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.^[20]

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.

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$Growth plate (physeal) fractures. Oblique view of$ Growth plate (physeal) fractures. Oblique view of distal femur reveals Salter-Harris III fracture of distal femur.

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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.

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$Growth plate (physeal) fractures. Radial head frac$ 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.

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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 the metaphysis in injuries around the knee and elbow.^[21]

Overuse injury to the physes often appears as widening of the physis on plain radiographs.^[22] Additional changes with chronic stress to apophyses include fragmentation and irregular ossification (typically seen in Osgood-Schlatter disease, for example).

Computed tomography

Computed tomography (CT) is at times necessary to delineate fragmentation and orientation of severely comminuted epiphyseal and metaphyseal fractures.^[23] CT is indicated for cases where 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 modalities (including CT and magnetic resonance imaging [MRI]) show greater average displacement than plain radiographs do.^[24]

$Growth plate (physeal) fractures. Tillaux fracture$ Growth plate (physeal) fractures. Tillaux fracture of distal tibia epiphysis that is not well seen on anteroposterior radiograph.

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$Growth plate (physeal) fractures. Tillaux fracture$ Growth plate (physeal) fractures. Tillaux fracture that was not well seen on plain radiographs is now relatively easy to see on axial CT image.

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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.^[25]

Treatment & Management

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Media Gallery

Growth plate (physeal) fractures. Clinical appearance of knee of patient with minimally displaced Salter-Harris I fracture of distal femur. Impressive swelling was noted adjacent to joint, but no evidence of intra-articular swelling was present. Patient was markedly tender to palpation about distal femoral physis.
Growth plate (physeal) fractures. Anteroposterior radiograph of knee of patient in previous image. Note subtle physeal widening, confirming diagnosis of Salter-Harris I fracture of distal femur.
Growth plate (physeal) fractures. Anteroposterior ankle radiograph demonstrates impressively displaced Salter-Harris II fracture of distal tibial epiphysis (along with comminuted fracture of distal fibular diaphysis).
Growth plate (physeal) fractures. Displaced Salter-Harris II fracture of distal femur. Large Thurstan Holland (metaphyseal) fragment may serve as important fixation point for either Steinmann pin or lag screw.
Growth plate (physeal) fractures. Multiple computed tomography (CT) scans depict displaced Salter-Harris III fracture of distal anterolateral tibial epiphysis (ie, Tillaux fracture).
Growth plate (physeal) fractures. Displaced Salter-Harris IV fracture of proximal tibia. Lateral portion of epiphysis (with Thurstan Holland fragment) and medial portion of epiphysis are independently displaced (ie, each is free-floating fragment).
Growth plate (physeal) fractures. Salter-Harris V fracture pattern must be strongly suspected whenever mechanism of injury includes significant compressive forces. This is initial injury radiograph of child's ankle that was subjected to significant compressive and inversion forces. It demonstrates minimally displaced fractures of tibia and fibula with apparent maintenance of distal tibial physeal architecture.
Growth plate (physeal) fractures. Follow-up radiograph of ankle of child in preceding image. This radiograph depicts growth arrest secondary to Salter-Harris V nature of the injury. Note markedly asymmetric Park-Harris growth recovery line, indicating that lateral portion of growth plate continues to function and medial portion does not.
Growth plate (physeal) fractures. Mortise radiograph demonstrating somewhat subtle physeal injury to distal tibia. Salter-Harris VI pattern may be suspected on basis of history and physical examination. In this case, radiograph indicates that it is quite likely that small portion of peripheral medial physis (as well as small amount of adjacent epiphyseal and metaphyseal bone) has been avulsed.
Growth plate (physeal) fractures. Clinical photograph of patient above with displaced Salter-Harris II fracture of distal femur. Mechanism of injury and physical examination findings are consistent with Salter-Harris VI physeal injury pattern. Some may also refer to this injury type as Kessel fracture.
Growth plate (physeal) fractures. Radiographic evidence of pediatric stubbed great toe.
Growth plate (physeal) fractures. Clinical appearance of pediatric stubbed great toe. Note subungual hematoma, representative of open fracture.
Growth plate (physeal) fractures. Oblique view of distal femur reveals Salter-Harris III fracture of distal femur.
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. Fixation of Salter-Harris III fracture of distal femur.
Growth plate (physeal) fractures. Proximal tibia apophyseal avulsion fracture (anteroposterior, lateral, and oblique images).
Growth plate (physeal) fractures. Proximal tibial apophyseal tuberosity avulsion fracture.
Growth plate (physeal) fractures. Proximal tibia apophysis avulsion as seen on CT.
Growth plate (physeal) fractures. Fixation of proximal tibia apophysis avulsion fracture (healed).
Growth plate (physeal) fractures. Triplane fracture of distal tibia (anteroposterior and lateral images).
