What is the treatment for a physeal injury?

Treatment of Physeal Injuries

The treatment of physeal injuries requires early stabilization with immobilization as the primary approach, with surgical intervention reserved for specific fracture patterns to reduce the risk of growth disturbance and long-term morbidity. 1

Initial Assessment and Management

• Immediate stabilization: Assume any injury to an extremity includes a bone fracture and stabilize the extremity in the position found 1
• Cover open wounds with a clean dressing to prevent contamination and infection 1, 2
• Do not attempt to straighten an angulated suspected fracture as this may cause further injury 1
• Vascular assessment: Check for pulses, capillary refill time, and note temperature and color changes in the extremity 2
  • If the extremity appears blue or extremely pale, activate emergency medical services immediately 1

Diagnostic Approach

• Radiographs are the initial imaging modality for suspected physeal injuries 1
• MRI is beneficial in assessing physeal injuries, especially in pediatric patients, as it is sensitive for diagnosing bone marrow contusion and evaluating the growth plate 1
• CT may be necessary for complex fracture patterns to better visualize the fracture configuration

Treatment Algorithm Based on Injury Type

Non-Displaced Physeal Fractures

1. Immobilization with cast or splint for 3-6 weeks depending on location and severity 3
2. Weight-bearing restrictions until clinical and radiographic healing
3. Regular follow-up to monitor for growth disturbances

Displaced Physeal Fractures

1. Closed reduction under appropriate anesthesia
2. Immobilization if reduction is stable
3. Surgical fixation if:
   • Reduction cannot be maintained
   • Intra-articular involvement
   • Significant displacement
   • Unstable fracture pattern

Specific Considerations for Distal Femoral Physeal Fractures

• These have worse prognosis than similar injuries in other locations 4
• Higher risk of vascular injury - requires thorough neurovascular assessment
• Higher risk of growth arrest - needs close monitoring during healing and growth

Rehabilitation Phases

1. Early phase (1-2 weeks): Pain and swelling management, protected immobilization 2
2. Intermediate phase (2-6 weeks): Progressive weight-bearing as tolerated, range of motion exercises when safe 2
3. Late phase (6+ weeks): Strengthening exercises and proprioceptive training 2

Complications and Monitoring

• Growth disturbance: Depends on extent of injury and remaining growth potential 5
• Regular follow-up: Monitor for limb length discrepancy and angular deformities
• Long-term monitoring: 5-33% of patients may still have pain after 1 year 2

Special Considerations

• Overuse physeal injuries require extended periods of active rest and joint immobilization when necessary 6
• Risk factors for physeal injuries include:
  • Periods of accelerated growth
  • Body size
  • Training volume
  • Previous injury 6, 7
• Sport-specific concerns: Soccer, alpine skiing, gymnastics, weight lifting, and baseball are commonly associated with physeal injuries 5

Prevention Strategies

• Participation limitations during periods of rapid growth 6
• Sport-specific training programs that account for skeletal maturity 6
• Regular monitoring of modifiable risk factors such as flexibility, strength, and training volume 6

The most important principle in treating physeal injuries is to respect the growth plate and minimize further damage to prevent long-term growth disturbances that could lead to significant morbidity.