Salter-Harris Research Articles

Physeal Fractures of Distal Tibia: A Systematic Review and Meta-analysis.

Fractures involving the distal tibia growth plate are common in children. Injury or treatment that damages the growth plate may result in progressive angular deformity or leg length discrepancy. There is no consensus on treatment and follow-up of these injuries. This study aims to describe which factors increase the risk of premature physeal closure (PPC). A systematic review and meta-analysis were performed. Altogether 395 articles were reviewed, and ultimately 12 of them were found eligible, comprising 1997 patients. The most usual type of fracture was Salter-Harris (SH) II (n=855, 49%) followed by SH III (n=296, 17%) and SH I (n=261, 15%). The risk of PPC according to number of reduction attempts, method of treatment, and residual displacement was the primary outcome. The total rate of PPC was 13% (n=245). The PPC rate varied from 0.2% to 42% across the studies. Patients with SH IV fractures were most likely to develop PPC (20%), followed by those with SH II (12%) (P<0.05) and repeated (>2) reduction maneuvers were associated with a higher risk of PPC (pooled odds ratio, 8.5; 95% confidence interval, 6.3-12.17; P<0.05). Open reduction was associated with a lower risk of PPC when analyzing only displaced fractures (odds ratio, 0.63; 95% confidence interval, 0.38-0.91; P<0.05). This meta-analysis implies that residual displacement after reduction is the most significant factor in predicting PPC. It seems that open reduction might reduce the PPC rate among patients with dislocated fractures. In addition, there is some evidence that a higher number of reduction attempts correlates positively with the risk of PPC.

The Implementation of Therapeutic Alliance in the Rehabilitation of an Elite Pediatric Athlete with Salter-Harris Fracture: A Case Report.

Background/PurposeAlthough research on the value of therapeutic alliance is prominent in other areas of health care, physical therapy research is limited. The purpose is to describe the incorporation of therapeutic alliance concepts throughout the rehabilitation of an elite pediatric athlete with a complicated recovery following a fracture to the distal femoral epiphysis.Case DescriptionA 14-year-old male was referred to physical therapy following an open reduction and internal fixation to address a type IV Salter-Harris fracture of the right distal femoral epiphysis. Post-operative care included immobilization in a brace for six weeks and he initiated physical therapy for four weeks (post-op weeks 6-10). At 10-weeks post-injury his range of motion and strength were severely limited compared to expected post-operative milestones. Due to these deficits an arthroscopic debridement of the subject’s right knee, hardware removal, and manipulation under anesthesia was performed. The subject then reported to the physical therapist on post-operative day three for evaluation and treatment without bracing or weight-bearing restrictions.OutcomesThe episode of care spanned 17 weeks and included 25 physical therapy sessions. To facilitate therapeutic alliance with the subject, clear communication and easily measurable goals were established and connected to the subject’s relevant needs as an athlete. The plan of care was divided into three phases using “chunking” techniques to establish the rehabilitation priorities. The subject demonstrated improved range of motion, strength and was able to return to hydroplane racing and won a national championship in his age group.DiscussionThe unique aspect of this case was the incorporation of therapeutic alliance concepts and techniques into the rehabilitative management of a subject with a complicated fracture to the distal femoral epiphysis. The physical therapist built trust with the subject and facilitated a successful return to elite hydroplane boat racing.Level of Evidence4Study DesignCase Report

