Physeal Injury Research Articles

Pediatric orthopedic trauma: principles in management.

Optimal management of pediatric orthopedic trauma requires understanding the unique characteristics of the immature musculoskeletal system. The principles of pediatric orthopedic trauma management include anticipating future growth and bone remodeling potential, minimizing physeal injury, and aggressive treatment of open fractures and compartment syndromes. This article discusses the fundamentals of the pediatric musculoskeletal system and pediatric orthopedic trauma management in general and as they apply to specific injuries.

Wrist pain, distal radial physeal injury, and ulnar variance in young gymnasts: does a relationship exist?

Chronic wrist pain affects up to 79% of young gymnasts. Distal radial growth plate injury and positive ulnar variance have also been reported in this population. There is a relationship between wrist pain, radiographic findings of distal radial growth plate injury, and ulnar variance in skeletally immature young gymnasts. Cross-sectional study. Fifty-nine gymnasts (28 girls and 31 boys; average age, 9.3 years) completed a questionnaire detailing training and wrist pain symptoms. Each received a wrist examination, grip strength measurement, and bilateral wrist radiographs. Wrist pain was reported by 56% of the gymnasts (33 of 59), with 45% (15 of 33) describing pain of at least 6 months' duration. Factors significantly associated with wrist pain included higher skill level, older age, and more years of training. For those between 10 and 14 years of age, 83% had wrist pain, compared with 44% for those outside of that age range. Fifty-one percent of the gymnasts (30 of 59) had findings of stress injury to the distal radial physis of at least a grade 2; 7% (4) had frank widening of the growth plate. Wrist pain prevalence was significantly related to the grade of radiographic injury. Mean ulnar variance was significantly more positive than established norms. Ulnar variance was not associated with wrist pain or radiographic injury of the distal radial physis. Radiographic findings of distal radial physeal injury are associated with wrist pain among young nonelite gymnasts.

Osteochondral Sequelae of Meningococcemia: Radiographic Aspects

The authors retrospectively analyzed the files of 11 patients with osteochondral sequelae of meningococcemia, which were referred to this service between 1988 and 1996. The purpose of this study was to radiographically evaluate bone and physeal injuries observed in these patients, deformities caused by them and correlate these findings with the current literature. During radiographic evaluation of patients with sequelae of meningococcemia, two distinct parameters should be observed: bone injury and physeal plate injury patterns. The most frequent bone injury pattern was lytic lesion and the most common physeal plate injury pattern was peripheral asymmetric physis destruction. The most frequent deformities were lower limb length discrepancy, angular deformities and digital amputations. Based upon the findings of the present research, a descriptive radiographic classification was proposed.

Osteochondritis of the base of the first metacarpal following a physeal injury

An eight year old girl sustained a Salter–Harris II fracture of the proximal physis of the dominant thumb metacarpal by tumbling over a gate (Fig. 1). Eleven days later she was able to mobilise the thumb and was discharged from the clinic.

Traumatic injuries of the distal femoral physis. Retrospective study on 151 cases

This is a retrospective study on a series of 151 injuries involving the distal femoral physis. The average age at the time of injury was 12.3 years. Patients were followed for an average of 8.2 years. The complications encountered were not insignificant and the satisfactory results were relatively low (64.9%). The juvenile age group was the most affected with complications. Salter–Harris type II injuries predominated (43.0%) and they did not have a good prognosis as previously suggested. Symptomatic knee ligamentous laxity was found in 12 patients (7.9%). Compartment syndrome is a devastating complication that occurred in 2 cases (1.3%). We stress the point that a child with a physeal injury of the distal femur should be followed for several years after injury and preferably until skeletal maturity. The surgeon must have high index of suspicious for compartment syndrome. Physeal injuries of the distal femur and in particular Salter and Harris type II should be reduced anatomically and fixed well. Whether this should be achieved by closed or opened means, requires a controlled prospective study to provide a confident answer.

