Skeletal Radiology

, Volume 44, Issue 10, pp 1547–1551 | Cite as

Imaging appearance of entrapped periosteum within a distal femoral Salter-Harris II fracture

  • Johnathan Chen
  • Mark F. Abel
  • Michael G. FoxEmail author
Case Report


Salter Harris II fractures of the distal femur are associated with a high incidence of complications, especially premature physeal closure. Many risk factors for this high rate of premature physeal closure have been proposed. More recently, entrapment of periosteum within the physis has been suggested as an additional predisposing factor for premature physeal closure. The radiographic diagnosis of entrapped soft tissues, including periosteum, can be suggested in the setting of a Salter-Harris II fracture when the fracture does not reduce and physeal widening >3 mm remains. We report a patient who sustained a distal femoral Salter-Harris II fracture following a valgus injury. The patient had persistent distal medial physeal widening >5 mm following attempted reduction. A subsequent MRI revealed a torn periosteum entrapped within the distal femoral physis. Following removal of the periosteum, the patient developed a leg length discrepancy which required physiodesis of the contralateral distal femur. We present this case to raise awareness of the importance of having a high index of suspicion of periosteal entrapment in the setting of Salter-Harris II fractures since most consider entrapped periosteum an indication for surgery.


Femoral fractures Periosteum Growth plate MRI Leg length inequality 


Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Ecklund K, Jaramillo D. Imaging of growth disturbance in children. Radiol Clin N Am. 2001;39:823–41.CrossRefPubMedGoogle Scholar
  2. 2.
    Ilharreborde B, Raquillet C, Morel E, et al. Long-term prognosis of Salter-Harris type 2 injuries of the distal femoral physis. J Pediatr Orthop B. 2006;15(6):433–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Segal LS, Shrader MW. Periosteal entrapment in distal femoral physeal fractures: harbinger for premature physeal arrest? Acta Orthop Belg. 2011;77:684–90.PubMedGoogle Scholar
  4. 4.
    Lombardo SJ, Harvey Jr JP. Fractures of the distal femoral epiphyses: factors influencing prognosis—a review of thirty-four cases. J Bone Joint Surg Am. 1977;59:742–51.PubMedGoogle Scholar
  5. 5.
    Basener CJ, Mehlman CT, DiPasquale TG. Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis. J Orthop Trauma. 2009;23(9):663–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Dahl WJ, Silva S, Vanderhave KL. Distal femoral physeal fixation: are smooth pins really safe? J Pediatr Orthop. 2014;34(2):134–8.CrossRefPubMedGoogle Scholar
  7. 7.
    McAnally JL, Eberhardt SC, Mlady GW, et al. Medial collateral ligament tear entrapped within a proximal tibial physeal separation: imaging findings and operative reduction. Skeletal Radiol. 2008;37:943–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Eid AM, Hafez MA. Traumatic injuries of the distal femoral physis: retrospective study on 151 cases. Injury. 2002;33:251–5.CrossRefPubMedGoogle Scholar
  9. 9.
    Arkader A, Warner WC, Horn D, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007;27(6):703–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Garrett BR, Hoffman EB, Carrara H. The effect of percutaneous pin fixation in the treatment of distal femoral physeal fractures. J Bone Joint Surg Br. 2011;93(5):689–94.CrossRefPubMedGoogle Scholar
  11. 11.
    Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Ortop. 2003;23(6):733–9.CrossRefGoogle Scholar
  12. 12.
    Harryman 2nd DT, Jordan 3rd TF. Physeal phalangeal fracture with flexor tendon entrapment: a case report and review of the literature. Clin Orthop Relat Res. 1990;250:194–6.PubMedGoogle Scholar
  13. 13.
    Soulier R, Fallat L. Irreducible Salter Harris type II distal tibial physeal fracture secondary to interposition of the posterior tibial tendon: a case report. J Foot Ankle Surg. 2010;49(4):399.e5–9.CrossRefGoogle Scholar
  14. 14.
    Raman S, Wallace EC. MRI diagnosis of trapped periosteum following incomplete closed reduction of distal tibial Salter-Harris II fracture. Pediatr Radiol. 2011;41(12):1591–4.CrossRefPubMedGoogle Scholar
  15. 15.
    Whan A, Breidahl W, Janes G. MRI of trapped periosteum in a proximal tibial physeal injury of a pediatric patient. Am J Roentgenol. 2003;181(5):1397–9.CrossRefGoogle Scholar
  16. 16.
    Lesko PD, Georgis T, Slabaugh P. Irreducible Salter-Harris type I1 fracture of the distal radial epiphysis. J Pediatr Orthop. 1987;7:719–21.CrossRefPubMedGoogle Scholar
  17. 17.
    Wirth T, Byers S, Byard RW, Hopwood JJ, Foster BK. The implantation of cartilaginous and periosteal tissue into growth plate defects. Int Orthop. 1994;18:220–8.PubMedGoogle Scholar
  18. 18.
    Phieffer LS, Meyer RA, Gruber HE, Easley M, Wattenbarger JM. Effect of interposed periosteum in an animal physeal fracture model. Clin Orthop Relat Res. 2000;376:15–25.CrossRefPubMedGoogle Scholar

Copyright information

© ISS 2015

Authors and Affiliations

  • Johnathan Chen
    • 1
    • 3
  • Mark F. Abel
    • 2
  • Michael G. Fox
    • 1
    Email author
  1. 1.Department of Radiology and Medical ImagingUniversity of VirginiaCharlottesvilleUSA
  2. 2.Department of OrthopedicsUniversity of VirginiaCharlottesvilleUSA
  3. 3.Department of RadiologyChildren’s Hospital of Los AngelesLos AngelesUSA

Personalised recommendations