Premature Physeal Closure Research Articles

Varus deformity of the ankle in a child: correction using external fixation

Introduction and objective Varus deformity of the ankle during infancy is a not uncommon after effect after epiphysiolysis of the distal tibial or an infection in this area during childhood. The authors review the cases treated using external fixation. Material and methods A retrospective review was made of 14 cases of varus ankle clinically and radiologically studied using lower limb antero-posterior teleradiography in the standing position and treated using monolateral external fixation. The cause of the deformity, its magnitude, procedure employed, complications, and premature physeal closure after treatment. Results All cases of varus ankle were retrospectively reviewed, with the most frequent cause of the deformity in ankle varus during infancy being epiphysiolysis of the middle portion of the distal tibia (SH II, III or IV lesions), distal tibia infection or sepsis. There were two cases of epiphysiolysis type II, three of type III, and three of type IV. The methods of correction employed were, physeal distraction when the physis was open in four cases, and distal metaphyseal osteotomy and subsequent callus distraction in eight cases. In two cases correction was performed acutely combining another treatment method to correct a concomitant discrepancy. The callotasis was performed on all of them using fibular osteotomy, fixing it with a Kirschner wire, except in three cases. The most frequent complications were infections around the screws and ad-latum displacement. Discussion and conclusions Good results have been obtained in this series of varus deformity of the ankle in the child by means of physeal distraction, osteotomy and callotasis. Physeal distraction before reaching skeletal maturity may be the method of choice. If it is performed earlier the premature closure of the rest of the fertile physis is likely. If the treatment is hemicallotasis, besides the fibular osteotomy, intramedullary fixation with a Kirschner wire is also recommended.

Avaliação da técnica de epifisiodese temporária com o uso das placas de Sherman: resultados preliminares

OBJECTIVE: To evaluate the preliminary results of a technique using temporary epiphysiodesis plates using a Sherman plate in the treatment of disorders and deformities of the lower limbs. METHODS: We retrospectively reviewed 27 patients who underwent temporary epiphysiodesis of the distal femur or proximal tibia with Sherman plates, comprising 28 procedures. The mean age at surgery was 11.2 years (3-15 years). The two-hole plates were made of steel alloy and had a central hole to be used as a guide. The fixation was performed with two 3.5 mm cannulated screws. Indications for treatment were the angular deviations of the lower limbs in valgus (n = 10), varus (n = 2) and mixed (n = 1), limb length discrepancy (n = 9), and the flexion contracture of the knee (n = 5). RESULTS: The mean follow-up period was 11.78 months (± 4.07). We observed only one adverse event (migration of the implant) in a patient who underwent anterior epiphysiodesis of the distal femur for the correction of knee flexion. There were no cases of equipment failure or premature physeal closure. CONCLUSION: The temporary epiphysiodesis procedure using the Sherman plates proved to be easy to execute and was involved with a low rate of complications and lower cost than similar titanium implants. Because it is a procedure with low morbidity, this surgical technique may be indicated for a wide age range and for a variety of disorders of the immature skeleton.

Nonunion of Capital Femoral Physeal Fracture with a Large Metaphyseal Fragment

This report presents a case demonstrating the nonunion of a capital femoral physeal fracture with a large metaphyseal fragment in a 10-year-old boy. To our knowledge, there is no previously reported case of this type of nonunion. The treatment of this nonunion presented a potential risk of premature physeal closure and avascular necrosis of the femoral head, so internal fixation using cannulated screws and percutaneously drilling with a Kirschner wire to the metaphyseal fragment was used and was effective in bone union without these complications.

Effect of Intra-articular Pressurization Associated With Arthroscopy on the Immature Physis: Investigation in an Animal Model

Despite the increased use of arthroscopy in pediatric orthopaedics, there is a paucity of data regarding the potential long-term effects of this procedure on the immature physis. The purpose of this study was to test the hypothesis that elevated intra-articular pressures used during arthroscopic surgery do not result in growth disturbances or morphologic alterations in the epiphyseal plate. Twenty-seven 6-week-old skeletally immature New Zealand white rabbits were divided into experimental (n=21) and control groups (n=6). In the experimental group, a hydraulic pump was used to pressurize 1 randomly assigned knee joint per rabbit to intra-articular pressures of 120 mm Hg for 2 hours. In the control group, rabbits received a sham intervention. All rabbits were killed at 6 months of age (skeletal maturity), and their tissues were evaluated grossly, radiographically, and histologically. Data collection included gross measurements (femur and tibia lengths, evaluation of varus/valgus angulation, and knee joint range of motion) and histologic analyses to determine whether morphologic changes were present in the articular cartilage or physis. Confidence intervals were used to test for statistical equivalence. The pressurized and control groups had statistically equivalent gross measurements. No significant articular cartilage or physeal lesions were identified in histologic sections or radiographic studies. This study provided no evidence that arthroscopic pressurization of the knee joint to 120 mm Hg for 2 hours significantly affected physeal growth in a skeletally immature rabbit model. This study provides the first direct evidence that arthroscopic pressurization of immature joints has no clinically significant adverse long-term effects. Therefore, novel uses of arthroscopy in pediatric patients should be explored without undue concern with regard to premature physeal closure.

