Physeal Fractures

Physeal (growth plate) Injuries
Shadrick G Lungu
Lecture Outline
1. Definition
2. Anatomy
3. Classification
4. Management
5. Complication
6. Take home
The growth plate, or physis, is the translucent,

cartilaginous disc separating the epiphysis from
the metaphysis and is responsible for
longitudinal growth of long bones
.
• The key difference between the child's bone

and that of an adult is the presence of a physis
• Physeal injuries are very common in children,

making up 15-30% of all bony injuries..
• The cells of the physis are arranged in columns or
layers
• The germinal or resting layer,

• The proliferative zone,
• The hypertrophic zone and
• The zone of provisional calcification
• The proliferative zone –
• Chondrocytes undergo rapid division by

mitosis and is the most metabolically active
zone.
• Osteoblasts use the chondrocyte columns as a
scaffold for ossification in the zone of
provisional calcification.
• The hypertrophic zone is the weakest because
it lacks both collagen and calcified tissue.
• Most physeal separations occur through this
layer because it is less able to resist shearing
stress.
Salter-Harris classification of physeal
injuries
• About 90% of children with physeal injuries -

use Salter-Harris class from plain x-rays.
• 5% defy classification, "unclassifiable pattern"

= additional imaging, including oblique views,
an arthrogram, CT or MRI.
• Knee – High stress –
• integrates with bone mammalian bodies
• Wrist (Radial) – more linear & rarely arrest

• Transverse fracture
• Periosteum is usually
torn
• If not torn, difficult Dx
• Heals within 2-3wks
• 75% of all physeal
injuries
• Transverse &
metaphyseal #
• Poor fixation with PoP
• ? Trapped periosteum
• Ankle
• 8% of all physeal injuries

• Older children (closing
physis)
• Horizontal # line thru
the physis & a vertical #
line
• Disturbed growth
leading to OA
• May require ORIF

• 10% of all physeal #
• Vertical (metaphysis,
physis, epiphysis &
cartilage)
• Humerus (lat condyle)
• ORIF
• Rare and difficult to see
on x-ray
• Compression # or
crushing of the growth
plate
• Diagnosed
retrospectively
• Management of physeal injuries
– Look for and define the exact lines of separation

on good quality x-rays using multiple views
– Occasionally views of the opposite side may help
– Classify the injury using the Salter-Harris

classification
– If not readily classifiable, consider CT, MRI and

urgent referral to orthopaedics
– The majority of type I and II injuries are treated by

closed reduction and cast immobilisation
• The majority of type III and IV injuries require

ORIF
• Physeal injuries become "sticky" and unite

very quickly, in good position or in bad
• They should not be referred to "next available

clinic" but reduced in ED or by orthopaedics
within 24 hours of presentation
• Reduction should therefore be early and
gentle
– so that iatrogenic trauma is not added to the
original trauma
• If an acceptable reduction is not possible at

the first attempt,
– referral for open reduction should be considered
promptly.
• The majority of type I and II injuries should

not have attempted manipulation after 5 days.
• Most will remodel and the rest can be

managed by osteotomy.
• The situation is more complex with type III

and type IV injuries.
• ORIF may be considered for many weeks after

injury but outcomes become exponentially
worse with time
• Open versus closed reduction
• Type I and type II injuries are common at the wrist,

ankle, knee and shoulder.
• An exact anatomic reduction is not essential at the wrist

or shoulder because remodelling will take care of minor
degrees of displacement.
• Accurate reduction is more critical at the ankle and knee.

• Type III and type IV injuries involve the joint

surface and an anatomic reduction is
mandatory
• These injuries require prompt referral,

accurate reduction and usually some form of
fixation, either percutaneous or open fixation.
• Complications
• The majority of physeal injuries heal quickly

and recover fully
• In a minority, growth disturbance or arrest

may occur, and can result in deformity and
impaired function.
• Physeal growth may be disturbed by:
– Avascular necrosis
– Direct crushing (Salter-Harris type V)
– The formation of a bony bar
– Non-union
– Hyperaemia
• Take Home
• Physeal # are unique

• Suspect early
• Do the other side of x-rays
• Treat early
• Maybe diagnosed in retrospect (late)
The end!

Physeal Fractures

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Physeal Fractures

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Physeal (growth plate) Injuries

The growth plate, or physis, is the translucent,

• The key difference between the child's bone

• Physeal injuries are very common in children,

• The germinal or resting layer,

• The proliferative zone –

• Chondrocytes undergo rapid division by

• About 90% of children with physeal injuries -

• 5% defy classification, "unclassifiable pattern"

• Wrist (Radial) – more linear & rarely arrest

• 8% of all physeal injuries

• May require ORIF

• Humerus (lat condyle)

– Look for and define the exact lines of separation

– Occasionally views of the opposite side may help

– Classify the injury using the Salter-Harris

– If not readily classifiable, consider CT, MRI and

– The majority of type I and II injuries are treated by

• The majority of type III and IV injuries require

• Physeal injuries become "sticky" and unite

• They should not be referred to "next available

• If an acceptable reduction is not possible at

• The majority of type I and II injuries should

• Most will remodel and the rest can be

• The situation is more complex with type III

• ORIF may be considered for many weeks after

• Type I and type II injuries are common at the wrist,

• An exact anatomic reduction is not essential at the wrist

• Accurate reduction is more critical at the ankle and knee.

• Type III and type IV injuries involve the joint

• These injuries require prompt referral,

• The majority of physeal injuries heal quickly

• In a minority, growth disturbance or arrest

• Physeal # are unique

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