Post-physeal deformity around the ankle treated by acute or gradual correction

Introduction: Post traumatic distal tibial deformities can cause long term complications. Type 3,4,&5 Salter harris physeal injuries have higher propensity for deformities and limb length discrepancy. Furthermore, altered mechanical alignment in these patients can lead to arthritis in adjacent joints. Management options are varied from acute correction using internal fixation to gradual correction using ringed external fixators. In this study we have detailed the outcomes of patients with post-physeal injury deformity around the ankle treated by acutre and gradual correction.Methodology: Fifteen patients with fractures involving the distal tibial epiphysis injury and deformity, presenting at Government medical college, Kozhikode, Kerala, India between 2010 and2018, were reviewed. All patients in age group of 5 to 15 years, both males and females, varus and valgus deformity of the ankle were included. Demographic data and hospital records were obtained, radiological records were taken from the patients at subsequent follow-ups at union and 2 years from last surgery.Results: There were nine boys and six girls with an average age at presentation of deformity was 14+ 0.528 years (range 9–15) years. 10 injuries were low energy type (sports/Running/slip and fall), while five were high energy type (motor vehicle accidents).Average duration of follow-up was 3.933 + 0.566 years with a range 2-10 years. Gradual correction of the deformity was done in 11 cases using a circular external fixator with hinges while acute correction was done in 4 cases. Average pre-operative deformity of the ankle was 30.4+7.17 degrees. Range -20 to 40 degrees (20 degrees). AOFAS was used to assess the improvement in the functionality of the ankle. The average improvement in the ankle score was 18 points after surgery. There was no significant difference between the varus and valgus ankles. On analysis of pre-operative and post-operative deformity, higher correction was achieved in varus ankles (27.11 degrees- p value-0.00087) as compared to average correction of 21.17 degrees (p value-0.0004) in Valgus ankles.Conclusion: From our study we concluded that Salter harris 3 and 4 have higher propensity for physeal bar formation, greater degree of deformity and limb length discrepancy. In case of gross deformities (>20degrees) gradual correction with an Ilizarov has better clinical, functional and radiological outcomes. In case of smaller deformities (

349 The Physical Examination Is Unreliable in Determining the Location of the Ankle Physis in Healthy Children

Pediatric ankle injuries are a common presentation to the emergency department (ED). The Salter-Harris classification defines a type 1 fracture of the distal fibula as tenderness overlying the physis of the distal fibula without radiographic evidence of a fracture. Our primary objective was to establish the reliability of physical examination performed by pediatric emergency physicians in determining the location of the physis of the distal fibula as compared to a criterion standard using ultrasound. This was a prospective, observational, single-site study of a convenience sample of pediatric patients aged 4 to 10 years old. It was performed at an urban academic pediatric ED between March 2019 and April 2020. Otherwise healthy children presenting to the ED for reasons other than lower extremity injury were eligible to participate. A pediatric emergency physician or fellow performed a physical examination of the patient’s distal fibula and marked the location of the physis based on his or her examination with a marker. After this, the study investigator (an ultrasound fellow) scanned the distal fibula, established the location of the physis on ultrasound, and used an invisible ink pen to mark the location of the physis. Using an ultraviolet light, the investigator measured the distance between the clinician’s estimated position and the actual sonographic position of the physis. Because the distal fibular physis measures only 3 mm on average, a clinically accurate position was defined a priori as a marked point located within a 5 mm distance of the sonographic marking. We compared the accuracy rate of physical examination to ultrasound landmarking using proportions as well as means with 95% confidence intervals (CI). Using a simulation assuming the participation of at least 15 physicians assessing multiple patients, we calculated a sample size of 90 patients to detect a difference in 70% versus 50% physician accuracy with at least 80% power. Enrolment was stopped early due to the novel coronavirus pandemic, so we were unable to recruit our target sample size of 90 participants. We enrolled 71 patients, of whom 52 (73%) were male. The mean age was 6.7 years and the mean weight was 25.5 kg. Participating pediatric emergency physicians included 18 staff physicians and 2 fellows. The assessments were performed by staff physicians in 60 (85%) patients and by fellows in 11 (15%) patients. Each physician examined a mean of 3.6 patients (range 1-15). The physis of the distal fibula was correctly identified in only 24 patients, yielding an accuracy rate of 34% (95% CI 23%-46%). The mean distance between the physician’s estimated position of the physis and the sonographic position was 7.4 mm (95% CI 6.4-8.4 mm). In a sensitivity analysis where the remaining 19 patient examinations would have all been accurate, the probability of accurate identification was 48% (95 CI 37%-59%). We found that pediatric emergency physicians were only 34% accurate with their physical examination in identifying the physis of the distal fibula. This calls into question the utility of the definition of a type 1 Salter-Harris fracture given that the physical examination is unreliable in identifying the location of the physis of the distal fibula.

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

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.