Functional and radiological outcome after delayed fixation of femoral neck fractures in pediatric patients

BackgroundComplications that develop after femoral neck fracture in children—especially osteonecrosis—have been retrospectively attributed to inadvertent delayed fixation and fracture type. Prospective evaluation of results after delayed fixation of femoral neck fractures in children beyond the first 24 h is not reported in the literature and requires evaluation to increase our understanding of the procedure and improve fixation methods. Also, the role of capsular decompression in initial management needs to be elucidated.Materials and methodsRadiological and functional evaluation was done for delayed fixation (>24 h) of displaced fractures in the femoral neck in 21 children (21 hips) treated over 11 years. Mean patient age was 11.8 (median 12, range 5–15) years. Extraphyseal fixation was done using partially threaded cannulated cancellous screws after closed or open reduction. Patients were allowed full weight bearing after 12–18 weeks. Results were assessed on the basis of modified Ratliff criteria. Patients were followed for a mean of 81 (range 66–129) months.ResultsAll fractures united at a mean duration of 12 (range 10.6–14) weeks. Three (14.3%) patients had osteonecrosis of the hip, which was significantly related to poor outcome (r = 0.495; P = 0.022). There was a significant correlation (r = 0.52) between development of osteonecrosis and delayed fracture fixation of >10 days (P = 0.016) and open reduction (P = 0.016).ConclusionsOutcome following temporal delay in fracture fixation of the femoral neck is primarily affected by osteonecrosis of the femoral head, whereas restriction of movements, shortening, and premature physeal closure has no significant influence. Osteonecrosis is primarily linked to delay and open reduction, whereas fracture type, age, and sex seem insignificant factors. Capsular decompression does not seem to affect the outcome in delayed presentations and may hinder definitive treatment.

Complication rate after operative treatment of paediatric femoral neck fractures

Paediatric fractured neck of femur injuries is rare and historically has high complication rates postoperatively. We present results from the Birmingham Children's Hospital. Fifteen displaced femoral neck fractures were identified in 14 children over a 10-year period (1997-2006). Mean age at the time of injury was 10 years (range 6-14 years). Mean follow-up was 31 months (range 6-110 months). Anatomical reduction and internal fixation was performed in all cases. Two fractures were classified as Delbet's type-I (13.3%), four type-II (26.7%), six type-III (40%) and three type-IV fractures (20%). Eleven patients were operated on within 24 h (range 4-19 h) and four after 24 h (range 2-11 days). The rate of avascular necrosis was 6.7% overall and 10% excluding pathological fractures. The rate of premature physeal closure was 33.3% overall and 40% excluding pathological fractures. Ninety-three percent of the total study population had a good result according to the Ratliff scoring system. There were no nonunions. One patient had a poor result with avascular necrosis and collapse.

Physeal Fractures of the Distal Tibia

A retrospective review of 124 patients was undertaken to determine the incidence of physeal growth arrest (premature physeal closure [PPC]) after physeal fractures of the distal end of the tibia in children. We also sought to identify clinical predictors of PPC. We defined PPC as radiographic evidence of physeal closure as compared to the uninjured side in this patient population. We reviewed the charts of 124 pediatric patients with distal tibia physeal fractures. All patients were followed up until symmetric growth was noted (by Harris growth lines) for a minimum of 1 year or until physiologic closure of the growth plates had been documented radiographically. We calculated the overall incidence of PPC and the incidence by fracture type. Cox multivariate regression analysis was also performed for a number of clinical variables. The mean follow-up was 57 weeks. Fifteen fractures (12.1%) were complicated by PPC. In our study, 67% of the PPC observed occurred in Salter-Harris II fractures, followed by 13% in Salter-Harris III, 13% in Salter Harris IV, and 7% in triplane fractures. We did not observe any physeal arrest in the Salter-Harris I or Tillaux fractures. Using a Cox multivariate regression analysis, we were able to demonstrate statistically significant correlations between mechanism of injury and PPC and between the amount of initial fracture displacement and the rate of PPC. There was a strong relationship between mechanism of injury and PPC. There were trends seen about residual displacement after reduction and the number of attempted reductions and the rate of PPC, but these correlations were not statistically significant. For each millimeter of initial displacement, there was a relative risk of 1.15 (P < 0.01). Recent articles have shown a much higher rate of PPC after distal tibia physeal fracture than what was observed in our cohort. The amount of initial fracture displacement and the mechanism of injury have a statistically significant predictive value in determining the likelihood of PPC development after distal tibia physeal fracture. Trends were seen regarding residual displacement and the number of fracture reductions but were not statistically significant in predicting the occurrence of a PPC. Level III: Retrospective Review.

