Extra-Articular Injuries of the Knee

David L. Skaggs

FRACTURES OF THE DISTAL FEMORAL EPIPHYSIS
Fractures i nvol vi ng the physes about the knee are parti cul arl y prone to compl i cati ons
and associ ated i njuri es and must be approached wi th care (Tabl e 23-1). There i s qui te a
si gni fi cant ri sk of permanent i njury to the physi s, whi ch may l ead to growth di sturbance
and requi res fol l ow-up after fracture heal i ng, and possi bl y future surgi cal treatment. In
addi ti on, associ ated i njuri es to nerves, vascul ar structures, l i gaments, and the
possi bi l i ty of compartment syndrome requi re attenti on to detai l i n the eval uati on and
management of these fractures.

Principles of Management
Mechanism of Injury
Di stal femoral physeal i njuri es account for 6% to 9% of al l physeal i njuri es and far fewer
than 1% of al l fractures i n chi l dren (1,2). In adul ts, l i gaments usual l y fai l before bone
when a bendi ng stress i s appl i ed across the knee j oi nt. A common exampl e of thi s i s
when an athl ete wi th a pl anted foot i s struck by an opponent on the l ateral si de of the
knee, the val gus force may cause a fai l ure of the medi al col l ateral l i gament (Fi g. 23-1).
In a skel etal l y mature i ndi vi dual , the medi al col l ateral l i gament and other soft -ti ssue
structures are l i kel y to fai l as the knee fal l s i nto val gus (Fi g. 23-2A). In an i mmature
skel eton, the physi s wi l l fai l i n tensi on and the knee wi l l fal l i nto val gus though a Sal ter
I or II fracture (Fi g. 23-2B).
Both compressi on and di stracti on forces may occur si mul taneousl y, i n whi ch case a
Sal ter II fracture i s more l i kel y. On the tensi on si de, the carti l agi nous matri x of the
physi s i s more vul nerabl e to di stracti on, whereas on the compressi on si de, the osseous
metaphysi s i s more vul nerabl e to shear fai l ure from compressi on (Fi g. 23-3). A wel l -
descri bed mechani sm of i njury i s forced hyperextensi on of the knee wi th posteri or fai l ure
of the physi s i n tensi on. Pure compressi on i njuri es of the physi s, al so referred to as a
Sal ter V i njury, have been descri bed, though are consi dered to be qui te rare. A case of a
10-year-ol d gi rl wi th a Sal ter V i njury has been reported i n whi ch a pure compressi on
i njury l ed to l ater val gus deformi ty of the knee, wi th tomograms i ndi cati ng a fi ne mesh
of bony beams passi ng through a conti nuous and apparentl y i ntact growth pl ate rather
than one si ngl e bri dge (3).

A seri es of 63 di stal femoral physeal fractures i n chi l dren aged 2 to 11 years were
al most i nvari abl y caused by severe trauma, however those occurri ng i n ol der chi l dren
were usual l y secondary to l ess extensi ve trauma, most often sports i njuri es (4).

One mechani sm of i njury deservi ng of speci al attenti on i s an unrecogni zed physeal i njury
i n associ ati on wi th nonphyseal fractures i n the femur or ti bi a (5,6). For exampl e,
Navascues et al reports on si x chi l dren who sustai ned di stal femoral growth arrest after
ti bi al shaft fractures (7).
Unusual mechani sms or underl yi ng condi ti ons, such as arthrogryposi s,
myel omeni ngocel e, and l i ghteni ng stri ke, may al so cause di stal femoral physeal i njuri es
(8,9,10,11). Rodgers et al noted that physeal i njuri es i n chi l dren wi th myel omeni ngocel e
may heal more sl owl y than metaphyseal fractures and may requi re spl i nti ng or casti ng
for a l onger peri od (10). Cases of epi physeal separati on of the di stal femur have been
reported i n i nfants wi th breech del i very, even i n cases of Caesarean secti on (12).

