What is Pediatric Physeal Injuries Overview?

Fractures in children often involve the growth plate, a part of the bone that allows growth, about 15 to 18% of the time. The first mention of injuries to the growth plate was by a doctor named Foucher in 1863, while the first system to classify these injuries was introduced by another physician called Poland in 1898. Today, the most commonly used system to categorize these injuries is called the Salter-Harris classification. This system, presented by Dr. Salter and Dr. Harris in 1963, was the first to identify that the injury happens in a certain part of the growth plate called the zone of provisional calcification. This area is particularly susceptible to injury as it’s a transition point between the hardened and unhardened parts of the growth plate.

What Causes Pediatric Physeal Injuries Overview?

Bones can break during events like accidental falls, sports activities, or car accidents.

Risk Factors and Frequency for Pediatric Physeal Injuries Overview

Physeal injuries, or damage to the growth plate in bones, are a common occurrence in children and make up about 30% of all bone injuries in this age group. These injuries are most commonly seen in children who can walk and are very common among teenagers. Kids who are involved in sporting activities have a higher chance of getting these injuries. Overall, boys have twice the risk of experiencing a physeal injury compared to girls. The most frequent physeal injury involves the phalanges, the bones in the fingers and toes, and makes up 30% of such cases.

Signs and Symptoms of Pediatric Physeal Injuries Overview

In situations involving serious injuries, it’s crucial to first focus on the patient’s medical history. It’s important to start with basic trauma checks – ensuring the patient’s airway is clear, they’re able to breathe, and their blood circulation is functioning. After these essentials are addressed, other injuries can be evaluated. Knowing how the injury happened can help understand how severe the trauma to any limbs might be.

It’s necessary to check the skin for signs of an open fracture, like puncture wounds or skin that looks like it’s being pulled tight over a swelling fracture. A neurovascular assessment should be carried out to make sure there’s no disruption before any interventions start. It’s also crucial to check whether an area of the body is developing compartment syndrome, a serious condition that involves increased pressure in a muscle compartment, especially in cases of high-energy trauma.

In the case of children’s fractures, it’s important to look out for signs that the injury might have been caused by something other than an accident. Non-accidental injuries could present as orthopedic injuries and may include:

Metaphyseal corner fractures
Healing fractures at different stages
Multiple fractures
Long bone fractures in children who can’t walk yet
Epiphyseal separation, separation of the end part of a long bone from the main shaft of the bone

Testing for Pediatric Physeal Injuries Overview

After your doctor has completed their physical examination, they may order further medical imaging tests to investigate any injuries in more detail. Medical imaging tests can provide a clearer picture of what’s happening inside your body. An ultrasound may be used for very young patients, before the cartilage in their bodies has hardened into bone. However, a plain X-ray is usually the most effective way to detect fractures in the growth plate of bones.

The way these fractures appear on X-rays or other images can be described using the Salter-Harris Classification, which ranges from type I to type V. Each type corresponds to a different way the growth plate might be fractured, and higher numbers mean a higher risk of the fracture affecting the bone’s growth. Here’s a summary of what each type means:

Salter-Harris I: A fracture that goes through the growth plate and separates the end and the main body of the bone.
Salter-Harris II: A fracture that goes through the growth plate and extends into the main part of the bone. When this happens, a small piece of bone, called the Thurston-Holland fragment, separates. This is the most common type of growth plate fracture.
Salter-Harris III: A fracture that goes through the growth plate and into the end of the bone. This type of fracture has a risk of causing arthritis later in life.
Salter-Harris IV: This is a fracture that extends from the main part of the bone, through the growth plate and into the end of the bone. Depending on where the fracture is located, this type can have a varied impact on bone growth.
Salter-Harris V: This is a crush injury to the growth plate.

The Salter-Harris Classification can be a useful way for doctors to categorize growth plate fractures, but it’s important to remember that the accuracy of this classification can vary depending on the expertise of the person who is reviewing the medical images.

Treatment Options for Pediatric Physeal Injuries Overview

Following all accidents causing physical injuries, it’s crucial to first deal with the ABCs: Airway, Breathing, Circulation. This ensures that the person can breathe and has a pulse. After making certain these basic needs are addressed, we can then focus on treating the fracture or broken bone.

In the early stages of a fracture, the first step of treatment usually involves setting the bone back into its normal position under anesthesia. This procedure is known as a closed reduction. For certain types of fractures, called Salter-Harris 1 and 2, if the person comes in a week to ten days after the injury, the doctor might allow some misalignment of the fracture to avoid causing extra harm to the growth plate, which helps bones to grow.