Composite bridge internal fixation for limb metaphyseal fractures in children

Objective To evaluate composite bridge internal fixation in the treatment of limb metaphyseal fractures in children. Methods From October 2015 to December 2018, 16 children was treated by composite bridge internal fixation for limb metaphyseal fractures at Department of Orthopaedics, The Second People's Hospital of Changzhou. They were 11 boys and 5 girls, aged from 8 to 14 years (average, 11.0 years). Their fractures were located at proximal humerus in 4 cases, at distal femur in 3 cases, at proximal tibia in 3 cases and at distal tibia in 6 cases. According to the Salter-Harris classification, 6 cases were type Ⅱ, 5 cases type Ⅲ and 5 cases type Ⅳ. The time from injury to surgery ranged from 3 to 8 days, averaging 5.3 days. The fracture healing time, postoperative complications (infection and implant failure) and postoperative functional recovery were recorded. Results This cohort obtained follow-up from 12 to 18 months (average, 13 months). All the children obtained bony union after 2 to 5 months (average, 2.4 months). At the last follow-up, the 4 proximal humeral fractures were evaluated by the Neer scores, giving 4 excellent cases; the 6 distal femoral and proximal tibial fractures were evaluated by the knee function scores of The Hospital for Special Surgery (HSS), giving 5 excellent and one good cases; the 6 distal tibial fractures were evaluated by the Baird scores, giving 5 excellent and one good cases. Follow-ups found no complications like postoperative infection, loosening or breakage of implants, or bone nonunion. Conclusion Composite bridge internal fixation is a good alternative treatment for children metaphyseal fractures, because it has advantages of minimal invasion, operative simplicity, reliable fixation and limited postoperative complications. Key words: Extremities; Fractures, bone; Fracture fixation, internal; Internal fixators; Children

Treatment and outcomes of distal tibia salter harris II fractures

BackgroundDistal Salter-Harris (SH) II fractures of the tibia are common injuries in the pediatric population. The purpose of this study is to evaluate our treatment and outcomes of SH II fractures of the distal tibia. MethodsThe study was approved by the medical school's institutional review board (IRB). Fifty-one distal tibia SH type II fractures were treated from 2003 to 2017. We performed a retrospective review of all patients. Patients with displacement less than 3 mm, on x-ray, were treated with a cast. Patients with displacement greater than or equal to 3 mm displacement were initially treated with closed reduction in the emergency department with conscious sedation. Patients were also categorized based on the mechanism of injury and complications were noted. Patients were followed for an average of 4 months (range, 4 weeks-28 months). ResultsFifty-one patients, 28 females and 23 males, were included in the study, with a mean age of 9.4 years (range, 13 months-13 years) at presentation. The most common mechanism of injury was participation in sports (43%). Out of the 51 patients, 45 were minimally displaced and treated with cast. Six displaced fractures were treated with closed reduction. The mean displacement in the closed reduction group at presentation was 5.7 (range, 3- 8.8) mm. Five out of 6 patients had reduction to less than 3 mm. The overall complication rate was 1 out of 51 patients, 2%. When examining displaced fractures, the complication rate was 1 out of 6 patients, 17%. ConclusionMost SH II fractures of the distal tibia are minimally displaced and do not need a reduction. 6/51 cases (12%) in the current study were displaced and were indicated for a reduction. Displacement greater than or equal to 3 mm can be treated with closed reduction followed by a cast; if closed reduction fails, open reduction is indicated. Displaced fractures have a small risk of growth arrest.

Pattern and extent of traumatic epiphyseal injuries at Almadinah Almunawwarah

Objectives: Epiphyseal plate is responsible for bone growth; hence, its preservation is vital for normal bone growth to occur. This study aimed to present the pattern of traumatic epiphyseal injury in a single regional hospital and list the most common causes of these injuries. Methods: This is a retrospective study, with a 1-year duration, started from October 30, 2017, using the hospital database of all admitted fracture cases for data collection at King Fahad Hospital, Almadinah Almunawwarah city, Saudi Arabia. Radiographs of all cases were reviewed. Epiphyseal injuries cases were included and classified using Salter–Harris (SH) classification. Results: The 1-year prevalence of epiphyseal injury in this project was 7.8% out of 770 fractures. Falls were the most commonly incurred type of injury. Humerus was the most common fractured bone (48.3%), followed by radius (10%). Type II SH fracture was the most frequent type observed. Fractured bones and type were significantly related to the mechanism of injury, whereas gender and type of fracture were significantly related to the age group in years. Conclusion: The 1-year prevalence of epiphyseal injuries in this study is moderately low. Falls were the most frequent mechanism of injury, and the humerus was the most commonly fractured bone, whereas SH Type II fracture was the most common morphology.