Growth plate (physeal) fractures. Healed triplane fracture of distal tibia after internal fixation.
Growth plate (physeal) fractures. Sagittal and axial CT images of triplane fracture of distal tibia.
Growth plate (physeal) fractures. 3D CT images of triplane fracture of distal tibia are useful for preoperative planning.
Growth plate (physeal) fractures. Tillaux fracture of distal tibia seen on anteroposterior radiograph.
Growth plate (physeal) fractures. Healed Tillaux fracture of distal tibia after internal fixation.
Growth plate (physeal) fractures. Tillaux fracture of distal tibia epiphysis that is not well seen on anteroposterior radiograph.
Growth plate (physeal) fractures. Tillaux fracture that was not well seen on plain radiographs is now relatively easy to see on axial CT image.
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 fracture in child that was difficult to see on anteroposterior and lateral images is now well seen on oblique view.
Growth plate (physeal) fractures. Open reduction and internal fixation of radial head fracture in child.
Growth plate (physeal) fractures. Angulated proximal humerus fracture in child (anteroposterior and Y views).
Growth plate (physeal) fractures. Healed proximal humerus with abundant callus and angulation in child.
Growth plate (physeal) fractures. Remodeling of proximal humerus fracture in child.
Growth plate (physeal) fractures. Displaced Salter-Harris II fracture of distal femur.
Growth plate (physeal) fractures. Percutaneous internal fixation of Salter-Harris II fracture of distal femur after anatomic stable closed reduction.
Growth plate (physeal) fractures. Healed Salter-Harris II fracture of distal femur in anatomic position.
Growth plate (physeal) fractures. Anatomic reduction of previously displaced Salter-Harris II fracture of distal femur.
Growth plate (physeal) fractures. Posttraumatic Madelung deformity treated with epiphyseodesis of distal ulna to allow radius growth to catch up.
Growth plate (physeal) fractures. Comparison views of two wrists show almost equal ulnar variance (with correction of previously Madelung deformity by epiphyseodesis).
Growth plate (physeal) fractures. Posttraumatic Madelung deformity with ulna outgrowing radius in skeletally immature child.
Growth plate (physeal) fractures. Application of Ilizarov external fixator frame with corticotomy for distraction osteogenesis correction of leg-length discrepancy.
Growth plate (physeal) fractures. Equal leg lengths (healing) after Ilizarov distraction osteogenesis.
Growth plate (physeal) fractures. 14-year-old girl with leg-length discrepancy.
Growth plate (physeal) fractures. Ilizarov distraction osteogenesis for leg-length discrepancy.
Growth plate (physeal) fractures. Procurvatum of proximal tibia after open reduction and internal fixation of proximal tibia apophysis injury.
Growth plate (physeal) fractures. Epiphyseodesis performed too late to correct procurvatum deformity of proximal tibia.
Growth plate (physeal) fractures. Anatomic reduction with percutaneous cross pinning of Salter-Harris II fracture distal femur.
Growth plate (physeal) fractures. Growth arrest of distal femur at skeletal maturity after Salter-Harris II fracture of distal femur.
Growth plate (physeal) fractures. Scanograms to assess leg lengths after growth plate arrest following Salter-Harris II fracture of distal femur.
Growth plate (physeal) fractures. Corrective osteotomy after growth arrest deformity following Salter-Harris II fracture of distal femur.
Growth plate (physeal) fractures. Healed Salter-Harris III fracture of distal femur with pain over retained hardware (screw head).
Growth plate (physeal) fractures. Resolution of pain after removal of hardware; healed Salter-Harris II fracture of distal femur.
Growth plate (physeal) fractures. Minimally displaced Salter-Harris III fracture of distal radius.
Growth plate (physeal) fractures. Central deformity of distal radius with growth retardation and relative lengthening of distal ulna after Salter-Harris III fracture of distal radius.
Growth plate (physeal) fractures. Partial correction of deformity (improvement of ulnar variance) after ulnar epiphyseodesis to correct growth retardation of distal radius following Salter-Harris III fracture. Earlier diagnosis and intervention might have improved results.
Growth plate (physeal) fractures. Growth retardation of distal ulna with negative ulnar variance after open reduction and internal fixation of distal radius fracture.
Growth plate (physeal) fractures. Tibia shaft fracture in child.
Growth plate (physeal) fractures. Healed tibia shaft fracture in child.
Growth plate (physeal) fractures. Comparison radiographic views (anteroposterior and lateral, both knees) showing procurvatum deformity of proximal tibia due to growth retardation remote from prior tibial shaft fracture.
Growth plate (physeal) fractures. Opening wedge osteotomy to correct procurvatum deformity of proximal tibia.
Growth plate (physeal) fractures. Healed proximal tibia osteotomy.
Growth plate (physeal) fractures. Salter-Harris I fracture of distal radius.
Growth plate (physeal) fractures. Healed and remodeled Salter-Harris I fracture of distal radius.
Growth plate (physeal) fractures. Closed reduction and percutaneous pinning of Salter-Harris II fracture of distal radius.
Growth plate (physeal) fractures. Triradiate cartilage fracture seen on anteroposterior pelvis x-ray.
Growth plate (physeal) fractures. Triradiate cartilage fracture seen on axial CT.
Growth plate (physeal) injuries. Little League shoulder. Note irregularity of proximal humeral physis with metaphyseal sclerosis.
Growth plate (physeal) injuries. Little League elbow. Note widening of medial epicondyle physis.
Growth plate (physeal) injuries. Medial epicondyle avulsion fracture in child. Note widening of medial apophysis.