Interfering with the growth plate during treatment can stop bone growth and cause deformities. If these occur, they can be corrected later on with surgery. In contrast, fractures with more severe dislocation or involving the joint surface demand a more precise realignment. The doctor may use CT scan images to see if the alignment is good.

After the closed reduction, the next step is to stabilize the fracture. This may involve using a cast for about a month or two. If the fracture is unstable, which means it’s likely to move out of position, or if a piece of tissue is preventing a good alignment, surgical intervention may be required. This might involve using wires or pins to hold the bone in place, or even a surgical procedure to position the bone correctly.

In instances when the bone stops growing after the fracture is treated (a condition termed growth arrest), the choice of further treatment depends on how much left the bone has to grow. It’s crucial to know that boys usually continue to grow until age 16 and girls until 14. There’s a variety of treatments to choose from, depending on how much growth is left. Some of these options include simply observing the condition, completing growth early, or removing the blockage to growth. Further treatment details depend upon the specifics of the situation and the person’s remaining growth potential.

Where an obstruction occurs and a large amount of growth remains for the bone, the obstruction is usually removed in a procedure called a bone bar resection, with fat tissue placed in the vacant space. However, if there isn’t enough healthy growth plate left for the bone to continue growing, other treatments are considered.

In some cases, the bone may be corrected surgically if its angle of alignment is greater than 20 degrees, while an angle of less than 20 degrees may self-correct with growth. However, this isn’t always the case, and sometimes further treatment is required.

Injuries to the growth plate, or “physeal injuries”, can sometimes show unclear symptoms, which can be mistaken for a range of other possible issues. These include:

Infection
Non-accidental or intentional trauma
Accidental trauma
Muscle strain
Fractures in the metaphysis or diaphysis, which are parts of the bone
Bone bruise
Injuries to the ligaments

What to expect with Pediatric Physeal Injuries Overview

The outcome of injuries to the growth plate, called physeal injuries, depends on numerous factors. These include the type and location of the fracture, how quickly treatment is given, the quality of the fracture alignment (how well the bones are put back in place), and consistent follow-up with a bone specialist (orthopedic). Typically, the outlook (prognosis) for pediatric growth plate fractures is positive.

Most cases heal well with the right alignment through non-surgical (closed) treatment. However, if these injuries aren’t managed properly right at the beginning, it can lead to complications like the ceasing of growth, misalignment of the bone, and potential lifelong problems for the patient.

Possible Complications When Diagnosed with Pediatric Physeal Injuries Overview

Complications affecting the growth plate can happen to between 2% to 14% of patients after it’s injured. This growth disturbance, known as ‘growth arrest,’ is quite rare but can occur more frequently in certain body areas like the lower part of the shin bone (distal tibia), with about 27.2% incidence.

Growth arrest can be more likely if a bone healing element called periosteum gets inside the fracture, leading to the formation of a so-called ‘physeal bar.’ This formation might just stop the growth completely or disturb it, leading to irregularities. Certain scans, like an MRI or CT, can be useful in identifying a presence of this physeal bar.
Unfortunately, growth arrest might not be visible until many months after the injury.

Growth disturbances can be classified using the Peterson’s system:

Type A is a disturbance around the edge of the growth plate
Type B is a central bar crossing the entire growth plate with healthy sectors on the sides
Type C is a central disruption surrounded by healthy growth plate

To prevent growth arrest, it’s advisable to keep the number of changes in positioning (reduction attempts) as low as possible. With one single attempt, there’s already an 11% risk of growth arrest, and after two attempts, such risk jumps to 24%.

After the injury to the growth plate, it is possible that lines known as ‘harris growth arrest lines’ may form. These can give us clues about the ongoing growth – if the line appears horizontal and parallel to the growth plate, it indicates a uniform growth. But if the harris line seems uneven, it may suggest uneven growth following the injury.

Apart from growth disturbances, other severe complications can occur like infections, failure of bone healing (non-union, malunion), injuries to nerves or blood vessels (neurovascular injury) and a condition where bone tissue dies (osteonecrosis).

Preventing Pediatric Physeal Injuries Overview

Injuries to the growth plate, or ‘physeal injuries’, are common in children. It’s crucial to explain to the child and their family the risk of growth stopping prematurely or the limb developing abnormally after such an injury. Doctors need to monitor the child for any differences in leg length and should be prepared to consider surgery if it’s necessary, depending on the child’s age and how much growing they still have left to do.