Signs and Symptoms
Physical Findings

The pati ent usual l y cannot wal k or bear wei ght on the i njured l i mb i mmedi atel y after
sustai ni ng a di spl aced separati on of the di stal femoral epi physi s. Most often these
i njuri es resul t from si gni fi cant force, so mal al i gnment of the l i mb, swel l i ng, and/or
ecchymosi s make the di agnosi s of a fracture l i kel y from observati on al one. Abrasi on or
l acerati on of the overl yi ng soft ti ssues may be a cl ue to the mechani sm of i njury or to an
open fracture. In Sal ter I and II fractures i n whi ch the peri osteum may be i nt act on the
compressi on si de, more swel l i ng may be noted on the opposi te si de whi ch opened i n
tensi on.
Usual l y these chi l dren are i n si gni fi cant pai n, and i f the di agnosi s of a fracture i s
suspected, i t i s probabl y ki nder to perform x-rays before any mani pul ati on. If muscl e
spasm can be rel axed, i nstabi l i ty just above the knee j oi nt may be fel t. Crepi tus
someti mes may be absent i f the peri osteum i s i nterposed between the metaphysi s and
the epi physi s. Abnormal l axi ty i n a pati ent wi th negati ve x-rays may be caused by a
nondi spl aced physeal i njury rather than by a l i gamentous tear. At ti mes there i s a
nondi spl aced separati on i n whi ch the pati ent may be abl e to wal k. It someti mes i s
possi bl e to l ocal i ze tenderness to the l evel of the physi s i n cases of physeal f racture,
whi ch i s at approxi matel y the same l evel as the upper pol e of the patel l a and the
adductor tubercl e, both of whi ch can be used as reference poi nts.
Extravasati on of bl ood i nto the soft ti ssues of the di stal thi gh and popl i teal fossa
produces ecchymosi s that may become apparent wi thi n 72 hours after i njury.
Whenever a di agnosi s of epi physeal separati on i s suspected, careful neurovascul ar
exami nati on of the l ower l eg and foot shoul d be done, i ncl udi ng pul ses, col or,
temperature, and motor and sensory status. The extremi ty may become cyanoti c i f
venous return i s i mpai red. The use of the Doppl er may be hel pful i n eval uati ng
ci rcul ati on di stal to the i njury. Compartmental pressure recordi ngs shoul d be obtai ned i f
there are cl i ni cal fi ndi ngs of compartment syndrome.

Direction of Displacement
Most commonl y, di spl acement of the epi physi s occurs i n the coronal pl ane, produci ng
varus or val gus deformi ty. The protrudi ng end of the metaphysi s may be pal pated
through the di stal porti on of the vastus medi al i s wi t h val gus i njuri es, or through the
vastus l ateral i s wi th varus i njuri es.
Wi th anteri or di spl acement, the patel l a, ri di ng forward on the femoral epi physi s,
becomes extremel y promi nent. There i s a pal pabl e depressi on across the anteri or thi gh
just proxi mal to the patel l a, and ful l ness i n the popl i teal fossa i s produced by posteri or
di spl acement of the di stal end of the metaphysi s. Posteri or protrusi on of the metaphysi s
may put pressure on the popl i teal artery, so that pul sati ons become pal pabl e i n the
subcutaneous regi on of the popl i teal fossa.
Wi th posteri or di spl acement of the di stal femoral epi physi s, the di stal end of the
metaphysi s i s promi nent on the anteri or aspect of the di stal thi gh di rectl y above the
patel l a, and the epi physi s can be fel t as a pal pabl e ful l ness i n the popl i teal fossa.
Whatever the di recti on of di spl acement, the patel l a and femoral condyl es remai n i n l i ne
wi th the proxi mal ti bi a, a poi nt useful i n di fferenti ati ng epi physeal separati on from
di sl ocati on of the knee.
Associated Injuries
Ligamentous Injuries
Symptomati c knee j oi nt i nstabi l i ty may persi st after the epi physeal separati on has
heal ed. Thi s fi ndi ng at fol l ow-up i mpl i es concomi tant i njury to knee l i gaments, often
unappreci ated at the ti me of i ni ti al management of the epi physeal separati on. Berti n an d
Gobl e found that 6 of 16 pati ents seen i n fol l ow-up for di stal femoral physeal fractures
had posi ti ve anteri or drawer and Lachman tests; 1 pati ent had l axi ty to val gus stress
(13). A 2002 revi ew of 151 chi l dren wi th di stal femoral physeal fractures found
symptomati c knee l i gamentous l axi ty i n 12 pati ents (8%) (14). Brone and Wrobl e (15)
reported three pati ents wi th Sal ter-Harri s type III fractures of the femoral condyl e
associ ated wi th anteri or cruci ate l i gament (ACL) tears, and found two more reported i n
the l i terature. Al l were near skel etal maturi ty. They emphasi zed the i mportance of earl y
di agnosi s of associ ated l i gament i njury. If there i s no meni scal i njury, a rehabi l i tati on
program i s i ndi cated i ni ti al l y. If there i s a reparabl e meni scal tear, cruci ate
reconstructi on at the ti me of meni scal repai r after physeal heal i ng may be i ndi cated,
dependi ng on the pati ent' s age and acti vi ty l evel .