Patterns of premature physeal arrest: MR imaging of 111 children.

The purpose of this study was to use MR imaging, especially fat-suppressed three-dimensional (3D) spoiled gradient-recalled echo sequences, to identify patterns of growth arrest after physeal insult in children. We evaluated 111 children with physeal bone bridges (median age, 11.4 years) using MR imaging to analyze bridge size, location in physis, signal intensity, growth recovery lines, avascular necrosis, and metaphyseal cartilage tongues. Fifty-eight patients underwent fat-suppressed 3D spoiled gradient-recalled echo imaging with physeal mapping. The cause, bone involved, radiographic appearance, and surgical interventions (60/111) were also correlated. Data were analyzed with the two-tailed Fisher's exact test. Posttraumatic bridges, accounting for 70% (78/111) of patients, were most often distal, especially of the tibia (n = 43) and femur (n = 14), whereas those due to the other miscellaneous causes were more frequently proximal (p < 0.0001). The position of the bridge in the physis was related to the bone involved (p < 0.0001). Sixty-five percent of distal tibial bridges involved the anteromedial physis, whereas 60% of the distal femoral arrests were central. Larger bridges had higher T1 signal intensity (p < 0.008). Oblique growth recovery lines were seen exclusively with bridges involving the peripheral physis (p = 0.002) and smaller, more potentially resectable bridges. Metaphyseal cartilaginous tongues were seen with all causes, but avascular necrosis was exclusively posttraumatic (p = 0.03). Signal characteristics and bridge size did not vary with the cause. Premature physeal bony bridging in children is most often posttraumatic and disproportionately involves the distal tibia and femur where bridges tend to develop at the sites of earliest physiologic closure, namely anteromedially and centrally, respectively. MR imaging, especially with the use of fat-suppressed 3D spoiled gradient-recalled echo imaging, exquisitely shows the growth disturbance and associated abnormalities that may follow physeal injury and guides surgical management.

The Effect of Osteogenic Protein-1 in an In Vivo Physeal Injury Model

The physis has limited ability to undergo repair, and injury may result in growth arrest. Osteogenic protein-1 promotes bone formation in diaphyseal defects, chondrocyte proliferation, and matrix synthesis. The authors' goal was to determine if the presence of osteogenic protein-1 in a defect involving the physis would promote cartilage repair, and in doing so, to determine the effect of osteogenic protein-1 on physeal growth. An ovine model of growth plate damage was used, in which the proximal medial physis of the tibia was partially ablated. The defect was filled with a Type I collagen paste containing osteogenic protein-1 (350 microg) or collagen alone. Growth rate was measured at 4, 14, and 56 days, and the defects were analyzed histologically at 4, 14, and 56 days. Bone bridge formation occurred within the defect site. However, osteogenic protein-1 promoted outgrowth of the adjacent physeal cartilage. The physeal cartilage underwent expansion until the mineral forming within the defect site blocked its progress. The effect was localized because only that portion of the physis at the defect margin appeared to be affected.

けい・ひ骨遠位骨端線損傷の分類の有用性と問題点

The Dias-Tachdjian classification is a common method for classifying the physeal injuries of the ankle in children. But this classification has certain drabacks. The mechanism of the position of foot trauma is complicated. It is difficult to distinguish supination plantar flexion from supination external rotation stage 1. Although the mechanism of Tillaux fracture and Triplane fracture is supination external rotation, they are classified as others. We studied 34 patients with epiphyseal injuries of the ankle in children and investigated the advantages and drawbacks of the Dias classification. The purpose of this study is to apply Lauge-Hannsen classification to physeal injuries of the ankle in children.

Ultrasound examination of ankle injuries in children.

Fourteen children with ankle injuries, an open tibia and fibula physis, and negative radiographs had ultrasonography of their injured ankles. Five had an anterior talofibular ligament injury and five had an anterior tibiofibular ligament injury. Four had normal ultrasound examinations. Only two had a physeal injury, both of which were associated with a ligament injury. Eleven children had only lateral ankle tenderness. Ultrasound of these 11 revealed ligamentous injuries, normal examinations, and the two physeal injuries. Ligamentous injury was not associated with other tenderness patterns.

