 The physis or the growth cartilage which is a specialized layer

of tissue unique to children provides for both longitudinal and

latitudinal growth of bone.
 Injuries to the physis can cause cessation of growth and
resultant angular deformities.
 Physeal injuries are not uncommon, represent 15–20% of all
injuries in children.
 Physeal injury due to various causes such as trauma, infection,
etc.
 may result in growth arrest, which may cause
shortening, limb length discrepancy (LLD) and/or
deformity, which may be angular, rotational at or
translational
 Additionally, in the growing child, there is a fourth
dimension of deformity: time. LLD changes over
time.
 Phalanges are the most common site 37%, distal radius
18% and distal tibia 10%.
 The physis is divided into four zones, the resting or
germinal zone,the proliferative zone, the zone of
hypertrophy and the zone of enchondral ossifcation.
 The physis has three distinct sources
of blood supply:
1. Invading metaphyseal vessels
from the nutrient artery.
2. Peripheral periosteal vessels
supply the perichondrial ring area.
3. Epiphyseal vessels nourish the
central portion of the physis.
 Loss of blood supply to the
epiphysis produces physeal necrosis
and thereby growth cessation.
 Many fundamental concepts of physeal growth are still not
understood.
 In the lower limb, more longitudinal growth takes place at the
epiphyseal plates in the region of the knee, and in the upper limb, more
growth takes place in the region of shoulder and wrist.
 No plausible explanation is available for such differences in
the rate of growth within individual bones.
 In open physeal injuries, there is
contamination of the tissues, and Closed physeal injuries have been
possibly loss of tissues, which classifed by Aitken, Ogden,Weber and
determines the prognosis. others.
Infection might destroy the
physis with resultant cessation of
growth.
 Physeal injuries can also be
caused by drugs, irradiation, The most commonly used classifcation,
thermal injuries, infections and which is based on the roentgenographic
tumors. appearance of the fracture is that of
 Physeal stress injuries have been Salter and Harris, which is used here
documented following
unaccustomed work or sports
 Salter and Harris Classifcation
 Peterson’s Classifcation
 The most widely utilized classifcation is that
of Salter and Harris, as it is a satisfactory
working classifcation.
 Tis classifcation is based on the mechanism
of injury, the relationship of the fracture line
to the physis, the method of treatment and the
prognosis.
• Separation through the physis, usually through areas of the
hypertrophic and degenerating cartilages cell columns.
 Fracture through a portion of the physis that extends through the
metaphyses.
 This metaphyseal fragment is called the Thurston-Holland sign.
 Mechanism: Shear or avulsion with angular force; cartilage failure
on the tension side; metaphyseal failure on the compression side.
 Fracture through a portion of the physis that extends the epiphysis
and into the joint.
 This type of fraction generally occurs when the growth plate is
partially fused.
 This type of injury is uncommon and is mostly seen at the lower
tibial epiphysis.
 The intra-articular fracture extends from the joint surface
through the epiphysis, the entire thickness of the physis
and a portion of the metaphysis.
 A severe crushing force applied through the epiphysis to one area
of the epiphyseal plate.
 Mechanism of this injury is by longitudinal compression, which
damages the germinal layer of physeal cells.
 This type of injury was described by Rang as a perichondrial
injury, which may result from burn, a blow to the surface of
the extremity or in run-over injury.
 30% of which involved the physes.
 The distal radius was the most frequent site of injury (44%)
 Followed by the distal humerus (13%), distal fibula, distal tibia,
distal ulna, proximal humerus, distal femur, proximal tibia, and
proximal fibula.
 males were affected more than twice as often as females.
 Females were most frequently affected at a younger age than
males (11-12 years vs 12-14 years).
 Growth plate fractures are often caused by a single event, such
as a fall or car accident.
 All children who are still growing are at risk for growth plate
injuries, but there are certain factors that may make them more
likely to occur:
 Growth plate fractures occur twice as often in boys as in girls,
because girls finish growing earlier than boys.
 One-third of all growth plate fractures occur during participation in
competitive sports such as football, basketball, or gymnastics.
 About 20% of all growth plate fractures occur during participation in
recreational activities such as biking, sledding, skiing, or skateboarding.
 The incidence of growth plate fractures peaks in adolescence.
 A growth plate fracture
usually causes persistent or
severe pain. Other common
symptoms include:
 Visible deformity, such as a
crooked appearance of the
limb
 An inability to move or put
pressure on the limb
 Swelling, warmth, and
tenderness in the area around
the end of the bone, near the
joint
 The main differential in a pediatric patient with pain and
swelling at the distal end of a long bone with normal x-
rays is a sprain.
