Growth Plate (Physeal) Fractures Workup

Updated: Sep 26, 2019
  • Author: Steven I Rabin, MD, FAAOS; Chief Editor: Jeffrey D Thomson, MD  more...
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Workup

Plain Radiography

Many acute physeal injuries are not clearly visible on plain radiographs, because of the cartilaginous-osseous nature and irregular contours of the physes. [14]

Plain radiographs may depict physeal widening as the only sign of displacement. In order to help delineate the injury, two views perpendicular to each other (usually anteroposterior [AP] and lateral) are necessary. Oblique images may also better define a fracture. An example is shown below, in which a Salter-Harris (SH) type III fracture is not well seen on the usual AP and lateral images (see the first image below) but is well seen on the oblique image (see the second image below).

Growth plate (physeal) fractures. Anteroposterior Growth plate (physeal) fractures. Anteroposterior and lateral views of distal femur Salter-Harris III fracture where fracture is not well seen.
Growth plate (physeal) fractures. Oblique view of Growth plate (physeal) fractures. Oblique view of distal femur reveals Salter-Harris III fracture of distal femur.

Another example is shown below, in which a radial head fracture is not well seen on the usual AP and lateral images (see the first image below) but is well seen on the oblique image (see the second image below).

Growth plate (physeal) fractures. Radial head frac Growth plate (physeal) fractures. Radial head fracture in child that is difficult to see on standard anteroposterior and lateral images.
Growth plate (physeal) fractures. Radial head frac Growth plate (physeal) fractures. Radial head fracture in child that was difficult to see on anteroposterior and lateral images is now well seen on oblique view.

Occasionally, comparison views of the opposite extremity may be helpful. Comparison views can help establish occult separation of the physis, as in an SH I injury. 

Radiographic stress views (varus and valgus) may be indicated in certain patients. They are not recommended in all instances, because stress maneuvers may cause further physeal damage. However, stress radiographs may be necessary in order to accurately diagnose physeal plate injury. Stress views may prove particularly useful for demonstrating separation between the epiphysis and metaphysis in injuries around the knee and elbow. [15]

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Other Imaging Modalities

Computed tomography

Computed tomography (CT) is at times necessary to delineate fragmentation and orientation of severely comminuted epiphyseal and metaphyseal fractures. [16]  CT is indicated when the patient has tenderness over the physis but plain radiographs are normal or for preoperative planning to aid the surgeon in reduction or fixation. (See the images below.)  Advanced imaging (including CT and magnetic resonance imaging [MRI]) show greater average displacement than plain radiographs. [17]

Growth plate (physeal) fractures. Tillaux fracture Growth plate (physeal) fractures. Tillaux fracture of distal tibia epiphysis that is not well seen on anteroposterior radiograph.
Growth plate (physeal) fractures. Tillaux fracture Growth plate (physeal) fractures. Tillaux fracture that was not well seen on plain radiographs is now relatively easy to see on axial CT image.

Bone scanning

Bone scans are not particularly helpful, because the physes are normally relatively active on nuclear scans.

Magnetic resonance imaging

MRI has proved to be the most accurate evaluation tool for the fracture anatomy when performed in the acute phase of injury (initial 10 days). MRI can depict altered arrest lines and transphyseal bridging abnormalities before they are evident on plain radiographs. [18]

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