Physeal Injury in a Lightning Strike Survivor

Electrical injuries resulting in physeal injury in children are an uncommon but well-recognized clinical entity. Almost all these injuries are sustained from man-made electrical sources. To date, there have been no published cases of growth arrest after lightning strike. The authors report the case of a 12-year-old girl who survived a lightning strike 2 years ago and who presented with asymmetric growth arrest in both legs. The authors discuss the pathophysiology of lightning strike and consider the evidence for direct electrical injury versus ischemic insult to the physis as explanations for the cause of the growth arrest observed in this patient.

Comparison views for subtle physeal injury in the pediatric ankle

This study addresses whether physicians should obtain routine comparison views to detect subtle fractures. Twenty-two cases of Salter-Harris I fractures of the fibula and 16 cases of nonfracture ankle injury were viewed by 26 radiology and orthopedic physicians. For each case, participants made a diagnosis and indicated whether they were highly certain, moderately certain, or uncertain in that diagnosis for the injured side alone and then for the injured side by comparison with the uninjured side (comparison view). Overall film reading accuracy was 43 % without comparison views vs 65 % with comparison views; accuracy for nonphyseal injuries was 65 % vs 88 %, accuracy for physeal injuries was 27 % vs 49 % (all p < 0.0001, X2 test). Comparison views increased certainty scores by 0.26 on a 2-point scale (p = 0.0002, t-test). Accuracy and certainty in the diagnosis of ankle injuries improved significantly with comparison views, supporting the opinion that comparison views are valuable for the accurate detection of subtle physeal injury.

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.

Functional treatment of physeal and periphyseal injuries of the metacarpal and proximal phalangeal bones

Background/Purpose: Hand fractures are common injuries in infants. Complications are rare because of potent remodeling dimension and rapid healing of growing bone. There is limited remodeling capacity for angular and rotational deformity so displaced fractures often require open reduction and internal fixation. Methods: The authors present a splint system for a protected reduction and mobilization program of displaced proximal phalanx and metacarpal fractures. The custom-molded 2-component thermoplastic splint allows motion of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints. It has been developed to allow bone healing and recovery of motion at the same time. In this study, the authors evaluated the clinical and radiologic results of a series of 11 consecutive infants with displaced metacarpal fractures and 13 displaced proximal phalanx fractures who received functional treatment. Results: Fracture consolidation and full active motion was achieved simultaneously in 4 weeks in 21 children; 2 infants required physiotherapy, and 1 child was lost to follow-up. No further growth abnormality was seen within a 12-month observation period. Conclusion: When there is no damage of soft tissue the functional mobilization program can lead to good results treating displaced physeal and periphyseal hand injuries of proximal phalanx and metacarpal fractures. J Pediatr Surg 36:611-615. Copyright © 2001 by W.B. Saunders Company.

Clinical and radiographic evaluation of bowlegs.

Lower extremity bowing is a normal physiologic process that commonly occurs in walking children under the age of 2 years. After this age, any significant amount of residual bowing is abnormal and may be due to infections, traumatic physeal injuries, genetic predisposition, metabolic factors, or a combination of these. Of the pathologic conditions, infantile Blount's disease is the most common and is predominantly found in obese children with an early onset of walking. Because of its frequency in occurrence and general tendency for spontaneous resolution, physiologic genu varum must be clearly distinguished from other pathologic processes that result in bowleggedness. Treatment of the latter cases may consist of early bracing or surgery.

Acute elbow trauma in children: spectrum of injury revealed by MR imaging not apparent on radiographs.

