How can growth disturbance be minimized in a growth plate fracture?

Minimizing Growth Disturbance in Growth Plate Fractures

Anatomic reduction and fixation from the metaphyseal side rather than the epiphyseal side is the most effective approach to minimize growth disturbance in growth plate fractures.

Understanding Growth Plate Fracture Risks

Growth plate (physeal) fractures present unique challenges in pediatric orthopedics due to their potential to cause permanent growth disturbances. The risk of complications varies by fracture type:

• Salter-Harris classification correlates with risk of growth disturbance:

  • Type I: 36% risk of growth disturbance
  • Type II: 58% risk
  • Type III: 49% risk
  • Type IV: 64% risk (highest risk) 1

• Displaced fractures have 4 times greater odds of developing growth arrest compared to non-displaced fractures 1

Key Principles for Management

1. Anatomic Reduction

• Perfect anatomic reduction is critical, especially for Salter-Harris types III and IV fractures
• Poor reduction is associated with higher rates of growth arrest and subsequent deformity
• Even minimal displacement may require operative intervention 2

2. Proper Fixation Technique

• Always insert fixation hardware (K-wires or screws) from the metaphyseal side rather than the epiphyseal side 3
• Metaphyseal approach results in only temporary growth disturbance that typically resolves
• Epiphyseal approach causes severe, permanent growth disturbances 3
• When possible, place fixation in the center of the growth plate 3

3. Fracture-Specific Management

• Salter-Harris Type I: May be treated with casting if non-displaced
• Salter-Harris Type II: Often requires reduction and possible fixation
• Salter-Harris Types III and IV: Almost always require open reduction and internal fixation 2
• Avoid crossing the growth plate with hardware when possible

4. Timing of Intervention

• Early intervention is crucial for optimal outcomes
• Delayed treatment increases risk of malunion and growth arrest
• Open fractures require urgent debridement and stabilization

Monitoring and Follow-up

• Regular clinical and radiographic follow-up is essential until skeletal maturity
• Initial follow-up radiographs at 12 months after treatment, or sooner if clinical worsening 4
• Monitor for:
  • Angular deformities (varus/valgus)
  • Leg length discrepancies
  • Joint incongruity

Complications to Watch For

• Growth arrest (partial or complete)
• Angular deformities
• Leg length discrepancy (22% of distal femoral growth plate fractures develop leg length discrepancy >1.5 cm) 1
• Post-traumatic arthritis

Special Considerations

• Avoid fixation across open growth plates in children whenever possible
• If growth plate fixation is necessary, temporary fixation with planned removal is preferred
• In cases of significant displacement or instability, the benefits of fixation outweigh the risks of growth disturbance
• Consider consultation with a pediatric orthopedic surgeon for complex cases 4

Pitfalls to Avoid

1. Inadequate reduction of Salter-Harris III and IV fractures
2. Inserting fixation from the epiphyseal side
3. Delayed treatment of displaced fractures
4. Insufficient follow-up monitoring for growth disturbances
5. Failure to recognize and address early signs of growth arrest

By following these principles, the risk of growth disturbance after growth plate fractures can be significantly reduced, improving long-term outcomes for pediatric patients.