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Distal Femoral Physeal Fractures - Pediatric

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Topic updated on 12/31/15 11:16pm
Introduction
  • Most commonly seen as a Salter-Harris II fracture
  • Mechanism
    • often a varus or valgus force on the knee
    • physis fails under traumatic force before ligaments in children
    • disruption occurs thru multiple zones of the growth plate
  • Physeal arrest
    • high incidence of physeal arrest that often leads to growth disturbance and deformity
      • be sure to counsel parents of poor prognosis associated with this fracture pattern
      • an increased incidence of complications have been associated with q
        • Salter-Harris classification type
        • fracture displacement
        • surgical hardware invading the physis
Anatomy
  • Physeal considerations of the knee
    • general assumptions
      • leg growth continues until 
        • 16 yrs in boys
        • 14 yrs in girls
    • growth contribution
      • leg grows 23 mm/year, with most of that coming from the knee (15 mm/yr)
        • proximal femur - 3 mm / yr (1/8 in)
        • distal femur - 9 mm / yr (3/8 in)
        • proximal tibia - 6 mm / yr (1/4 in)
        • distal tibia - 5 mm / yr (3/16 in)
Presentation
  • Symptoms
    • unable to bear weight
  • Physical exam
    • pain and swelling
    • tenderness along the physis in the presence of a knee effusion
    • may see varus or valgus knee instability on exam
Imaging
  • Imaging
    • MRI or ultrasound is now the diagnositic modality of choice when confirmation of a physeal fracture is needed
    • follow up radiographs after 2-3 weeks of casting can be used as treatment if physeal injury is likely but not identifiable on injury films 
    • stress radiographs to look for opening of the physis were indicated in the past if there was suspicion of physeal injury 
Treatment
  • Nonoperative
    • long leg casting q 
      • indications
        • stable nondisplaced fractures
      • close clinical followup is mandatory 
  • Operative
    • closed reduction and percutaneous pinning followed by casting q 
      • indications
        • displaced Salter-Harris I or II fractures
        • displaced fractures successfully reduced with closed methods should still be pinned (undulating physis makes unstable following reduction)
      • technique 
        • avoid multiple attempts at reduction
        • avoid physis with hardware if possible
          • if physis must be crossed (SH I and SH II with small Thurston-Holland fragments), use smooth k-wires
      • SH II fracture, if possible, should be fixed with lag screws across the metaphyseal segment avoiding the physis 
      • postoperatively follow closely to monitor for deformity
    • ORIF
      • indications
        • Salter-Harris III and IV in order to anatomically reduce articular surface
        • irreducible SHI and SHII fractures
          • reduction often blocked by periosteum infolding into fracture site
      • techniques
        • If anatomic reduction cannot be obtained via closed techniques, incision over the displaced physis to remove interposed periosteum is necessary.
Complications
  • Limb length discrepancy or angular deformity (most common)  
    • results from physeal arrest
    • occurs in 30-50% of displaced fractures
    • prevent with 
      • anatomic physeal alignment (critical)
      • close follow up following nonoperative or operative treatment
    • treatment
      • physeal bridge excision q
        • indicated when deformity is present with a physeal bar of <50% and at least 2 years or 2 cm of growth remaining
  • Popliteal Artery injury
    • rare and more common with anterior displacement of epiphysis
    • most common with anterior, or posteriorly, displaced fracture patterns

 

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Qbank (7 Questions)

TAG
(OBQ12.59) A 10-year-old female presents after being struck by a car while riding her bicycle. Her right leg shows significant swelling and deformity around the knee. An injury radiograph is shown in Figure A. Further radiographic work-up confirms the diagnosis of a Salter-Harris II fracture, without any other significant bony injury. The patient is treated definitively with open reduction and internal fixation with lag screws in the metaphysis. While all of the following have been studied with respect to this injury, which of the following is least predictive of the outcome? Topic Review Topic
FIGURES: A          

1. The Salter-Harris classification of the injury
2. Presence or absence of displacement
3. Violation of the physis by hardware with surgical treatment
4. Direction of fracture displacement
5. Presence of an open fracture

PREFERRED RESPONSE ▶
TAG
(OBQ06.26) An 11-year-old boy underwent surgical intervention for the injury shown in Figure A two years ago. He currently does not complain of knee pain, but the parents have noticed a progressive bow-leg deformity. Physical examination reveals 5 degrees of varus relative to contralateral side. Current radiographs are provided Figure B. Physeal mapping via CT demonstrates a bar involving 25% of the physis. The remainder of the physis is open. Which of the following is the most appropriate management? Topic Review Topic
FIGURES: A   B        

1. Observation with repeat radiographs in 1 year
2. Lateral opening wedge distal femoral osteotomy
3. Guided growth with temporary hemiephysiodesis of the lateral distal femoral physis
4. Physeal bridge resection with polymethylmethacrylate interposition
5. Distal femoral epiphysiodesis

PREFERRED RESPONSE ▶
TAG
(OBQ05.200) All of the variables listed are associated with an increased risk of complications with treatment of distal femoral epiphyseal fractures EXCEPT: Topic Review Topic

1. Articular incongruity
2. Presence of fracture displacement
3. Direction of fracture displacment
4. Surgical treatment
5. Violation of the physis with surgical hardware

PREFERRED RESPONSE ▶
TAG
(OBQ04.68) A 10-year-old boy presents to the emergency room after injuring his left knee while playing soccer. He localizes the pain to the distal femur, and is unable to bear weight on the affected leg. On physical exam the patient is tender to palpation only directly over the distal femoral physis. He has swelling about the distal thigh, without any signs of knee effusion. An AP and lateral radiograph of the affected knee are shown in Figures A and B. An AP and lateral radiograph of the contralateral knee are shown in Figures C and D. What is the most appropriate treatment? Topic Review Topic
FIGURES: A   B   C   D    

1. Hinged knee brace with early motion and weight bearing as tolerated
2. Cast immobilization with close clinical followup
3. Closed reduction and percutaneous pinning
4. Open reduction with pin fixation
5. Open reduction with plate fixation

PREFERRED RESPONSE ▶
TAG
(OBQ04.110) A 13-year-old boy is unable to bear weight after sustaining a twisting injury during football practice. Physical exam shows swelling and tenderness over the distal femur. Radiographs are shown in Figure A. What is the most appropriate treatment? Topic Review Topic
FIGURES: A          

1. Hinged knee brace and weight bearing as tolerated
2. Long leg cast and non-weightbearing
3. Skeletal traction for three weeks followed by cast immobilization
4. Closed reduction and percutaneous fixation
5. Open reduction and internal fixation of the distal femur with plate fixation

PREFERRED RESPONSE ▶
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