Epiphyseal Injuries

Epiphyseal Injuries is a topic covered in the 5-Minute Emergency Consult.

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  • Fractures through the physis accounts for 21–30% of pediatric long bone fractures with 30% of these leading to a growth disturbance:
    • Most frequently seen in the distal radius and ulna, distal tibia and fibula, and the phalanges
    • More common than ligamentous injury in children:
    • Tensile strength of pediatric bone is less than adjacent ligaments.
    • Physis is the weakest part of pediatric bone.
    • Similar injury in an adult usually causes a sprain.
  • Most common during peak growth:
    • Females: Age 9–12
    • Males: Age 12–15
    • Much less common in infancy and early childhood because epiphysis is not ossified and acts as a shock absorber
  • Twice as common in males because female bones mature earlier
  • Salter–Harris (SH) classification (introduced in 1963, simplest and most commonly used classification system):
    • Type I:
      • Fracture line confined to physis
      • Complete epiphyseal separation from metaphysis through the physis
      • If periosteum remains intact, epiphysis will not displace.
      • Clinical diagnosis made with focal tenderness over the physis
      • Most common example is SCFE.
      • Growth disturbance is rare.
    • Type II:
      • Accounts for ∼80% of physeal fracture patterns
      • Fracture propagates along physis, and fragment from metaphysis accompanies the displaced epiphysis (Thurston–Holland sign)
      • Periosteum torn opposite metaphyseal fragment
      • Growth is rarely disturbed.
    • Type III:
      • Rare
      • Fracture through a portion of physis extending through the epiphysis
      • Distal tibia most commonly affected
      • If displaced, requires reduction to maintain anatomic alignment
      • Growth disturbance may occur despite anatomic reduction because blood supply can be affected.
    • Type IV:
      • Fracture originates at articular surface.
      • Extends through physis and into metaphysis
      • Distal humerus most commonly affected
      • Also has Thurston–Holland fragment
      • Anatomic reduction essential and displaced fractures require ORIF
      • Growth arrest is common even with optimal treatment.
    • Type V:
      • Results from severe crush injury to physis
      • No immediately visible radiographic alteration so almost impossible to diagnose initially
      • Compression forces lead to physeal injuries and inevitable growth disturbances.
      • Often found in retrospect
  • Ogden modified the SH system to include injuries to the surrounding anatomy—periosteum, perichondrium, and zone of Ranvier:
    • Ogden Type VI: Involves the peripheral perichondrium including the zone of Ranvier
    • Ogden Type VII: Involves epiphysis only
  • Peterson classification system, 1994:
    • Result of a 10 yr retrospective study
    • Showed that 16% of physeal injuries could not be classified by the SH system
    • Includes 2 different fracture patterns:
      • Peterson Type I—transverse fracture through the metaphysis with 1 or more longitudinal extensions into the physis (this is similar to SH II except most of the energy is transmitted through the metaphysis, leading to a fracture, and not the physis; there is very little growth plate disturbance, this was actually the most common fracture pattern found)
      • Peterson Type VI—a part of the epiphysis, physis, and metaphysis are missing due to an open injury, classically by a lawnmower. Severe growth disturbance.
      • Peterson Types II–V are similar to the SH II–V.


  • Competitive and recreational injuries
  • Traumatic injuries
  • Child abuse
  • Extreme cold
  • Radiation injury
  • Genetic, neurologic, and metabolic disease

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