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Table 1. Physeal Injury Patterns in Male and Female Athletes

Table 1. Physeal Injury Patterns in Male and Female Athletes

Mechanism and Site of Injury	Males	Females
Mechanism
Acute trauma	58.2%	37.5%
Overuse	41.8%	62.5%
Site
Lower extremity	53.7%	65.8%
Upper extremity	29.8%	15.1%
Spine	8.2%	11.3%

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Author

Steven I Rabin, MD, FAAOS Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Musculoskeletal Services, Dreyer Medical Clinic

Steven I Rabin, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Fracture Association, American Orthopaedic Association, AO Foundation, Chicago Metropolitan Trauma Society, Illinois Association of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society, Mid-America Orthopaedic Association, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

George H Thompson, MD Director of Pediatric Orthopedic Surgery, Rainbow Babies and Children’s Hospital, University Hospitals Case Medical Center, and MetroHealth Medical Center; Professor of Orthopedic Surgery and Pediatrics, Case Western Reserve University School of Medicine

George H Thompson, MD is a member of the following medical societies: American Orthopaedic Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons

Disclosure: Received none from OrthoPediatrics for consulting; Received salary from Journal of Pediatric Orthopaedics for management position; Received none from SpineForm for consulting; Received none from SICOT for board membership.

Chief Editor

Jeffrey D Thomson, MD Professor of Orthopedic Surgery, University of Connecticut School of Medicine; Director of Orthopedic Surgery, Connecticut Children’s Medical Center; Vice President of Medical Staff, Connecticut Children's Medical Center

Jeffrey D Thomson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Pediatric Orthopaedic Society of North America, Scoliosis Research Society

Disclosure: Nothing to disclose.

Additional Contributors

Charles T Mehlman, DO, MPH Professor of Pediatrics and Pediatric Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Director, Musculoskeletal Outcomes Research, Cincinnati Children's Hospital Medical Center

Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics, American Fracture Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society, Ohio State Medical Association

Disclosure: Nothing to disclose.

Matthew E Koepplinger, DO Assistant Professor, Department of Orthopedic Surgery, Baylor College of Medicine; Staff Physician, Department of Orthopedic Surgery, Ben Taub General Hospital

Matthew E Koepplinger, DO is a member of the following medical societies: American Osteopathic Association, American Osteopathic Academy of Orthopedics

Disclosure: Nothing to disclose.

Mininder S Kocher, MD, MPH Associate Professor of Orthopedic Surgery, Harvard Medical School/Harvard School of Public Health; Associate Director, Division of Sports Medicine, Department of Orthopedic Surgery, Children's Hospital Boston

Mininder S Kocher, MD, MPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Sports Medicine, Pediatric Orthopaedic Society of North America, American Association for the History of Medicine, American Orthopaedic Society for Sports Medicine, Massachusetts Medical Society

Disclosure: Received consulting fee from Smith & Nephew Endoscopy for consulting; Received consulting fee from EBI Biomet for consulting; Received consulting fee from OrthoPediatrics for consulting; Received stock from Pivot Medical for consulting; Received consulting fee from pediped for consulting; Received royalty from WB Saunders for none; Received stock from Fixes-4-Kids for consulting.