Vascular Impairment
Vascul ar i njuri es are uncommon wi th thi s fracture, wi th many seri es not reporti ng any
vascul ar i njuri es (4,14,16,17). Inti mal tear and thrombosi s i n the popl i teal artery may
be caused by trauma from the di stal end of the metaphysi s when the epi physi s i s
di spl aced anteri orl y wi th a hyperextensi on i njury (18).
Arteri al spasm or di rect mechani cal obst ructi on of the artery by the proxi mal fragment
may be associ ated wi th di spl acement i n the sagi ttal pl ane and resol ve wi th fracture
reducti on. If vascul ar i mpi ngement occurs but i s rel i eved by prompt reducti on of the
di spl aced epi physi s, the pati ent shoul d be observed to rul e out an i nti mal tear wi th
thrombosi s. If however, fol l owi ng fracture reducti on and stabi l i zati on, the l eg remai ns
poorl y perfused, arteri ography and vascul ar consul tati on shoul d be consi dered. If there
i s an associ ated fracture of the pel vi s or femoral shaft, arteri ography may be necessary
to l ocal i ze the vascul ar i njury. In the cases of known vascul ar i njury, as may occur i n
open fractures, vascul ar repai r shoul d be carri ed out fol l owi ng fracture stabi l i zati on and
arteri ography may not be i ndi cated. Vascul ar i mpai rment may devel op sl owl y from
i ncreasi ng compartmental pressure. If the pati ent has i nordi nate persi stent pai n, wi th a
cool and pal e foot, a femoral arteri ogram and compartment pressure measurement
shoul d be consi dered, even i f peri pheral pul ses are present.

Whether vascul ar repai r or fracture stabi l i zati on shoul d be carri ed out fi rst i s open to
debate (19,20). The vascul ar repai r i s at ri sk for avul si on duri ng mani pul ati on for
fracture repai r, i f the vascul ar structures are repai red fi rst. However, i f there has been
si gni fi cant i schemi a ti me, temporary re-vascul ari zati on of the artery wi th IV tubi ng
shoul d be consi dered pri or to defi ni ti ve fracture care to mi ni mi ze the overal l i schemi a
ti me (19).

Peroneal Nerve Injury
The peroneal nerve i s the onl y nerve i nj ured wi th any appreci abl e frequency i n thi s type
of fracture. It may be stretched by anteri or or medi al di spl acement of the epi physi s. It
rarel y requi res treatment other than reducti on of the separati on. Resol uti on of pe roneal
neuropraxi a may occur up to 6 months fol l owi ng fracture reducti on (18,21). The
excepti on to thi s i s a transected nerve i n associ ati on wi th an open i njury, whi ch may be
treated wi th repai r or grafti ng. Persi stent neurol ogi c defi ci t after 3 to 6 months warrants
el ectromyographi c exami nati on. If the conducti on ti me i s prol onged and fi bri l l ati on or
denervati on i s present i n di stal muscl es, expl orati on and mi croneural reanastomosi s or
resecti on of any neuroma may be i ndi cated.

Diagnosis and Classification
Separati ons of the di stal femoral epi physi s have been cl assi fi ed accordi ng to the pattern
of fracture, the di recti on of di spl acement, or the mechani sm of i njury (Tabl e 23-2). The
Sal ter-Harri s cl assi fi cati on (Fi g. 23-4) (22) i s useful for descri pti on and treatment
pl anni ng. The di recti on and degree of di spl acement may hel p predi ct the type and
severi ty of compl i cati ons. Mechani sms of i njury, as wel l as the i mpl i cati ons of growth
di sturbance, vary wi th the pati ent' s age.

