Advertisement

Current Reviews in Musculoskeletal Medicine

, Volume 9, Issue 4, pp 478–486 | Cite as

Physeal fractures about the knee

  • Rhianna M. Little
  • Matthew D. MilewskiEmail author
Pediatric Orthopedics (B Heyworth, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Pediatric Orthopedics

Abstract

While some fractures may be managed similarly in adults and children, physeal fractures are uniquely limited to the pediatric population and require special consideration. Although physeal fractures about the knee are relatively rare, they are occurring more frequently due to increasing youth participation in sports and high-energy recreational activities. The evaluation and management of distal femoral and proximal tibial physeal fractures are similar to one another, but fractures of the tibial spine and tibial tubercle are approached somewhat differently. A thorough understanding of the pertinent developmental anatomy is critical for correlating the clinical findings with the imaging work-up, and for anticipating the most common and the most serious complications of each fracture. Diagnosis is usually made with appropriate plain radiographs with advanced imaging often used for preoperative planning. In general, fracture pattern and degree of displacement determine the need for surgical intervention and the overall outcome. While a variety of fixation techniques or constructs may be used, because of the importance of restoring physeal and articular anatomy for avoidance of growth disturbance and degenerative joint disease, respectively, achieving anatomic, rigid fixation is of greater importance than with many other fracture locations in the growing skeleton.

Keywords

Distal femoral epiphysis Pediatric fracture Pediatric trauma Physeal fracture Proximal tibial epiphysis Tibial tubercle avulsion 

Notes

Compliance with ethical standards

Conflict of interest

Rhianna M. Little declares that she has no conflict of interest.

Matthew D. Milewski reports personal fees from Elsevier, Inc, and grants from Pediatric Orthopaedic Society of North America outside the submitted work.