Isolated anterior dislocation of the elbow in an adolescent

Although elbow dislocation is the most common dislocation in children, anterior elbow dislocation is considered to be rare. When it occurs rarely as an isolated elbow dislocation with no associated fractures. This report is about a case of isolated elbow dislocation with a rare mechanism of injury. A 14-year-old girl presented to the emergency department with an acute closed injury to her right elbow after her arm got caught and twisted in a washing machine. There was no associated neurovascular injury. A trial of closed reduction failed, so open surgical reduction was performed to avoid growth plate injury or fracture. Urgent open reduction was successful with a good outcome. Anterior elbow dislocation without fracture is a very rare injury and can occur with a vigorous twisting mechanism. Proper management is important to regain normal function. The aim of reporting this case is to emphasize that a rare isolated anterior elbow dislocation can occur by a twisting injury and an open reduction may be needed if a gentle closed reduction could not reduce it, to avoid growth plate injury in a skeletally immature patient.

Salter-Harris II Fractures of the Distal Femur: Does displacement, size of Thurston-Holland Fragment, or time to surgery affect treatment or risk of complication?

Purpose: Despite recognition that physeal fractures of the distal femur have a high risk of growth arrest, specific factors contributory to this risk are poorly understood. The purpose of this study is to evaluate fracture characteristics that may affect treatment or outcome of Salter-Harris type II (SH-II) fractures. Method: A retrospective review of 53 patients diagnosed with SH-II fracture, under the age of 19, was performed. Subjects were identified via ICD-9 and ICD-10 codes and attending operative notes at a single level-1 …

The Community Orthopaedic Surgeon Taking Trauma Call: Lateral Humeral Condyle Fracture Pearls and Pitfalls.

Lateral condyle fractures are second only to supracondylar humeral fractures when it comes to pediatric elbow fractures. Whether minimally displaced or substantially displaced, these growth plate fractures may present significant treatment challenges. These include nonunion, malunion, avascular necrosis, and growth disturbance. It must be remembered that lateral condyle fractures often represent significantly displaced intra-articular fractures involving the epiphysis that demand anatomic reduction and stable internal fixation. This article focuses on some of the pertinent pearls and pitfalls regarding these common elbow injuries using ample clinical examples.

Effectiveness of Surgical versus Conservative Treatment for Distal Femoral Growth Plate Fractures: A Systematic Review

Background and Objective:The objective of this review was to determine whether surgery, in comparison to conservative treatment, is a safe and effective intervention for the management of distal femoral growth plate fractures.Methods:A systematic literature review was performed using a three-step search strategy. The PubMed, Embase and Scopus databases were utilized to identify current studies from 1 January 1990 to 8 January 2017. Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments. Primary outcomes of interest were rates of growth arrest and angular deformity.Results:Of the 7740 studies identified with the search, 15 case studies with data inclusive of outcomes of interest were selected for inclusion. A total of 466 patients were included.The rate of complication in the surgical population was 37.8%. In the conservative population the rate of complication was 34.0%. Five of the 15 papers showed Salter-Harris (SH) classification to correlate with prognosis, three papers showed the presence of displacement to correlate with prognosis which would have had an influence on the results of these higher graded injuries likely to have been managed operatively. A high rate of position loss and subsequent growth abnormalities was observed when conservative management was instituted.Conclusion:The rate of complication was marginally higher in the surgical population than that in the conservative population. This study also identified that higher severity distal femur physeal fractures, determined by the amount of displacement and Salter Harris grade, may associate a poorer outcome. It appears that managing higher severity distal femoral physeal injuries conservatively would be less likely to achieve and maintain reduction and therefore associate higher risks of malunion with subsequent growth arrest, leg length discrepancy and angular deformity as compared with surgical intervention. Further studies with higher patient numbers and comparable cohorts are needed to compare surgical and conservative interventions for the lower severity distal femoral physeal fractures.

