Growth Plate Injuries in Kids Who Play Sports

Dr. Ebraheim’s educational animated video describes growth plate injuries..
The growth plates produce longitudinal growth of the bone. Growth plates are divided into layers or zones..
•Reserve zone: the reserve zone is inactive and allows for matrix production, is used for storage and have low oxygen tension. It has the highest type II collagen content..
•Proliferating zone: cellular proliferation and longitudinal growth. Has a high metabolic rate. Has the highest rate of extracellular matrix production. Has the highest oxygen tension..
•Hypertrophic zone: maturation, degeneration and provisional calcification. The cartilage cells increase 5-10 times in size. There is degeneration of the cells and the matrix is prepared for calcification. Low oxygen tension, low vascularity, chondrocytes die and calcium is released for matrix calcification. It facilitates calcium deposition. The majority of growth plates injuries occur in the hypertrophic zone. This zone is weak and weaker than the ligaments and provides a cleavage pathway for the fracture..
Several classification systems of growth plate fractures have been developed and most widely used is the Salter-Harris classification..
•Type I: fracture through the growth plate. There may be no obvious displacement..
•Type II: fracture through the growth plate and the metaphysis, sparing the epiphysis..
•Type III: fracture through growth plate and epiphysis sparing the metaphysis..
•Type IV: fracture through all three elements, the growth plate, the metaphysis and the epiphysis..
•Type V: compression fracture of the growth plate..
Salter-Harris type I & type II have a better prognosis than types III & IV. Salter-Harris type I & II in general may not require surgery.Salter-Harris type III & IV is an intra-articular joint fracture that usually requires surgery. The reduction has to be anatomic and the prognosis is fair.type V is rare with a poor prognosis..
Physeal arrest.
1-Total growth plate arrest: the limb length decreases substantially..
2-Central: partial cessation of longitudinal growth. Progressive shortening..
3-Peripheral: leads to angular deformity and decreased length: corrective osteotomy..
Child abuse and growth plate injuries: usually you will find multiple fractures in different stages of healing. You will find physeal fracture or separation such as in the distal humerus, trans epiphyseal distal humeral fracture. A corner fracture is a traction/rotation injury pathognomonic of child abuse. 15% of all fractures in children involve the growth plate. These growth plate injuries occur more distal than proximal. Any fracture that involves the growth plate may create deformity and limb inequality..
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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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One of the biggest challenges with ACL injuries in young athletes is the fact that kids are still growing and developing. This means that their growth plates, the parts of their bones that help them grow taller, are still open. This video features Scott Van Valin, MD, a pediatric orthopedic surgeon at Children’s Hospital of Wisconsin. Learn more: http://www.chw.org/display/PPF/DocID/48506/router.asp

Dr. David L. Marshall, Medical Director, Sports Medicine Program at Children’s Healthcare of Atlanta discusses grow plate injuries and prevention.

Dr. Joy Maxey talks about growth plate injuries in youth sports.

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Dr Marshall and host Casey discuss the warning signs, prevention, and treatment of growth plate injuries (Osgood Schlatter Disease).