 Ligamentous laxity tests of the joints of the injured side
may elicit pain and positive findings similar to those
indicative of joint injury.
 Do not dismiss positive joint laxity test findings as only
involving the related joint tissues.
 Physeal injuries are often missed.
 History of injury, pain, swelling restricted movement and
deformity near joint point to physeal injury should be
carefully noted.
 Plane X-rays, Anteroposterior, lateral and oblique help in
the diagnosis.
 Ultrasonography or CT or MRI is helpful, if X-rays are
doubtful.
 Factors that affect
treatment decisions
include the following
 Severity of the injury
 Anatomic location of the
injury
 Classification of the fracture
 Plane of the deformity
 Patient age
 Growth potential of the
involved physis
Nonoperative Therapy
• Closed reduction
• casting
• splinting
Options for Surgical
Therapy
• Open reduction and
internal fixation
or closed reduction and
percutaneous fixation
 Most SH I and II injuries can
be treated with closed
reduction and casting or
splinting and then
reexamination in 7-10 days to
evaluate maintenance of the
reduction.
 Some sites, such as the
proximal humerus and
clavicle, have excellent
potential to heal and remodel
even with severe-appearing
deformity.
 More severe injuries, especially
those involving intra-articular
fractures, typically require anatomic
reduction with open reduction and
internal fixation (ORIF) that avoids
crossing the physis.
 Unstable fractures that are suitable
for closed reduction will benefit
from percutaneous pin fixation to
maintain the reduction.
 Smooth pins should parallel the
physis in the epiphysis or
metaphysis, avoiding the physis
 Prognosis: Depends upon the following factors, viz.
severity of injury-displacement comminution and open
versus closed and age.
Types of Injury
In type III and IV, complications rate •Age at the time of injury
is higher. Though absolute
accuracy in the prediction of future
•Blood supply to the epiphysis
growth disturbance is not possible, a •Severity of the injury
few factors help in estimating the •Method of reduction
prognosis. •Closed or open injury
Types of injury Prognosis
• I, II and III Good
• IV Bad
•V Worst
 Growth Acceleration
 Malunion
 Nonunion
 Osteomyelitis
 Neurological Complications
 Vascular Complications
 Avascular Necrosis of Epiphysis
 Growth Arrest
 Long-term follow-up is essential for determining whether
complications will occur.
 The first phase involves ensuring bone healing, and the second phase
involves monitoring growth.
 Most growth plate (physeal) injuries should be reevaluated in the
short term to ensure maintenance of reduction and proper anatomic
relations
 Physeal fractures that are considered to be at increased risk for
growth arrest include fractures to the following growth plates:
 Distal femur
 Distal tibia
 Distal radius and ulna
 Proximal tibia
 Triradiate cartilage
1. Bright RW. In: Rockwood CA, Wilkins KE, King RE (Eds). Fractures in Children. Philadelphia: JB
Lippincott; 1984. p. 3.
2. Tachdijian MO. Pediatric Orthopaedics. Philadelphia: WB Saunder 1990.
3. Canale S. In: Crenshaw AH (Ed). Campbell’s Operative Orthopaedics. St. Louis: Mosby Year-Book; 1992.
4. Brooks M. The Blood Supply of Bones. Oxford: Butterworth and Co; 1971.
5. Spira E, Farin I. The vascular supply to the epiphyseal plate under normal and pathological conditions. Acta
Orthop Scand. 1967;38: 1-22.
6. Trueta J. Studies of the Development and Decay of the Human Frame. Philadelphia: WB Saunders; 1968.
7. Aitken AP. Fractures of the epiphyses. Clin Orthop Relat Res. 1965;41:19-23.
8. Ogden JA. Injury to the growth mechanism of the immature
skeleton. Skeletal Radiol. 1981;6:237-53. 9. Weber BC. Treatment of Fractures in Children and Adolescents.
New York: Springer-Verlag; 1980. pp. 20-57.
10. Saltar RB, Harris RW. Injuries involving the epiphyseal plate. JBJS. 1963;45A:587-9.
11. Cooperman DR, Spiegel PG, Laros GS. Tibial fractures involving the ankle in children. JBJS.
1978;60A:1040-64.
12. Silverman FN. Sequel to an unusual complication of scurvy. JBJS. 1987;52A:384-90.