DISTAL ULNA PHYSEAL ARREST FOLLOWING DISTAL FOREARM FRACTURES IN CHILDREN

Background: Pediatric forearm fractures are a common injury with only a small subset of these involving the distal physes of the radius and ulna. A common mechanism of injury in these fractures are from sports related injuries or fall on outstretch hand. Physeal fractures of the distal radius are well-studied, with varying rates of growth arrest and potential for deformity depending on the type of physeal fracture. The incidence and long-term complications of pediatric forearm fractures involving the distal ulna physis remains largely unknown. Distal ulnar physeal arrest can lead to the development of radioulnar length discrepancy and angular deformities. Two previous studies of limited sample size report a 50-55% of physeal arrest when the ulnar physiss was involved in the fractur, which seems higher than what is seen at our institution. The purpose of this study was to investigate the demographic distribution, as well as the incidence of physeal arrest following a physeal fracture of the distal ulna. Methods: After institutional review board approval, a retrospective study was performed of all patients with distal forearm fractures treated at our institution from January 2003 until December 2017. We included patients &lt; 18 years of age who presented to our level-1 emergency department or to our orthopaedic department and excluded those with extra-physeal fracture and closed physis. Wrist x-rays of 1,618 patients with distal forearm fractures were reviewed revealing a total of 52 patients with distal ulna physeal fracture. Patient demographics including age, gender, height, weight, mechanism of injury, and age at follow up was recorded. Each injury x-ray was reviewed and the distal ulna physeal fracture was categorized using the Salter-Harris (SH) classification system. Concomitant injuries were also recorded and if there was a radial physeal injury the SH classification system was used again. All follow up radiographs &gt; 6 months post-injury were reviewed to assess for physeal arrest. Results: There were a total of 11 patients (average age at injury 10 ± 2 years; 5 males, 6 females; average height 1.5 0.2 m, average weight 47 ± 23 kg) with at least 6 months follow up post injury (average follow up time 2.4 ± 2.2 years. Of these, the most common mechanism was fall on outstretch hand occurring 64% of the time (n = 7), followed by sports in 18% (1 football, 1 baseball), and 9% fall from bike (n = 1), and 9% from ATV accident (n = 1). The most frequent distal ulna physeal fracture was SH type 2 occurring 55% of the time (n = 6), while 36% had a SH type 3 (n = 4), and 9% had a SH type 1 (n = 1). Eight patients had an ipsilateral radius fracture with 45% having a metaphyseal fracture (n = 5) and 27% having a distal radius physeal fracture (n = 3; one SH type 1, and two SH type 2). One patient had an ipsilateral supracondylar fracture and another patient had a Galeazzi fracture. Casting was the most frequent treatment occurring 64% of the time (n = 7), followed by closed reduction and casting in 18% (n = 2). Closed reduction and percutaneous pinning was done in 9% (n = 1), and open reduction and internal fixation (ORIF) was done in 9% (n = 1). None of these patients developed distal ulna physeal arrest (while one of them developed a distal radius physeal arrest. The one patient with the Galezzi fracture did go on to develop a malunion with clicking of his wrist despite being treated with ORIF and required a revision osteotomy 7 months later. The remainder of patients had no complications. Conclusion/Significance: The most important finding of this study is that the rate of distal ulna physeal arrest following fracture was 0%. This is in contrast to previous studies of limited sample size that reported a rate of 50-55%. Our results demonstrate a much lower incidence of distal ulnar physeal arrest than previously thought in the pediatric population with distal forearm fractures. These findings suggest that the majority of patients with distal ulna physeal fractures do well with conservative management, and may only require routine clinical and radiographic follow up.

Intraobserver and Interobserver Reliability of Radiographic Analysis of Proximal Humerus Fractures in Adolescents.

Multiple studies have shown low intrarater and interrater agreement of radiographic classification systems for proximal humerus fractures (PHFs) in adults. There is no standardized method of measuring angulation of pediatric PHFs, nor is there consensus as to the amount of angulation and displacement that require operative fixation of adolescent PHFs. We propose a new standardized method to measure fracture angulation that is similar to the method used to measure the epiphyseal-shaft angle for slipped capital femoral epiphysis. The primary purpose of this study was to evaluate the intraobserver and interobserver reliability of our proposed method compared with a nonstandardized method. The secondary purpose was to evaluate the intrarater and interrater agreement of the Neer and Horowitz (NH), and Salter-Harris (SH) classification systems. Seven raters evaluated 26 deidentified anteroposterior shoulder radiographs of patients 10 to 16 years of age with PHFs. Raters classified each fracture using the NH and SH systems, and used their own method to measure fracture angulation. This process was repeated 2 weeks later. During the second round, raters also measured fracture angulation using our proposed standardized method. Two weeks after the second round, raters reevaluated the radiographs using the standardized method. Intraclass correlation coefficients were calculated. Excellent intraobserver and interobserver agreement was achieved for the standardized method of measuring fracture angulation. All of the raters had an intrarater reliability classified as excellent (>0.80) using the standardized method. Good intrarater and excellent interrater agreement was achieved when raters used their own fracture angulation measurement method but wide confidence intervals suggested that the results were less precise. Fair to moderate intrarater and interrater reliability was seen for the NH and SH classifications. Our standardized method for measuring angulation in adolescent PHFs demonstrated excellent intrarater and interrater reliability. We propose that this technique may be a more precise method of measuring fracture angulation and this method should be used in future studies that evaluate indications for operative management of adolescent PHFs. Level III-diagnostic.