Hip Fractures in Children

Hip fractures account for <1% of all pediatric fractures. Most are caused by high-energy mechanisms, but pathologic hip fractures also occur, usually from low-energy trauma. Complications occur at a high rate because the vascular and osseous anatomy of the child's proximal femur is vulnerable to injury. Surgical options vary based on the child's age, Delbet classification type, and degree of displacement. Anatomic reduction and surgical stabilization are indicated for most displaced hip fractures. Other options include smooth-wire or screw fixation, often supplemented by spica cast immobilization in younger children, or compression screw and side plate fixation. Achievement of fracture stability is more important than preservation of the proximal femoral physis. Capsular decompression after reduction and fixation may diminish the risk of osteonecrosis. Osteonecrosis, coxa vara, premature physeal closure of the proximal femur, and nonunion are complications that account for poor outcomes.

Factors Influencing Premature Physeal Closure following Physeal Injury of the Ankle in Children

Purpose: To evaluate the factors influencing premature physeal closure (PPC) following physeal fractures of the ankle in children. Materials and Methods: Forty-eight children with physeal injuries of the ankle were analyzed retrospectively after a minimum follow-up of 1 year. We undertook statistical analysis according to age, gender, cause, fracture type, mechanism of injury, and treatment methods for incidence of PPC. Results: Ten fractures (28.3%) were complicated by PPC. There were three cases of leg length discrepancy (LLD) more than 2 cm, five cases of angulation with LLD more than 2 cm, and two cases of fibula shortening. There were no correlation between PPC and age, sex, cause, or injury mechanism (p＞0.05). There was a statistically significant correlation between the rate of PPC and treatment methods (p=0.018). Conclusion: Operative treatment may decrease the frequency of PPC in some fractures. Regardless of treatment method, we recommend anatomic reduction to decrease the risk of PPC.

Transradioulnar Single Kirschner-Wire Fixation Versus Conventional Kirschner-Wire Fixation for Unstable Fractures of Both of the Distal Forearm Bones in Children

The purpose of this study was to introduce transradioulnar single Kirschner-wire (K-wire) fixation technique for unstable fractures of both of the distal forearm bones in children and to evaluate the differences in clinical and radiographic results of osteosynthesis between this method and conventional K-wire fixation. Forty-one patients (20 conventional K-wire fixation, 21 transradioulnar single K-wire fixation) were reviewed who underwent a closed or mini-open reduction with K-wire fixation for fractures of both of the distal forearm bones. Their mean age at operation was 10.7 years (range, 8-16 years). Surgical intervention was indicated (1) when in addition to a complete ulnar fracture, the radius showed a 50% of displacement or greater, or 20-degree angulation or greater, (2) when in addition to an incomplete ulnar fracture, the radius was completely displaced, and (3) when reangulation was 15 degrees or greater in any direction at follow-up. The minimum follow-up period was 2 years. Bony union was achieved in both groups at approximately 7 weeks after surgery, and there were no significant differences in the operative time, duration of hospitalization, and duration of external support between the 2 groups. There were no major complications such as nonunion, radioulnar synostosis, premature physeal closure, or redisplacement or reangulation. Transradioulnar single K-wire fixation technique was a relatively simple procedure with comparable outcomes compared with conventional K-wire fixation technique. In addition, physeal injuries could be avoided, and there was no need for passing across the fracture line. Thus, it is suggested that transradioulnar single K-wire fixation technique can be a good alternative method for high-risk fractures of both of the distal forearm bones in children.

Acetabular Fracture Through the Triradiate Cartilage After Low-Energy Trauma

Although rare, injury to the triradiate cartilage is both a diagnostic and therapeutic challenge. Trauma to the triradiate cartilage or its blood supply can adversely affect acetabular development due to premature physeal closure. A shallow acetabulum with a lateralized hip joint that is prone to subluxation, premature degenerative changes, chronic pain, and functional limitations can result. We present a case of an acetabular fracture with injury to the triradiate cartilage after low-energy trauma in an adolescent male treated nonoperatively and healed without complications.

