Physeal Fractures

CHAPTER 42

Physeal Fractures

Introduction/Etiology/Epidemiology

• Physes (epiphyseal plates or growth plates) are organized into zones of function, with cartilage cells growing continually on the epiphyseal side and bony replacement occurring on the metaphyseal side at the end of a long bone.

• These zones persist until skeletal maturity when the cartilage of the physis has been completely closed and converted to bone.

• While the physes are open, it is more common for a child to sustain a fracture or an injury through the relatively weaker area of the physis than to sustain a ligamentous injury (sprain) or dislocation of a joint.

• Salter-Harris classification of physeal fractures (Figure 42-1)

— A standard radiographic description or terminology to categorize injuries involving the growth plate. Like all fractures, physeal fractures may be displaced or non-displaced.

— Describes the plane or trajectory of the fracture through the physeal plate

— Has implications for treatment and prognosis of potential growth arrest

• Types

— Salter-Harris type I fracture

■Traverses across the physis without entering the epiphysis or metaphysis

■Accounts for 8% of physeal fractures

■More common in infants and younger children

— Salter-Harris type II fracture

■Extends across the physis for a variable distance and then exits into the metaphysis

■Most common type, representing 73% of physeal fractures

■Usually occurs in children older than 10 years

❖ Common in distal radius; high remodeling potential at the metaphysis

— Salter-Harris type III and IV fractures

■Extend either into the articular surface (type III) or into the articular surface and metaphysis (type IV)

■Account for 6% (type III) and 12% (type IV) of physeal fractures

■Because adequate reduction is necessary for subsequent physeal and articular function, it is important that anatomic reduction is achieved.

■Common about the ankle

— Salter-Harris type V fracture

■A crush injury to the physis often diagnosed retrospectively

■Rare

■High risk of physeal growth arrest is expected

Figure 42-1. Salter-Harris classification system for epiphyseal fractures. Type I includes the physis only; type II, physis and metaphysis; type III, through the physis and epiphysis; type IV, through the epiphysis, physis, and metaphysis; type V, impaction or crush. Abbreviations: E, epiphysis; M, metaphysis; ME, metaphysis and epiphysis.

From Metzl JD. Sports Medicine in the Pediatric Office. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

• Physeal fractures are common and account for 18% to 30% of all fractures in children.

• Distal radius physeal fractures comprise between 25% and 30% of physeal fractures, followed by the distal tibia, distal fibula, distal humerus, distal ulna, proximal humerus, and distal femur.

• Physeal fractures are more likely to occur around very rapidly growing physes and during times of rapid growth.

• Physeal injuries occur over the entire span of childhood years, increasing in occurrence with age.

• Highest incidence is in the preadolescent period, with girls peaking at 11 years of age and boys peaking at 12 to 14 years of age.

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