Human and animal rights and informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Arkader A, Warner Jr WC, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007;27:703–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Basener CJ, Mehlman CT, DiPasquale TG. Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis. J Orthop Trauma. 2009;23:663–7.CrossRefPubMedGoogle Scholar
  3. 3.
    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;93:689–94.CrossRefGoogle Scholar
  4. 4.
    Beaty JH, Kumar A. Fractures about the knee in children. J Bone Joint Surg Am. 1994;76:1870–80.CrossRefPubMedGoogle Scholar
  5. 5.
    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.CrossRefPubMedGoogle Scholar
  6. 6.
    Riccio AI, Wilson PL, Wimberly RL. Lower extremity injuries. In: Herring JA, editor. Tachdijan’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed: Elsevier Health Sciences; 2013:1353–516.Google Scholar
  7. 7.•
    Chen J, Abel MF, Fox MG. Imaging appearance of entrapped periosteum within a distal femoral Salter-Harris II fracture. Skelet Radiol. 2015;44:1547–51. Case report written to raise awareness of the importance of having a high index of suspicion of periosteal entrapment in the setting of Salter-Harris II fractures if physeal widening >3 mm persists following reduction. They recommend the use of urgent MRI in these cases to identify periosteal entrapment, and suggest surgical removal to minimize the risk of premature physeal closure.CrossRefGoogle Scholar
  8. 8.
    Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg Am. 1963;45:587–622.CrossRefGoogle Scholar
  9. 9.
    Thomson JD, Stricker SJ, Williams MM. Fractures of the distal femoral epiphyseal plate. J Pediatr Orthop. 1995;15:474–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Leary JT, Handling M, Talerico M, Yong L, Bowe JA. Physeal fractures of the distal tibia: predictive factors of premature physeal closure and growth arrest. J Pediatr Orthop. 2009;29:356–61.CrossRefPubMedGoogle Scholar
  11. 11.
    Lee BS, Esterhai JL, Jr., Das M. Fracture of the distal radial epiphysis. Characteristics and surgical treatment of premature, post-traumatic epiphyseal closure. Clin Orthop Relat Res. 1984:90–6.Google Scholar
  12. 12.•
    Dahl WJ, Silva S, Vanderhave KL. Distal femoral physeal fixation: are smooth pins really safe? J Pediatr Orthop. 2014;34:134–8. This animal study demonstrated that physeal bar formation occurs with smaller cross-sectional damage to the distal femoral physis than previously reported; essentially, there is no safe zone as crossing the physis with any size pin and in any location has the potential to induce physeal trauma.CrossRefPubMedGoogle Scholar
  13. 13.
    Skaggs DL. Extra-articular injuries of the knee. Rockwood and Wilkins Fractures in Children. 6tth ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 937–84.Google Scholar
  14. 14.
    Edmunds I, Nade S. Injuries of the distal femoral growth plate and epiphysis: should open reduction be performed? Aust N Z J Surg. 1993;63:195–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Eid AM, Hafez MA. Traumatic injuries of the distal femoral physis. Retrospective study on 151 cases. Injury. 2002;33:251–5.CrossRefPubMedGoogle Scholar
  16. 16.
    Gruber HE, Phieffer LS, Wattenbarger JM. Physeal fractures, part II: fate of interposed periosteum in a physeal fracture. J Pediatr Orthop. 2002;22:710–6.PubMedGoogle Scholar
  17. 17.
    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
  18. 18.
    Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13:47–58.CrossRefPubMedGoogle Scholar
  19. 19.
    Burkhart SS, Peterson HA. Fractures of the proximal tibial epiphysis. J Bone Joint Surg Am. 1979;61:996–1002.CrossRefPubMedGoogle Scholar
  20. 20.•
    Harb Z, Malhi A. Bilateral simultaneous avulsion fractures of the proximal Tibia in a 14-year-old athlete with vitamin-D deficiency. Case Rep Orthop. 2015;2015:783046. Unique case report describing a vitamin-D deficient athlete with simultaneous bilateral proximal tibial physeal fractures. Highlights the importance of ruling out an underlying bone metabolic disorder in seemingly healthy young patients with fractures.Google Scholar
  21. 21.
    Walker RN, Green NE, Spindler KP. Stress fractures in skeletally immature patients. J Pediatr Orthop. 1996;16:578–84.CrossRefPubMedGoogle Scholar
  22. 22.•
    Tony G, Charran A, Tins B, et al. Intra-epiphyseal stress injury of the proximal tibial epiphysis: preliminary experience of magnetic resonance imaging findings. Eur J Radiol. 2014;83:2051–7. Case series with first ever description of purely intra-epiphyseal stress injuries of the proximal tibial epiphysis.CrossRefPubMedGoogle Scholar
  23. 23.
