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Emergency And Acute Medicine - Epiphyseal Injuries
Basic description
Fractures involving the physis account for approximately 21–30% of pediatric long bone fractures, with up to 30% resulting in some degree of growth disturbance. These injuries most commonly affect the distal radius and ulna, distal tibia and fibula, and the phalanges.
Epiphyseal injuries are more common than ligamentous injuries in children because the tensile strength of pediatric bone is lower than that of adjacent ligaments, making the physis the weakest structural component. In adults, a similar mechanism more often produces a sprain.
These injuries are most frequent during periods of rapid growth: ages 9–12 years in females and 12–15 years in males. They are uncommon in infancy and early childhood because the epiphysis is not yet ossified and acts as a shock absorber. Overall incidence is about twice as high in males, as female bones mature earlier.
Salter–Harris classification
Introduced in 1963, this is the most widely used system for classifying physeal fractures.
Additional classification systems
Ogden expanded the Salter–Harris system to include injuries to surrounding structures such as the periosteum, perichondrium, and zone of Ranvier (Types VI and VII).
The Peterson classification (1994) identified fracture patterns not covered by Salter–Harris, including injuries where most force is transmitted through the metaphysis with minimal physeal disruption, as well as severe open injuries with loss of epiphysis, physis, and metaphysis.
Etiology
Common causes include competitive and recreational trauma, accidental injury, child abuse, extreme cold exposure, radiation injury, and underlying genetic, neurologic, or metabolic disorders.
Diagnosis – signs and symptoms
History
Most injuries occur after a fall or direct trauma. Less common mechanisms include cold injury and radiation exposure.
Physical examination
Findings include focal tenderness over the physis, swelling, limited range of motion, and possible non–weight-bearing status if the lower extremity is involved. Apparent joint laxity may reflect physeal injury rather than ligament damage.
Essential workup
Obtain radiographs to assess and classify the injury. Always evaluate distal pulses, capillary refill, motor and sensory function, and skin integrity. Identify and manage associated injuries.
Diagnosis tests and interpretation
Imaging
Differential diagnosis
Strain, sprain, and contusion.
Treatment – prehospital
Immobilize the limb in the position found if there is no vascular compromise. Apply ice or cold packs and assess neurovascular status. Consider the possibility of associated injuries.
Initial stabilization and therapy
Provide analgesia. Control bleeding and cover open wounds with sterile dressings.
Emergency department treatment
Displaced fractures require reduction to restore anatomic alignment. Immediate intervention is required if there is vascular or neurologic compromise.
All suspected or confirmed physeal injuries should be immobilized with a splint that stabilizes the joints above and below the injury in neutral alignment.
Open fractures require IV antibiotics, copious irrigation, sterile dressing, and urgent orthopedic consultation. Consultation is also indicated for displaced Salter–Harris type II injuries and all type III or higher injuries.
Medication
First line (analgesia)
If open fracture
Follow-up and disposition
Admission criteria
Open fractures, fractures requiring operative reduction, and consideration for higher-grade (type III–V) injuries.
Discharge criteria
Low-grade fractures, or higher-grade fractures with reliable follow-up, may be discharged with splinting, analgesia, ice, elevation, and orthopedic follow-up within one week.
Issues for referral
All physeal injuries require follow-up with a musculoskeletal specialist.
Follow-up recommendations
Ongoing monitoring is often necessary, particularly for higher-grade injuries, to assess for limb-length discrepancy or angular deformity through periodic examination and imaging.
Clinical pearls and common missteps
Growth plate injuries can result in limb-length discrepancy if the entire physis is affected, or angular deformity if only part is involved. When a Salter–Harris injury is suspected clinically but radiographs are normal, immobilization with short-interval follow-up is appropriate.
Basic description
Fractures involving the physis account for approximately 21–30% of pediatric long bone fractures, with up to 30% resulting in some degree of growth disturbance. These injuries most commonly affect the distal radius and ulna, distal tibia and fibula, and the phalanges.
Epiphyseal injuries are more common than ligamentous injuries in children because the tensile strength of pediatric bone is lower than that of adjacent ligaments, making the physis the weakest structural component. In adults, a similar mechanism more often produces a sprain.
These injuries are most frequent during periods of rapid growth: ages 9–12 years in females and 12–15 years in males. They are uncommon in infancy and early childhood because the epiphysis is not yet ossified and acts as a shock absorber. Overall incidence is about twice as high in males, as female bones mature earlier.
Salter–Harris classification
Introduced in 1963, this is the most widely used system for classifying physeal fractures.
- Type I: Fracture confined to the physis with complete separation of the epiphysis from the metaphysis. If the periosteum remains intact, displacement may be minimal. Diagnosis is often clinical, based on focal physeal tenderness. Growth disturbance is rare.