Tension band stabilisation of acetabular physeal fractures in four kittens.

The surgical repair of acetabular physeal fractures in four kittens using a screw and tension band technique is reported. This was an appropriate method for restoring articular congruency and improving pelvic alignment. All cases had an excellent outcome and full limb use following fracture repair. In kittens younger than 12 weeks, there is a possibility of premature fusion of the acetabular bone resulting in development of a deformed, shallow acetabulum and hip subluxation. However, surgery is still justified when there is pelvic canal narrowing to decrease the risk of future defecatory problems. Early implant removal in such young kittens may decrease the severity of deformity caused by premature physeal closure. In kittens of 16 weeks or older, the prognosis is good for normal acetabular development and implant removal is not necessary.

Salter-Harris I and II Fractures of the Distal Tibia

The distal tibial physis is the second most commonly injured physis in long bones. Recent reports demonstrate a high rate of premature physeal closure (PPC) in Salter-Harris (SH) type I or II fractures of the distal tibia. At our institution, 137 distal tibial SH type I or II fractures were treated from 1994 to 2002. Reviews were performed on all patients and 91 fractures met inclusion criteria. Patients were categorized according to treatment. We report a PPC rate of 39.6% in SH type I or II fractures of the distal tibial physis. We found a difference in PPC based on injury mechanism. The rate of PPC in patients with a supination-external-rotation-type injury was 35%, whereas patients with pronation-abduction-type injuries developed PPC in 54% of cases. Type of treatment may prevent PPC in some fractures. The most important determinant of PPC is the fracture displacement following reduction. PPC is a common problem following SH type I or II fractures of the distal tibia. Operative treatment may decrease the frequency of PPC in some fractures. Regardless of treatment method, we recommend anatomic reduction to decrease the risk of PPC.

Evaluation of complications of femoral neck fractures in children operated on at least 24 hours after initial trauma

We evaluated complications and the factors affecting the development of avascular necrosis of the femoral head in children who underwent surgery for femoral neck fractures after at least a 24-hour delay. We reviewed the results of 22 children (11 boys, 11 girls; mean age 10 years; range 4 to 14 years) who were operated on after the first 24 hours for femoral neck fractures. According to the Delbet classification, two patients had type I, eleven patients had type II, and nine patients had type III fractures. Associated injuries were detected in seven patients. The mean duration from trauma to surgery was seven days (range 1 to 15 days). Internal fixation was performed following closed (n=20) or open (n=2) reduction. The results were assessed using the Ratliff criteria at the end of a mean follow-up of 73 months (range 18 to 184 months). The patients were evaluated with respect to age, type of fracture, displacement, complications, and avascular necrosis. The results were good in 12 (54.6%), fair in eight (36.4%), and poor in two patients (9.1%). Complications developed in 17 patients (77.3%), 12 of whom had more than one. The most frequent complication was premature physeal closure (n=14; 63.6%) followed by avascular necrosis (n=12; 54.6%). No significant differences were found (i) with regard to age and the type of fracture between patients with and without avascular necrosis, and (ii) with regard to avascular necrosis between patients who were treated within the first and second week of trauma (p>0.05). The results of surgery performed after the first 24 hours are mainly influenced by the occurrence of avascular necrosis and, secondarily, by the type of fracture.

Chondrocyte injection in distraction epiphysiolysis (rabbit model)

The purpose of this study was to determine if cultured chondrocytes could prevent premature closure of the physis after physeal distraction in a rabbit model. Epiphyseal distraction at the proximal tibial epiphysis was performed in 24 immature rabbits. Chondrocytes were harvested from the iliac apophysis. The animals were divided into three groups: A, epiphyseal distraction alone; B, injection of phosphate buffered saline (PBS) after epiphyseal distraction; and C, injection of cultured chondrocytes after epiphyseal distraction. After epiphyseal separation was noted radiographically, each animal was evaluated at routine intervals. At 2 to 4 weeks, significant tibial lengthening as compared to the contralateral tibia was noted in all three groups. At 10 weeks, lengthening was apparent only in group C; in groups A and B, the operated tibia was shorter than the unoperated one. Histologic examination at 4 weeks revealed partial bony bridge formation with cell clustering in the fibrocartilaginous matrix in groups A and B. In group C, the matrix showed a typical hyaline aspect with cells organized in columns at the injection site. The zone of hypertrophic chondrocytes was enlarged. It appears that the injected cells differentiated into hypertrophic chondrocytes and delayed premature physeal closure. At 10 weeks after distraction of the physis, the width of the physis was restored to 75% of normal, but disordered chondrocyte growth with cell clustering was present in the cell-injected group.