    Hasler CC, Foster BK. Secondary tethers after physeal bar resection: a common source of failure? Clin Orthop Relat Res. 2002:242–9.Google Scholar
  24. 24.•
    Clark A, Hilt JZ, Milbrandt TA, Puleo DA. Treating proximal tibial growth plate injuries using poly(lactic-co-glycolic acid) scaffolds. Biores Open Access. 2015;4:65–74. This pilot animal study shows that growth factor-loaded PLGA scaffolds are not only equally effective as traditional fat graft treatment for growth plate regeneration, but actually decrease the bony bar reformation.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Lafrance RM, Giordano B, Goldblatt J, Voloshin I, Maloney M. Pediatric tibial eminence fractures: evaluation and management. J Am Acad Orthop Surg. 2010;18:395–405.CrossRefPubMedGoogle Scholar
  26. 26.
    Noyes FR, DeLucas JL, Torvik PJ. Biomechanics of anterior cruciate ligament failure: an analysis of strain-rate sensitivity and mechanisms of failure in primates. J Bone Joint Surg Am. 1974;56:236–53.CrossRefPubMedGoogle Scholar
  27. 27.
    Meyers MH, Mc KF. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am. 1959;41-A:209–20. discussion 20–2.CrossRefPubMedGoogle Scholar
  28. 28.
    Zaricznyj B. Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. J Bone Joint Surg Am. 1977;59:1111–4.CrossRefPubMedGoogle Scholar
  29. 29.
    Perugia D, Basiglini L, Vadala A, Ferretti A. Clinical and radiological results of arthroscopically treated tibial spine fractures in childhood. Int Orthop. 2009;33:243–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Anderson CN, Anderson AF. Tibial eminence fractures. Clin Sports Med. 2011;30:727–42.CrossRefPubMedGoogle Scholar
  31. 31.•
    Leeberg V, Sonne-Holm S, Krogh Christoffersen J, Wong C. Fractures of the knee in children-what can go wrong? A case file study of closed claims in The Patient Compensation Association covering 16 years. J Child Orthop. 2015;9:391–6. Utilizing a database within the Danish health care system, this study identified that when evaluating a child’s knee injury, an X-ray examination is the key to preventing missed diagnoses, delayed surgeries, and negative long-term sequelae.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Griffith JF, Antonio GE, Tong CW, Ming CK. Cruciate ligament avulsion fractures. Arthroscopy. 2004;20:803–12.CrossRefPubMedGoogle Scholar
  33. 33.
    Wilfinger C, Castellani C, Raith J, Pilhatsch A, Hollwarth ME, Weinberg AM. Nonoperative treatment of tibial spine fractures in children-38 patients with a minimum follow-up of 1 year. J Orthop Trauma. 2009;23:519–24.CrossRefPubMedGoogle Scholar
  34. 34.
    Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am. 1970;52:1677–84.CrossRefPubMedGoogle Scholar
  35. 35.
    Wiley JJ, Baxter MP. Tibial spine fractures in children. Clin Orthop Relat Res. 1990:54–60.Google Scholar
  36. 36.
    Ahmad CS, Stein BE, Jeshuran W, Nercessian OA, Henry JH. Anterior cruciate ligament function after tibial eminence fracture in skeletally mature patients. Am J Sports Med. 2001;29:339–45.PubMedGoogle Scholar
  37. 37.
    Molander ML, Wallin G, Wikstad I. Fracture of the intercondylar eminence of the tibia: a review of 35 patients. J Bone Joint Surg (Br). 1981;63-B:89–91.Google Scholar
  38. 38.
    Lubowitz JH, Elson WS, Guttmann D. Part II: arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fractures. Arthroscopy. 2005;21:86–92.CrossRefPubMedGoogle Scholar
  39. 39.
    Kocher MS, Micheli LJ, Gerbino P, Hresko MT. Tibial eminence fractures in children: prevalence of meniscal entrapment. Am J Sports Med. 2003;31:404–7.PubMedGoogle Scholar
  40. 40.
    Chandler JT, Miller TK. Tibial eminence fracture with meniscal entrapment. Arthroscopy. 1995;11:499–502.CrossRefPubMedGoogle Scholar
  41. 41.
    Senekovic V, Veselko M. Anterograde arthroscopic fixation of avulsion fractures of the tibial eminence with a cannulated screw: five-year results. Arthroscopy. 2003;19:54–61.CrossRefPubMedGoogle Scholar
  42. 42.
    Kluemper CT, Snyder GM, Coats AC, Johnson DL, Mair SD. Arthroscopic suture fixation of tibial eminence fractures. Orthopedics. 2013;36:e1401–6.CrossRefPubMedGoogle Scholar
  43. 43.
    Bong MR, Romero A, Kubiak E, et al. Suture versus screw fixation of displaced tibial eminence fractures: a biomechanical comparison. Arthroscopy. 2005;21:1172–6.CrossRefPubMedGoogle Scholar
  44. 44.
    Anderson CN, Nyman JS, McCullough KA, et al. Biomechanical evaluation of physeal-sparing fixation methods in tibial eminence fractures. Am J Sports Med. 2013;41:1586–94.CrossRefPubMedGoogle Scholar
  45. 45.
    Su WR, Wang PH, Wang HN, Lin CJ. A simple, modified arthroscopic suture fixation of avulsion fracture of the tibial intercondylar eminence in children. J Pediatr Orthop B. 2011;20:17–21.CrossRefPubMedGoogle Scholar
