Growth Plate Injuries , CHILDREN FRACTURES- Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes the different growth plate injuries.
The physis is the growth plate located between the metaphysis and the epiphysis. Metaphysis is the bone on the opposite side of the physis away from the joint. Epiphysis is the secondary ossification center located between the growth plate and the articular cartilage.
Growth plates layers and anatomy
•Reserve zone•Proliferating zone•Hypertrophic zone
Several classification systems of growth plate fractures have been developed and the most widely used is Salter-Harris classification.
•Type I: fracture through the growth plate. There may not be obvious displacement. •Type II: fracture through the growth plat and the metaphysis, sparing the epiphysis.
Salter-Harris type I & type II in general usually have a good result.
•Type III: fracture through growth plate and epiphysis, sparing the metaphysis. •Type IV: fractures through all three elements of the bone, the growth plate, metaphysis and epiphysis.
Salter-Harris type III & type IV usually involves the joint. Usually type III & type IV requires surgery and the outcome is worse than with type I & type II. •Type V: compression fracture of the growth plate. Type V has the worst prognosis and is very difficult to diagnose. Minimal apparent injury to the growth plate (diagnosis is usually late).
Growth plate fractures have different characteristics according to the site of injury.
Proximal clavicle physeal fracture: The secondary center at the proximal end of the clavicle appears at about 17-18 years of age and fuses with the shaft at 22-25 years of age. Fracture of the medial clavicle occurs in children with an open physeal growth plate. Suspect injury to the medial physeal growth plate in patients with a medial clavicle injury who are less than 25 years of age. It is a growth plate injury and not a sternoclavicular injury.
Distal clavicle physeal fracture: It is a rare injury that is equivalent to separation of the AC joint. When the fracture occurs in the distal third, the distal clavicle is usually stripped away from the physis and the periosteal sleeve. The injury is usually treated with sling.
Proximal humerus: 80% of the longitudinal growth of the humerus occurs in the proximal physis. Injuries are usually Salter-Harris type I or type II. Proximal humerus fractures allow for significant remodeling following injury of the proximal physis, even if the fracture is displaced in a young child. In young children, fractures are treated conservatively with a sling. The “little leaguer’s shoulder” is a widened growth plate of the proximal humerus and it is considered to be a stress fracture due to overuse. Treatment: cessation of throwing and period of rest.
Distal humerus: Two types of transepiphyseal fractures of the distal humerus:
1-Transepiphyseal separation in newborns
2-Transepiphyseal separation in an old child. Consider child abuse in these injuries.
Treatment: if displaced, treat the fracture by closed reduction and pinning.
Also child abuse should be considered if the patient has multiple fractures at different stages of healing, corner fractures, posterior rib fractures or fracture of the femur before they are of walking age.
Lateral condylar fracture: Most commonly Salter-Harris type IV fractures. Internal rotation oblique views show the fracture displacement. Fractures could be missed or unappreciated.
MILCH classification
•Type I: fracture line is lateral to the trochlear groove.
•Type II: fracture line into trochlear groove
JAKOB classification
•Type A: articular surface is intact.
•Type B: fracture into joint but no fracture fragment rotation
•Type C: fracture fragment is rotated & displaced.
Treatment
•Nondisplaced: long-term case 4-6 weeks. Close follow up in first two weeks.
•Displaced: ORIF if displaced. Rarely do arthrogram and closed reduction percutaneous pinning.
Complications
•Nonunion: cubitus valgus, tardy ulnar nerve palsy.
•Physeal growth arrest
•Interruption of the posterior blood supply could cause AVN.
Proximal ulna olecranon: Fracture of the olecranon growth plate can be confused with normal development of the growth plate and vice versa. The olecranon ossification center appears at 9 years of age and fuses at 16 years of age. Patient with fracture of the olecranon growth plate cannot extend the arm. There may be association with osteogenesis imperfecta.

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