 5 of the right pelvic limb, shortening and lateral deviation of the limb, crackling and painful sensation on abduction, and slight atrophy of the gluteal muscles on the affected side. In the radiographic examination, a femoral capital physeal fracture was found in the oblique ventro-dorsal projection. Once the diagnosis was performed, a colocefalectomy was realized, as the patient is a light and short horse. The patient underwent general anesthesia and was placed in the left lateral position. The access to the coxofemoral joint was made through the lateral face of the right hindlimb. The muscles of the region were incised and deviated, so a partial myotomy was performed in the deep gluteal and vastus lateralis. This procedure allowed to visualize the fracture, where the head of the femur remained congruent to the acetabulum. A hammer and a curved osteotome were used to section the round ligament, allowing the dislocation of the femoral head and with the aid of an oscillating orthopedic saw was performed the femoral neck ostectomy. Previously to the synthesis of the muscular planes and the skin, a passive tubular drain was fixed, in order to avoid the accumulation of exudate and consequent dehiscence of stitches, which was removed on the 6th postoperative day. For postoperative analgesia, epidural morphine was administered for 6 days and intravenous phenylbutazone for 3 days. Antibiotic therapy was performed with Ceftiofur and Metronidazole. The stitches were removed on the 15th postoperative day, after the correct healing of the surgical wound. The patient’s return to activity was gradual and he was pasture sound on the 42nd postoperative day. After medical discharge, contact with the owner was kept until the fifth postoperative month, and he related that the animal remained walking well and maintaining his reproductive function.Discussion: Femoral capital physeal fractures can occur in young animals, and are not common in clinical surgical care. Clinical signs are crackle of the joint on manipulation and presence of swelling in the affected region. The patient in question, in addition to evident lameness, had crackling and painful sensation during the abduction of the limb, but there was no local swelling, but an atrophy of the musculature of the limb, that occurs in cases of chronic femoral injury. Surgical intervention is the indicated method of treatment and should be performed as soon as possible after the injury has occurred, avoiding the worsening of bone and joint degeneration. Femoral head ostectomy is more suitable for animals less than 12 months old and weighing up to 100 kg. The technique has as a postoperative complication the contamination of the surgical wound, however the implantation of the passive tubular drain allowed rapid evolution of healing. Physical rehabilitation in the postoperative period is variable according to the progress of the animal’s locomotion. Therefore, the colocefalectomy technique aims to maintain the patient’s quality of life, even as in the case reported, it allowed the animal to maintain the reproductive function.

Segmental tibial fracture with physeal and diaphyseal fracture causing popliteal artery and common peroneal nerve injury in a 12-year-old child: A rare case with a unique injury mechanism

Proximal tibial physeal injuries with neurovascular injuries are rare. Here, we report the case of a 12-year-old boy with a rare fracture pattern that is segmental tibia fracture with physeal and diaphyseal fracture with popliteal artery and common peroneal nerve injury, which has never been reported earlier to the best of our knowledge. We also discuss the possible mechanism of injury and also describe the surgical decision-making and highlight the importance of prompt identification and early management of such patients for a good clinical outcome.