Left Femoral Artery Occlusion due to Neglected Closed Fracture Distal Femur: A Case Report

Background: Distal femur fractures must always be considered for vascular disorders given the high risk. The incidence rate of femoral fractures is 1/10000 patients per year with the incidence rate of vascular injury around 0.10% -2.00%. Salter-Harris (SH) fracture classification is used in cases of fractures involving the growth plate (physeal plate) in children. Volkmann's ischemic contracture is caused by severe injury to the deep tissue and nerves. If tissue pressure is equal to or more than the perfusion pressure of the capillary, the microcirculation will be disrupted and ischemic occur. Normal myosit cells will be replaced by fibroblasts that tend to contract. Subjects and Method: A 10 years old boy had a traffic accident while riding a motorcycle 6 days before the patient came to the hospital. The patient could not walk, feeling pain and swelling on the left knee, the patient didn’t bring to the hospital immediately after the accident. On physical examination, there was angulation in the distal left femur, there was tenderness on palpation and unable to do dorsiflexion or moving the fingers of the left foot but still could feel touch stimu­la­tion on the pedis. Results: In our patient case with the diagnosis of left femoral artery occlusion et causa closed fracture distal femur (Salter-Harris type II) managed by surgery to release the femoral artery with internal fixation to the distal femur using Kirschner wire (minimally invasive) and massage to the femoral artery give optimal results. Conclusion: Surgery to release the femoral artery with internal fixation to the distal femur using Kirschner wire (minimally invasive) and massage to the femoral artery give an optimal result. Key w ords: Salter-Harris fracture, femoral artery, Kirschner wire, Volkmann's ischaemic contracture Correspondence: Pamudji Utomo. Department of Orthopaedics and Traumatology, Prof. Dr. R. Soeharso Orthopaedics Hospital. Email: utomodr@yahoo.com Indonesian Journal of Medicine (2019), 4(1): 75-81 https://doi.org/10.26911/theijmed.2019.04.01.12

Comparison of Biomechanical Effects of Different Configurations of Kirschner Wires on the Epiphyseal Plate and Stability in a Salter-Harris Type 2 Distal Femoral Fracture Model

We sought to investigate the different configurations of Kirschner wires used in distal femur Salter-Harris (SH) type 2 epiphyseal fracture for stabilization after reduction under axial, rotational, and bending forces and to define the biomechanical effects on the epiphyseal plate and the fracture line and decide which was more advantageous. The SH type 2 fracture was modeled using design software for four different configurations: cross, cross-parallel, parallel medial, and parallel lateral with two Kirschner wires, and computer-aided numerical analyses of the different configurations after reduction were performed using the finite element method. For each configuration, the mesh process, loading condition (axial, bending, and rotational), boundary conditions, and material models were applied in finite element software, and growth cartilage and von Mises stress values occurring around the Kirschner wire groove were calculated. In growth cartilage, the stresses were highest in the parallel lateral configuration and lowest in the cross configuration. In Kirschner wires, the stresses were highest in the cross configuration and lowest in the cross-parallel and parallel lateral configurations. In the groove between the growth cartilage and the Kirschner wire interface, the stresses were highest in the parallel lateral configuration and lowest in the cross configuration. The results showed that the cross configuration is advantageous in fixation. In addition, in the SH type 2 epiphyseal fracture, we believe that the fixation shape should not be applied in the lateral configuration.

Posterior tibial slope angle is associated with flexion-type Salter-Harris II and Watson-Jones type IV fractures of the proximal tibia.

