Physeal Injuries

Proximal Tibial Physeal Injuries and Epiphyseal Fractures 213 ... 

In the tibia, a proximal physeal injury with displacement of the epiphysis is rare. The mechanism is due either to a direct force to the proximal tibia or, as more commonly occurs in adolescent boys, it is due to an indirect force. This indirect force is usually anterior, causing hyperextension to the proximal tibia. 

In children with ligamental injuries, it is important to detect associated meniscal injuries (Williams et al. 1996) and occult physeal injury as physeal arrest can occasionally occur following non-physeal injury of the lower extremity (Hresko and Kasser 1989). 

Ankle fractures account for approximately 5.5% (Landin 1983) of paediatric fractures and the distal tibial and fibular physes are common sites of physeal injury (Peterson and Peterson 1972). The potential consequences of ankle and distal tibial physeal injury are leg length inequality, angular and torsional malalignment and post-traumatic arthritis. 

In adults ankle fractures are traditionally classified according to the forces involved in producing the injury (Lauge-Hansen 1950). In children, the presence of the physis allows the same forces to produce different injury patterns. The Salter-Harris classification of physeal fractures is well recognised. Therefore, Dias and Tachdjian (1978) modified the Lauge-Hansen classification to include the Salter-Harris classification and describe physeal injuries of the ankle in children. In the original classification there were four types of injury, each with a two-part name ... 

The first part of the name refers to the position of the foot at the moment of the injury. The second part indicates the direction of the abnormal force applied to the ankle. A further four types of fracture - juvenile Tillaux, triplane, axial compression and miscellaneous physeal injuries - were added later to complete the classification. Whilst this classification is useful in understanding the deforming forces of the fracture, and hence the type of manoeuvre needed to achieve a satisfactory closed reduction, the Salter-Harris classification is easier to commit to memory and provides a better predictor of outcome in terms of complications (Spiegel et al. 1978). 

Magnetic resonance (MR) imaging for acute paediatric ankle injuries conveys no real advantage over radiography (Lohman et al. 2001). It is probably as useful as CT in the assessment of transitional fractures and is also helpful in the evaluation of the articular cartilage in traumatic osteochondral lesions of the talus. Where it is perhaps most useful is in the later stages, following physeal injury, to identify and characterise physeal arrest (Futami et al. 2000 Sailhan et al. 2004). 

The two main risks of distal tibial physeal injuries are premature physeal closure (PPG) and post-traumatic arthritis. Premature physeal closure may lead to angular deformity and/or leg-length discrepancy. Which of these occurs depends on the position and magnitude of the physeal arrest. The distal tibial physis accounts for about 3 mm per year of tibial growth which equates to 35%-40% of overall tibial length or 15%-20% of overall leg length. Obviously, the nearer the child is to skeletal maturity at the time of injury the less effect a PPG will have on growth. 

Dias LS, Tachdjian MO (1978) Physeal injuries ofthe ankle in children classification. Clin Orthop 136 230-233 Ertl JP, Barrack RL, Alexander AH et al (1988) Triplane fracture of the distal tibial epiphysis long term follow-up. J Bone Joint Surg 70A 967-976 Farley FA, Kuhns L, Jacobson JA et al (2001) Ultrasound examination of ankle injuries in children. J Pediatr Orthop 21 604-607... 

Fractures of the proximal humerus are uncommon - those involving the physis represent about 3% of physeal injuries (Schwendenwein et al. 2004). In children under 10 the fracture is typically metaphyseal, whilst in adolescence it is a Salter-Harris type 11 fracture. Salter-Harris type 111 fractures have been described in association with dislocation of the shoulder (Wang et al. 1997). 

Ogden JA (1984) Distal clavicular physeal injury. Clin Orthop 188 68-73... 

Milch Type 1 (Fig. 18.11) The fracture line exits lateral to the capitellar trochlear groove and the lateral crista remains intact for the ulna to articulate with. This corresponds to a Salter-Harris type IV physeal injury. 

McElfresh EC, Dobyns JH (1983) Intra-articular metacarpal head fractures. J Hand Surg [Am] 8 383-393 Mizuta T, Benson WM, Foster BK, Paterson DC, Morris LL (1987) Statistical analysis of the incidence of physeal injuries. J Pediatr Orthop 7 518-523... 

---