- See:
-
Growth Deformities of Limbs:
-
Growth Plate Arrest:
- Discussion:
-
anatomy of distal femoral physis:
- account for approx 5% of all physeal frx;
- displacement in sagittal plane is assoc w/ N/V injury in popliteal fossa and instability on closed reduction;
- common mechanism is hyperextsion causing anterior displacement of epiphysis;
- displacement in coronal plane is not assoc w/ other injuries, & joint may be stable after closed reduction.
- Physical Exam Findings:
- pts usually are unable to walk or bear wt on injured extremity;
- hamstring spasm causes knee to be held in flexion;
- thigh may appear angulated & short compared w/ contralat thigh;
- pain, knee effusion, & soft-tissue swelling usually are severe;
- hemarthrosis may be more severe in SH III and IV fractures;
- anterior dimpling may be seen w/ hyperextension injuries;
- vascular exam may reveal diminished or absent pulses;
- w/ diminished pulses consider
femoral arteriogram (
arterial injuries associated w/ fractures);
- hyperextension deformity is more commonly associated with vascular injury;
- sensation on dorsal & plantar aspects of foot may be abnormal if posterior tibial or peroneal nerve has been damaged;
- Radiographic Evaluation:
- Non Operative Treatment:
- non-displaced fx are Rx'ed w/ immobilization in an LLC or Single Leg
Hip Spica for 4-6 wks
- be aware that displaced fractures may tend to redisplace without some form of internal fixation;
-
acceptable reduction:
- posterior angulation upto 20 deg will remodel in kids < 10 yrs old,
- adolescent, however, will not remodle and will not tolerate this degree of angulation;
- no > 5 deg of varus-valgus angulation is acceptable;
-
Salter Harris Type II Fractures:
- displaced SH type-I or II frx are reduced closed w/ pt under GEA;
- SH III and IV:
- tense hemarthrosis may require preoperative aspiration;
- require anatomic reduction, which can not be obtained w/ close reduction;
- even minimally unstable fractures can be unstable;
- Operative Treatment of Salter Harris Type II Fractures:
- Operative Treatment: SH III and IV frx:
- operative treatment is required since, even slight physeal displacement can result in formation of
osseous bar that causes limb-length discrepancy & angular deformity;
- if minimally displaced, SH III and IV frx are treated by percutaneously manipulating fragment w/ pin;
- following reduction, pin is driven across frx, parallel to to physis;
- most often open reduction and fixation is required for an anatomic reduction;
- a large (2-3 cm-high) triangular metaphyseal spike may be amenable to fixation w/ 2 cannulated 4.0 or 6.5-mm screws, inserted transversely to fix
spike to metaphysis of femur w/o crossing physis.
- in other cases, pins or cannulated screws are inserted between the joint and the physis;
- long leg cast is applied with the knee in 5-10 deg of flexion.
- if fixation is not used, then immobilize in
spica cast, w/ frequent f/u x-rays to detect any slippage or loss of reduction;
- Complications: Growth Plate Arrest:
- limb length descrepancy of more than 1 cm may occur in over 40%.
- angular deformities may occur in a third of patients;
Injuries of the distal femoral growth plate and epiphysis: should open reduction be performed.
Salter-Harris type-III fracture of the medial femoral condyle occurring in the adolescent athlete.
Periarticular fractures after manipulation for knee contractures in children.
Fractures of the distal femoral epiphyses. Factors influencing prognosis: a review of thirty-four cases.
Traumatic injuries of the distal femoral physis. Retrospective study on 151 cases.
Supracondylar fractures of the femur in children: closed reduction and percutaneous pinning of displaced fractures.
Predicting the Outcome of Physeal Fractures of the Distal Femur.
Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis.
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