6.3 distal femoral physeal fractures

Distal femoral physealfractures

Prof. Dr. Thomas WirthDepartment of Orthopaedics

Olgahospital

Contents• frequency, mechanism of injury, fracture

pattern

• diagnostics

• treatment options

• complications

• management of complications

distal femoral physeal fractures

• account for 6 – 9% of physeal injuries• ~ 1% of children‘s fractures

• Causes– sports injuries ~49%– hit by a car ~25%– falls ~12%– car accident ~ 5%– other ~ 9%

Mechanism of injuryThe Growth plate generally is less resistant to bendingstresses in an immature skeleton. Ligamentous injuriesare less frequent than physeal fractures in children.

Varus or valgusdistraction forces

Hyperextensionforces

Compression forces


Fracturepattern,

classification

Salter III

Salter V(physealcompression)

Salter I

Salter IV

Salter II



classification according to direction of displacement

Displacement according to effective stresses:

anterior: anterolateral: anteromedial: poste-rior:

very rare

higher risk of associated vascular injury

• clinical signs:– inability to bear weight, axial deformity,

swelling, pain– skin damage, open fractures

• imaging:– conventional radiography– oblique radiographs in unclear cases– MRI-scans (Salter I and III)

• search for accompanying injuries

distal femoral physeal fracturesdiagnostics

• ligamentous damage– ACL– collateral ligaments– often diagnosed only after fracture healing

• vascular injury– popliteal artery

• nerve injury– peroneal nerve


associated injuries

treatment principles• risks:

– serious damage to the physis: 18 – 51% angular deformity; 36 – 68% shortening

– Loss of correction after reduction in 43 – 70% without internal fixation

– others (vascular or neural injury, compartment syndrome)

• treatment:– above knee plaster only for undisplaced and stable

fractures– closed or open reduction and internal fixation for any

displaced or unstable fracture



be aware of insufficient and incomplete closed reduction:

From: Rockwood & Wilkins: Fracturesin children 6th Ed. LWW, Philadelphia

The periosteum disrupts on theside of physeal fracture in Salter-Harris type II – fractures.

During reduction the periosteummay interpose within the fractureand prevent complete and anatomic reduction.

This may also favour loss of position with recurrence of deformity.

treatment principles


If possible, avoid implants which arecrossing the physis

From: Rockwood & Wilkins: Fracturesin children 6th Ed. LWW, Philadelphia

treatment5 year old boywith displacedSalter IVfracture of thedistal femur.

Open reductionand pinning with K-wires performed.Uneventful4 yearfollow-up

1 year

4 years


treatment

12 year old girl, Salter I fracture leftdistal femur (+ shaft fractures rightfemur and right tibia).Anatomic reduction achieved, K-wirestabilisation. Genu valgum, shortening


treatmentSalter II fracture of the distalfemur. Anatomic Reductionand K-wire fixation. In the following years a significant shortening of theleft femur developed, whichrequired leg lengthening.


treatment

Mildly displacedSalter II fractureof the right distal femur. Closed reduction and fixation of the metaphyseal fragment with a compression screw. The leg subsequently went into valgus with some shortening. Additionaltreatment was necessary.


• Physeal injury is very common.

• progressive angulation (and shortening)– 18 – 51 % (Czitrom et al [1981], Robert et al [1988], Thomson et al [1995],

Eid et al [2002])

• progressive leg-length discrepancy– 36 – 68% (Czitrom et al [1981], Robert et al [1988], Thomson et al [1995],

Eid et al [2002])

Physeal fractures aroundthe knee: growth disturbance


The degree of displacement of the fragments does most likelydefine the amount of growth disturbance to be expected.Lombardo et Harvey (1977), Thomson et al (1995)


treatment optionsShortening andgenu valgumafter physeal fracture of thedistal femur.Bone bridge resection and fatinterpositioning(Langenskjöldprocedure) as primary treatment to avoid further deformity.


Treatment

S-H-II distalfemoralphyseal fractureresulted in8 cm of femoral shorte-ning. Leg lengthening by useof unilateral frame andbone grafting for insuffi-cient callus formation,and blade plating gave agood final result.


12 years old boy with adistal femoralphyseal fracturewith subsequentgenu valgum.Treated by bonebridge resectionand temporary epiphyseodesis

Summary

• Physeal fractures of the distal femur are uncommon but severe injuries.

• Closed reduction is rarely the best treatment option.

• Open and anatomical reduction with stable internal fixation is the method of choice.

• High rate of growth disturbances and the need for secondary intervention

6.3 distal femoral physeal fractures

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