- Type II: The most common pattern (≈80%). The fracture extends along the physis with an associated metaphyseal fragment (Thurston–Holland sign). Growth disturbance is uncommon.
- Type III: Rare. The fracture extends through part of the physis and into the epiphysis, most often affecting the distal tibia. Anatomic reduction is required if displaced. Growth disturbance may occur due to vascular compromise.
- Type IV: Fracture crosses the articular surface, physis, and metaphysis. Commonly affects the distal humerus. Accurate anatomic reduction is essential, and displaced fractures usually require operative fixation. Growth arrest is common even with optimal care.
- Type V: Crush injury to the physis. Often radiographically occult initially and typically diagnosed in retrospect. Growth disturbance is inevitable.
Additional classification systems
Ogden expanded the Salter–Harris system to include injuries to surrounding structures such as the periosteum, perichondrium, and zone of Ranvier (Types VI and VII).
The Peterson classification (1994) identified fracture patterns not covered by Salter–Harris, including injuries where most force is transmitted through the metaphysis with minimal physeal disruption, as well as severe open injuries with loss of epiphysis, physis, and metaphysis.
Etiology
Common causes include competitive and recreational trauma, accidental injury, child abuse, extreme cold exposure, radiation injury, and underlying genetic, neurologic, or metabolic disorders.
Diagnosis – signs and symptoms
History
Most injuries occur after a fall or direct trauma. Less common mechanisms include cold injury and radiation exposure.
Physical examination
Findings include focal tenderness over the physis, swelling, limited range of motion, and possible non–weight-bearing status if the lower extremity is involved. Apparent joint laxity may reflect physeal injury rather than ligament damage.
Essential workup
Obtain radiographs to assess and classify the injury. Always evaluate distal pulses, capillary refill, motor and sensory function, and skin integrity. Identify and manage associated injuries.
Diagnosis tests and interpretation
Imaging
- Plain radiographs:
- Type I injuries may appear normal; subtle physeal widening or joint effusion may be present. Comparison views can be helpful.
- Types II–IV are usually evident on initial imaging.
- Type V injuries often appear normal initially; later imaging may show premature physeal closure.
- Ultrasound: Useful in infants with unossified cartilage.
- CT: Helpful for defining fragment orientation and comminution.
- MRI: Most sensitive in the acute phase; can identify physeal arrest lines and is recommended when diagnosis is uncertain and would alter management.
Differential diagnosis
Strain, sprain, and contusion.
Treatment – prehospital
Immobilize the limb in the position found if there is no vascular compromise. Apply ice or cold packs and assess neurovascular status. Consider the possibility of associated injuries.
Initial stabilization and therapy
Provide analgesia. Control bleeding and cover open wounds with sterile dressings.
Emergency department treatment
Displaced fractures require reduction to restore anatomic alignment. Immediate intervention is required if there is vascular or neurologic compromise.
All suspected or confirmed physeal injuries should be immobilized with a splint that stabilizes the joints above and below the injury in neutral alignment.
Open fractures require IV antibiotics, copious irrigation, sterile dressing, and urgent orthopedic consultation. Consultation is also indicated for displaced Salter–Harris type II injuries and all type III or higher injuries.
Medication
First line (analgesia)
- Fentanyl 2–3 μg/kg IV or transmucosal formulation 5–15 μg/kg (maximum 400 μg; avoid if <10 kg)< />pan>
- Morphine 0.1 mg/kg IV or IM
If open fracture
- Cefazolin 25–50 mg/kg/day IV or IM divided every 6–8 hours
- Penicillin G 100,000–300,000 U/kg/day IV or IM divided every 4–6 hours for farm-related injuries
- Gentamicin 5–7.5 mg/kg/day for heavily contaminated wounds
Follow-up and disposition
Admission criteria
Open fractures, fractures requiring operative reduction, and consideration for higher-grade (type III–V) injuries.
Discharge criteria
Low-grade fractures, or higher-grade fractures with reliable follow-up, may be discharged with splinting, analgesia, ice, elevation, and orthopedic follow-up within one week.
Issues for referral
All physeal injuries require follow-up with a musculoskeletal specialist.
Follow-up recommendations
Ongoing monitoring is often necessary, particularly for higher-grade injuries, to assess for limb-length discrepancy or angular deformity through periodic examination and imaging.
Clinical pearls and common missteps
Growth plate injuries can result in limb-length discrepancy if the entire physis is affected, or angular deformity if only part is involved. When a Salter–Harris injury is suspected clinically but radiographs are normal, immobilization with short-interval follow-up is appropriate.
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