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).


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).


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).
Other Imaging Modalities
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]


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]
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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.
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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.
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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).
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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.
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Growth plate (physeal) fractures. Multiple computed tomography (CT) scans depict displaced Salter-Harris III fracture of distal anterolateral tibial epiphysis (ie, Tillaux fracture).
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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).
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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.
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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.
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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.
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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.
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Growth plate (physeal) fractures. Radiographic evidence of pediatric stubbed great toe.
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Growth plate (physeal) fractures. Clinical appearance of pediatric stubbed great toe. Note subungual hematoma, representative of open fracture.
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Growth plate (physeal) fractures. Oblique view of distal femur reveals Salter-Harris III fracture of distal femur.
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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. Fixation of Salter-Harris III fracture of distal femur.
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Growth plate (physeal) fractures. Proximal tibia apophyseal avulsion fracture (anteroposterior, lateral, and oblique images).
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Growth plate (physeal) fractures. Proximal tibial apophyseal tuberosity avulsion fracture.
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Growth plate (physeal) fractures. Proximal tibia apophysis avulsion as seen on CT.
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Growth plate (physeal) fractures. Fixation of proximal tibia apophysis avulsion fracture (healed).
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Growth plate (physeal) fractures. Triplane fracture of distal tibia (anteroposterior and lateral images).
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Growth plate (physeal) fractures. Healed triplane fracture of distal tibia after internal fixation.
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Growth plate (physeal) fractures. Sagittal and axial CT images of triplane fracture of distal tibia.
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Growth plate (physeal) fractures. 3D CT images of triplane fracture of distal tibia are useful for preoperative planning.
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Growth plate (physeal) fractures. Tillaux fracture of distal tibia seen on anteroposterior radiograph.
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Growth plate (physeal) fractures. Healed Tillaux fracture of distal tibia after internal fixation.
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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 that was not well seen on plain radiographs is now relatively easy to see on axial CT image.
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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 fracture in child that was difficult to see on anteroposterior and lateral images is now well seen on oblique view.
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Growth plate (physeal) fractures. Open reduction and internal fixation of radial head fracture in child.
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Growth plate (physeal) fractures. Angulated proximal humerus fracture in child (anteroposterior and Y views).
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Growth plate (physeal) fractures. Healed proximal humerus with abundant callus and angulation in child.
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Growth plate (physeal) fractures. Remodeling of proximal humerus fracture in child.
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Growth plate (physeal) fractures. Displaced Salter-Harris II fracture of distal femur.
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Growth plate (physeal) fractures. Percutaneous internal fixation of Salter-Harris II fracture of distal femur after anatomic stable closed reduction.
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Growth plate (physeal) fractures. Healed Salter-Harris II fracture of distal femur in anatomic position.
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Growth plate (physeal) fractures. Anatomic reduction of previously displaced Salter-Harris II fracture of distal femur.
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Growth plate (physeal) fractures. Posttraumatic Madelung deformity treated with epiphyseodesis of distal ulna to allow radius growth to catch up.
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Growth plate (physeal) fractures. Comparison views of two wrists show almost equal ulnar variance (with correction of previously Madelung deformity by epiphyseodesis).
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Growth plate (physeal) fractures. Posttraumatic Madelung deformity with ulna outgrowing radius in skeletally immature child.
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Growth plate (physeal) fractures. Application of Ilizarov external fixator frame with corticotomy for distraction osteogenesis correction of leg-length discrepancy.
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Growth plate (physeal) fractures. Equal leg lengths (healing) after Ilizarov distraction osteogenesis.
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Growth plate (physeal) fractures. 14-year-old girl with leg-length discrepancy.
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Growth plate (physeal) fractures. Ilizarov distraction osteogenesis for leg-length discrepancy.
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Growth plate (physeal) fractures. Procurvatum of proximal tibia after open reduction and internal fixation of proximal tibia apophysis injury.
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Growth plate (physeal) fractures. Epiphyseodesis performed too late to correct procurvatum deformity of proximal tibia.
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Growth plate (physeal) fractures. Anatomic reduction with percutaneous cross pinning of Salter-Harris II fracture distal femur.
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Growth plate (physeal) fractures. Growth arrest of distal femur at skeletal maturity after Salter-Harris II fracture of distal femur.
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Growth plate (physeal) fractures. Scanograms to assess leg lengths after growth plate arrest following Salter-Harris II fracture of distal femur.
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Growth plate (physeal) fractures. Corrective osteotomy after growth arrest deformity following Salter-Harris II fracture of distal femur.
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Growth plate (physeal) fractures. Healed Salter-Harris III fracture of distal femur with pain over retained hardware (screw head).
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Growth plate (physeal) fractures. Resolution of pain after removal of hardware; healed Salter-Harris II fracture of distal femur.
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Growth plate (physeal) fractures. Minimally displaced Salter-Harris III fracture of distal radius.
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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.
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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.
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Growth plate (physeal) fractures. Growth retardation of distal ulna with negative ulnar variance after open reduction and internal fixation of distal radius fracture.
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Growth plate (physeal) fractures. Tibia shaft fracture in child.
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Growth plate (physeal) fractures. Healed tibia shaft fracture in child.
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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.
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Growth plate (physeal) fractures. Opening wedge osteotomy to correct procurvatum deformity of proximal tibia.
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Growth plate (physeal) fractures. Healed proximal tibia osteotomy.
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Growth plate (physeal) fractures. Salter-Harris I fracture of distal radius.
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Growth plate (physeal) fractures. Healed and remodeled Salter-Harris I fracture of distal radius.
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Growth plate (physeal) fractures. Closed reduction and percutaneous pinning of Salter-Harris II fracture of distal radius.
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Growth plate (physeal) fractures. Triradiate cartilage fracture seen on anteroposterior pelvis x-ray.
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Growth plate (physeal) fractures. Triradiate cartilage fracture seen on axial CT.
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Growth plate (physeal) injuries. Little League shoulder. Note irregularity of proximal humeral physis with metaphyseal sclerosis.
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Growth plate (physeal) injuries. Little League elbow. Note widening of medial epicondyle physis.
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Growth plate (physeal) injuries. Medial epicondyle avulsion fracture in child. Note widening of medial apophysis.