The objective of this study is to evaluate the frequency and significance of unrecognized bone or soft-tissue injury in pediatric patients with elbow trauma assessed with radiographs alone. Fifty children (32 boys and 18 girls; mean age, 7.3 years; age range, 2-12 years) with acute elbow trauma were examined with radiography and MR imaging. Radiographs were categorized into those showing normal findings, an effusion, an equivocal fracture, or an unequivocal fracture. MR examinations were assessed for an effusion, fracture, transphyseal fracture extension, physeal injury, bone bruising, and ligament or muscle injury. Average clinical follow-up was 1.6 years (range, 6-28 months) after injury. Radiographs showed normal findings in seven children (14%), an effusion only in 17 children (34%), and an unequivocal or equivocal fracture in 26 children (52%). MR imaging showed an effusion in 48 children (96%); unequivocal fracture in 37 children (74%), including transphyseal fracture in seven children (14%) and other physeal injury in three children (6%); bone bruising in 45 children (90%); ligament injury in six children (14%); and muscle injury in 19 children (38%). A less severe spectrum of injury occurred in children with normal findings on radiographs than in those with an effusion or fracture seen on radiography. Follow-up radiographs did not help in the detection of radiographically occult fractures. MR findings had no appreciable effect on patient treatment and no value in predicting duration of convalescence or clinical outcome at an average of 1.6 years after injury. In children with elbow trauma, MR imaging reveals a broad spectrum of bone and soft-tissue injury beyond that recognizable radiographically. However, the additional information afforded by MR imaging has little bearing on treatment or clinical outcome.

Effect of interposed periosteum in an animal physeal fracture model.

To study the effect of interposed periosteum on physeal fracture healing, 52 skeletally immature female Harlan Sprague-Dawley rats, 4 to 5 weeks of age, were randomized to one of three cohort groups. All animals underwent surgical dissection of the left proximal medial tibia; dissection consisted of superficial exposure and incision of a standard periosteal flap. Animals in Group I (fracture alone) underwent physeal fracture; those in Group II (fracture and periosteum) underwent physeal fracture with interposition of periosteum in the fracture site, and those in Group III (positive control) underwent physeal fracture, excision of 1/2 of the growth plate, and interposition of periosteum in the defect. After histologic examination of serial sections, fracture alone resulted in physeal injury frequently associated with small bar formation without a reduction in leg length. With the addition of interposition of periosteum into the fracture site, a small, but statistically significant, increase in leg length discrepancy frequently associated with small histologic bar formation occurred when compared with fracture alone.

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.

Upper extremity injuries in the paediatric athlete.

Injuries to the upper extremity in paediatric and adolescent athletes are increasingly being seen with expanded participation and higher competitive levels of youth sports. Injury patterns are unique to the growing musculoskeletal system and specific to the demands of the involved sport. Shoulder injuries include sternoclavicular joint injury, clavicle fracture, acromioclavicular joint injury, osteolysis of the distal clavicle, little league shoulder, proximal humerus fracture, glenohumeral instability and rotator cuff injury. Elbow injuries include supracondylar fracture, lateral condyle fracture, radial head/neck fracture, medial epicondyle avulsion, elbow dislocation and little league elbow. Wrist and hand injuries include distal radius fracture, distal radial physeal injury, triangular fibrocartilage tear, scaphoid fracture, wrist ligamentous injury thumb metacarpalphalangeal ulnar collateral ligament injury, proximal and distal interphalangeal joint injuries and finger fractures. Recognition of injury patterns with early activity modification and the initiation of efficacious treatment can prevent deformity/disability and return the youth athlete to sport.

Treatment of Peterson classification Type VI of Physeal Injury in Ankle Joint: 2 cases report

Treatment of Peterson classification Type VI of Physeal Injury in Ankle Joint: 2 cases report

Complications of Küntscher Intramedullary Nailing in a Child

A fracture of the femur in a 7-year-old boy who was treated with retrograde Küntscher nailing is described. The follow-up period was 8½ years. Deep infection, physeal injury of the femoral head, and trochanteric epiphysiodesis were serious consequences of the surgery.