Developmental Pattern of Femoral Shortening Following Devascularization of the Capital Femoral Epiphysis in Piglets

To investigate the developmental pattern of femoral shortening in Legg-Calve-Perthes disease, the authors made an experimental model of the disease in piglets by devascularizing the capital femoral epiphysis and following the piglets to skeletal maturity. The discrepancy first increased in the postoperative 0 to 8 weeks (1.2-1.9 mm of shortening per week), then decelerated for a considerable period during the postoperative 8 to 16 weeks (0.2-0.6 mm per week), and then increased again toward the end of the growth period of the postoperative 20 weeks (1.2 mm per week). The developmental pattern of femoral shortening showed an upward slope/plateau/upward slope pattern, as in type IV of the Shapiro classification. As the mechanism of the observed pattern, the authors presumed reduced epiphyseal height and growth retardation in the physis during the initial upward slope, a repair process at the plateau phase, and premature physeal closure during the second upward slope.

Pediatric foot and ankle disorders

Purpose of review Disorders of the pediatric foot and ankle are commonly evaluated and treated in the office setting. Most of these problems can be treated conservatively. This article reviews the current literature over the past year related to pediatric foot and ankle problems and their management. Recent findings The primary management of tarsal coalitions should always be conservative. The diagnosis of tarsal coalition is based on the history, physical examination, radiographs, and advanced imaging such as CT. Surgical correction is the last line of treatment. The standard of treatment for clubfoot deformities is conservative in the infant. There may be a relation between having a clubfoot and an ipsilateral limb length discrepancy. Physical examination will aid in screening for the need of limb equalization procedures in children with clubfeet. When surgical correction of talipes equinovarus is needed, the posterior capsule and the posterior talofibular ligament may not need to be released. Anatomic reduction of distal tibia physeal fractures should be attempted to diminish the chances of premature physeal closure. Summary The treatment of pediatric foot and ankle disorders continues to evolve, with further advancements in evaluation, imaging, and techniques reported in the growing body of published literature.

Common complications of fracture repair

Complications are a reality of fracture repair. Many can be avoided or minimized by being aware of their pathophysiology and predisposing factors. Others are unavoidable but their resolution may be aided by early diagnosis and appropriate treatment. Major complications of fracture repair include osteomyelitis, delayed union, nonunion, malunion, premature physeal closure, and fracture associated sarcoma. Consideration of these complications should factor into presurgical patient evaluation as well as postoperative management. This discussion focuses on how to avoid, recognize, and treat these complications.

Slipped capital femoral epiphysis in skeletally immature patients.

Fixation by a single screw is considered the current treatment of choice for a slipped capital femoral epiphysis. This approach promotes premature physeal closure. The use of a modified, standard, single, cannulated screw designed to maintain epiphyseal fixation without causing premature closure of the physis was reviewed in ten patients. The nine boys and one girl aged between 10.6 and 12.6 years with unilateral slipped capital femoral epiphysis (SCFE), were markedly skeletally immature (Tanner stage I, bone age 10 to 12.6 years). Clinical and radiological review at a mean follow-up of 44.3 months (36 to 76) showed no difference in the time to physeal closure between the involved and uninvolved side. Measurement of epiphyseal and physeal development showed continued growth and remodelling in all patients. Use of this device provided epiphyseal stability and maintained the capacity for physeal recovery and growth following treatment for both unstable and stable slipped capital femoral epiphysis.

Percutaneous transphyseal intramedullary Kirschner wire pinning: a safe and effective procedure for treatment of displaced diaphyseal forearm fracture in children.

Percutaneous transphyseal intramedullary Kirschner wire (K-wire) fixation was performed for diaphyseal fracture of the forearm in 84 children. In 60 patients (71%) closed reduction was performed, while in the remaining 24 (29%) closed reduction was supplemented with a mini-open reduction The K-wire was inserted transphyseally through the radial styloid or the Lister tubercle for the radius, and through the tip of the olecranon for the ulna. With an average follow-up of 70 months and a minimum follow-up of 2 years, all the patients reviewed were found to have good functional results; none had nonunion, deep infection, or premature physeal closure. Moreover, initial preoperative translation of the fracture of more than 100% displacement was found to be associated with a significantly higher chance of requiring a mini-open reduction. The authors concluded that percutaneous transphyseal intramedullary K-wire pining for forearm diaphyseal fracture in children is a convenient, effective, and safe operation, without any deleterious effects on subsequent growth of the distal radius.