Flexion-type Salter-Harris (SH) II fractures of the proximal tibia, also described as Watson-Jones (WJ) IV fractures, are rare injuries reported among adolescent athletes who are close to skeletal maturity and remain elusive. Due to this classification disagreement, the various treatments range from nonoperative to operative types, and no previous studies have explained the mechanisms of injury or the source of the fracture forces. This retrospective matched case-control study aimed to identify radiological factors that are associated with the fracture forces and to elucidate the mechanisms of these injuries. Sixteen flexion-type SH II/WJ IV fractures of the proximal tibia in 12 adolescents (12 males, mean age of 14.6years) were retrospectively reviewed, and knee alignment on plain radiographs was assessed to compare the radiological outcomes of the operated knees (n = 7), nonoperated knees (n = 9), and uninjured contralateral knees (n = 8). The results were compared to healthy age- and sex-matched control subjects (n = 24 knees). With regard to the radiological outcomes, the posterior tibial slope angle (PTSA) was significantly greater in the nonoperated knees (19.0° ± 1.6°), operated knees (16.8° ± 1.3°), and uninjured knees (13.6° ± 1.3°) than in the healthy knees of the matched control subjects (9.6° ± 0.4°). The anatomical tibiofemoral angle was significantly less in the nonoperated knees (0.7° ± 0.6°) than in the healthy knees of the matched control subjects (3.7° ± 0.4°). These findings suggest a relationship between an increased PTSA and flexion-type SH II/WJ IV fractures of the proximal tibia, considering the deteriorating effects of an increased PTSA on knee kinematics. Adolescent active athletes with an increased PTSA and partially closed epiphysis of the proximal tibia are at risk for suffering from flexion-type SH II/WJ IV fractures of the proximal tibia until the closure of the proximal tibial epiphysis. Case-control study, Level III.

Observation of the effect of external fixator combined with limited internal fixation in the treatment of adolescents distal tibial fracture involving the metaphysis

Objective To evaluate the clinical indications, complications and curative effects of external fixation combined with limited internal fixation in the treatment of adolescents distal tibial fracture involving the metaphysis. Methods From February 2013 to June 2017, 18 adolescent patients of distal tibial fracture involving stem epiphyseal in Luzhong Hospital of Beida Care were treated with external fixator combined with limited internal fixation.All 18 cases were closed fractures, according to Salter-Harris classification: type Ⅱ 8 cases, type Ⅲ 8 cases, type Ⅳ 2 cases.The fracture healing time, postoperative patients with limb full weight-bearing time, postoperative ankle function grading, postoperative incision of the skin, deep tissue and nail complications such as infection were observed. Results All patients received postoperative 12 to 24 months follow-up, with average of 16 months, the average postoperative fracture healing time was (8.4±3.2)weeks, the full load time of affected limb after operation was average (8.8±2.2)weeks, the ankle joint function score according to Kofoed score: 6 weeks after operation, Kofoed score was (86.6±6.8)points, excellent in 15 cases, good in 3 cases, and the excellent and good rate was 100%, 1 case with nail way out at postoperative 1 week, after the demolition of external fixator nail healed, no other blade and deep infection and other complications occurred. Conclusion The external fixation combined with limited internal fixation in the treatment of adolescents distal tibial fracture involving the metaphysic can avoid fracture end blood supply damage caused by open surgery, it is quick with small incision, fracture healing, fewer complications, and the advantages of ankle joint function restore is good, has good clinical therapeutic effect. Key words: Tibial fractures; Epiphyses; Fracture fixation, internal; External fixators; Adolescent

Should we really compress the fracture line in the treatment of Salter–Harris type 4 distal femoral fractures? A biomechanical study

In this study, the indirect effect on physeal plate during interfragmentary compression of a Salter–Harris (SH) type 4 distal femoral fracture has been investigated. Three Dimensional (3D) model of a single configuration has been performed via SolidWorks. ANSYS Workbench software was used for numerical analyses. All boundary conditions have been defined in finite element analysis software. Since it is premature to state that compression created an additional stress load on the physeal plate in vivo, according to our results, it has been found that lateromedial compression in SH type 4 fracture of the distal femur caused an additional stress load on the physeal plate ex vivo. It is believed that screws need to be fixed without compression to avoid an additional iatrogenic physeal injury.