Prevention of growth arrest by fibrin interposition into physeal injury

Management of Physeal Fractures: A Review Article

BACKGROUND

Physis is the weakest structure in the skeleton of a child and a frequent site of an injury or fracture. A physeal fracture presents a unique challenge in the management as the sequalae of such an injury could lead to growth disturbances.

METHODS

In this review, mainly focussing on traumatic physeal injuries, the authors discuss the applied anatomy, different fracture patterns, clinical assessment and management of physeal fractures in children.

RESULTS

Discussion on acute physeal injuries as well as physeal arrest and approach to its management is presented. Past attempts for treatment of physeal injuries and recent advances in their management is also discussed.

CONCLUSION

The ideal approach to treat physeal injuries should take into account the location of injury, age of the patient, fracture type and growth potential of the involved physis. Prompt diagnosis and physeal-respecting treatment techniques are important.

Physeal fractures of the distal femur: does a lower threshold for surgery lead to better outcomes?

Distal femur physeal fractures are known to have a high incidence of complications. Our previous reported experience (pre-2007) showed a 40% complication risk, which prompted changes in our approach. The purpose of this study was to evaluate and compare the complication rate and outcome after implementation of these changes. This is a retrospective study of children with distal femur physeal fractures treated at a level 1 pediatric trauma center between 2007 and 2016. Patient demographics, fracture patterns, treatment and outcomes including complications and its risk factors were recorded and analyzed. We compared current results with our previously reported multicenter cohort (n = 73). Patients were male in majority (57/70) with a mean age of 13 ± 4 years. Fractures were most commonly Salter-Harris Type 2 (49/70) and displaced (59/70) on presentation, although neither characteristic was associated with complications. Most patients (63/70) were treated surgically, and the overall complication incidence was 36% (25/70), including growth arrest in 20 patients. The pre-2007 cohort was statistically significantly younger (P < 0.001) and was more commonly treated nonoperatively (P < 0.001). However, there was no statistically significant difference in complication incidence between studies (36% versus 40%, respectively, P = 0.751). Despite a lower threshold for surgery for distal femur physeal fractures in the past decade, the complication rate is still high and unchanged at 40%, and presenting patients are older. There were no new prognostic factors that showed statistically significant association with subsequent complications; however, patients with high-energy injury mechanisms and greater fracture displacements did have higher complication rates. These results demonstrate the inherent high complication risk for these injuries. Level of Evidence: III.

The normal and fractured physis: an anatomic and physiologic overview

The growth plate (physis) is responsible for enabling and regulating longitudinal growth of upper and lower limbs. This regulation occurs through interaction of the cells in the growth plate with systemic and locally produced factors. This complex interaction leads to precisely controlled changes in chondrocyte size, receptors, and matrix, which ultimately result in endochondral bone formation. With advances in cellular and molecular biology, our knowledge about these complex interactions has increased significantly over the past decade. Deficiency of any of the regulating factors or physeal injury during childhood can alter this well-orchestrated sequence of events and lead to abnormalities in growth. This review highlights the histology of the normal physis, including recent findings at the cellular and molecular levels, mechanics and mechanobiology of the growth plate, pathologies that can affect the physis, and treatment options, including interposition materials.