  46. 46.
    Vander Have KL, Ganley TJ, Kocher MS, Price CT, Herrera-Soto JA. Arthrofibrosis after surgical fixation of tibial eminence fractures in children and adolescents. Am J Sports Med. 2010;38:298–301.CrossRefPubMedGoogle Scholar
  47. 47.
    Kocher MS, Foreman ES, Micheli LJ. Laxity and functional outcome after arthroscopic reduction and internal fixation of displaced tibial spine fractures in children. Arthroscopy. 2003;19:1085–90.CrossRefPubMedGoogle Scholar
  48. 48.
    Mylle J, Reynders P, Broos P. Transepiphysial fixation of anterior cruciate avulsion in a child. Report of a complication and review of the literature. Arch Orthop Trauma Surg. 1993;112:101–3.CrossRefPubMedGoogle Scholar
  49. 49.
    Ahn JH, Yoo JC. Clinical outcome of arthroscopic reduction and suture for displaced acute and chronic tibial spine fractures. Knee Surg Sports Traumatol Arthrosc. 2005;13:116–21.CrossRefPubMedGoogle Scholar
  50. 50.
    Pape JM, Goulet JA, Hensinger RN. Compartment syndrome complicating tibial tubercle avulsion. Clin Orthop Relat Res. 1993:201–4.Google Scholar
  51. 51.
    Christie MJ, Dvonch VM. Tibial tuberosity avulsion fracture in adolescents. J Pediatr Orthop. 1981;1:391–4.CrossRefPubMedGoogle Scholar
  52. 52.
    Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg Am. 1980;62:205–15.CrossRefPubMedGoogle Scholar
  53. 53.
    McKoy BE, Stanitski CL. Acute tibial tubercle avulsion fractures. Orthop Clin N Am. 2003;34:397–403.CrossRefGoogle Scholar
  54. 54.
    Frankl U, Wasilewski SA, Healy WL. Avulsion fracture of the tibial tubercle with avulsion of the patellar ligament. Report of two cases. J Bone Joint Surg Am. 1990;72:1411–3.CrossRefPubMedGoogle Scholar
  55. 55.
    Mosier SM, Stanitski CL. Acute tibial tubercle avulsion fractures. J Pediatr Orthop. 2004;24:181–4.CrossRefPubMedGoogle Scholar
  56. 56.
    Pyle SI, Hoerr NL. A radiographic standard of reference for the growing knee: CC Thomas. 1955.Google Scholar
  57. 57.
    Brey JM, Conoley J, Canale ST, et al. Tibial tuberosity fractures in adolescents: is a posterior metaphyseal fracture component a predictor of complications? J Pediatr Orthop. 2012;32:561–6.CrossRefPubMedGoogle Scholar
  58. 58.
    Watson-Jones R, Wilson J. Fractures and joint injuries. 1976.Google Scholar
  59. 59.
    Ryu RK, Debenham JO. An unusual avulsion fracture of the proximal tibial epiphysis. Case report and proposed addition to the Watson-Jones classification. Clin Orthop Relat Res. 1985:181–4.Google Scholar
  60. 60.•
    Stepanovich MT, Slakey JB. Combined tibial tubercle avulsion fracture and patellar avulsion fracture: an unusual variant in an adolescent patient. Am J Orthop (Belle Mead NJ). 2016;45:E31–4. First pediatric case report of an unusual variant of a tibial tubercle fracture (combined ipsilateral inferior lateral patellar avulsion fracture and an intra-articular tibial tubercle avulsion fracture with intervening longitudinal patellar tendon split).Google Scholar
  61. 61.•
    Williams D, Kahane S, Chou D, Vemulapalli K. Bilateral proximal tibial sleeve fractures in a child: a case report. Arch Trauma Res. 2015;4:e27898. Case report describing a rare, unclassified variant of a tibial tubercle avulsion fracture (bilateral proximal tibial sleeve fractures, each associated with rupture of the medial patellofemoral ligament and tear of the medial retinaculum).CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Desai RR, Parikh SN. Bilateral tibial tubercle sleeve fractures in a skeletally immature patient. Case Rep Orthop. 2013;2013:969405.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Pandya NK, Edmonds EW, Roocroft JH, Mubarak SJ. Tibial tubercle fractures: complications, classification, and the need for intra-articular assessment. J Pediatr Orthop. 2012;32:749–59.CrossRefPubMedGoogle Scholar
  64. 64.
    Abalo A, Akakpo-numado KG, Dossim A, Walla A, Gnassingbe K, Tekou AH. Avulsion fractures of the tibial tubercle. J Orthop Surg (Hong Kong). 2008;16:308–11.CrossRefGoogle Scholar
  65. 65.•
    Pretell-Mazzini J, Kelly DM, Sawyer JR, et al. Outcomes and complications of tibial tubercle fractures in pediatric patients: a systematic review of the literature. J Pediatr Orthop. 2016;36:440–6. Systematic review of 43 years of literature confirms: surgical treatment of most adolescent tibial tubercle fractures produces good clinical and radiologic results, fracture type correlates with potential complications, and intra-articular fractures tend to present with more associated injuries and have worse functional outcomes.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.Connecticut Children’s Medical CenterHartfordUSA
  2. 2.Elite Sports MedicineConnecticut Children’s Medical CenterFarmingtonUSA

Personalised recommendations