Classification by Fracture Pattern
The Sal ter-Harri s type I pattern i s a separati on through the di stal femoral physi s,
wi thout fracture through the adj acent epi physi s or metaphysi s (Fi g. 23-5). It occurs i n
newborns wi th bi rth i njury and i n adol escents, often as a nondi spl aced separati on. Ei ther
may go undetected. Someti mes the di agnosi s i s made onl y i n retrospect, when
subperi osteal new bone formati on occurs al ong the adj acent metaphysi s. If di spl acement
i s present, i t i s usual l y i n the sagi ttal pl ane. Growth di sturbance may occur after Sa l ter-
Harri s type I di stal femoral i njuri es, contrary to the usual expectati ons for Sal ter -Harri s
type I fractures i n other l ocati ons.
The Sal ter-Harri s type II pattern, characteri zed by an obl i que extensi on of the fracture
across one corner of the adj acent metaphysi s, i s the most common type of separati on at
the di stal femur and usual l y occurs i n adol escents (Fi g. 23-6). The metaphyseal corner,
whi ch remai ns attached to the epi physi s, i s cal l ed the Thurston-Hol l and fragment. The
physeal separati on occurs on the tensi on si de, i n whi ch the physi s i s fractured.
Di spl acement usual l y i s toward the si de of the metaphyseal fragment. The i nci dence of
premature growth arrest, even wi th sati sfactory reducti on, i s si gni fi cant. If asymmetri c
growth fol l ows a type II separati on, the porti on of the physi s underneath the
metaphyseal fracture usual l y i s spared (Fi g. 23-6). Therefore, i f the metaphyseal
fracture i s medi al , deformi ty i s more l i kel y to be val gus than varus.
A Sal ter-Harri s type III i njury consi sts of a parti al separati on of the physi s, wi th a
verti cal fracture l i ne extendi ng from the physi s down to the arti cul ar surface of the
epi physi s (Fi g. 23-7). The verti cal fracture l i ne i s usual l y i n l i ne wi th the i ntercondyl ar
notch. Sal ter-Harri s type III i njuri es most often are caused by val gus stress i n sports
and usual l y i nvol ve the medi al condyl e. The fracture may be nondi spl aced and detected
onl y wi th a stress x-rays or magneti c resonance i magi ng (MRI) (23).

Sal ter-Harri s type IV i njuri es of the di stal femur are uncommon. A sagi ttal fracture l i ne
extends from the metaphyseal cortex down across the physi s and enters the arti cul ar
surface of the epi physi s. Even sl i ght di spl acement of the fracture fragment may produce
growth di sturbance fol l owi ng formati on of a bony bri dge from the di spl aced epi physi s to
the metaphysi s. Therefore, anatomi c reducti on and i nternal fi xati on are advi sed. Fi gure
23-8 demonstrates that even mi ni mal l y di spl aced fractures shoul d be fol l owed cl osel y for
growth pl ate i njury.

Sal ter-Harri s type V i njuri es (wi thout fracture) are rare. Most commonl y, the di agnosi s i s
made i n retrospect at the ti me of eval uati on for premature growth arrest and l i mb-l ength
di screpancy or angul ar deformi ty (3).
Even l ess common i s an avul si on i njury to the edge of the physi s. A smal l fragment,
i ncl udi ng a porti on of the peri chondri um and underl yi ng bone, may be torn off when the
proxi mal attachment of the col l ateral l i gament i s avul sed. Thi s uncommon i njury may
al so l ead to l ocal i zed premature growth arrest and progressi ve angul ar deformi ty (5).
The bony bri dge usual l y i s smal l , l ocal i zed, and surgi cal l y accessi bl e, and exci si on i s
appropri ate.
A tri pl ane fracture i nfrequentl y occurs i n the di stal femur. Computed tomographi c (CT)
scans wi th three-di mensi onal (3D) model i ng may be hel pful i n i denti fyi ng and anal yzi ng
(24) thi s i njury.

Classification by Displacement
Anteri or di spl acement of the epi physi s resul ts from hyperextensi on of the knee. The
extensi on force on the di stal femur i s transmi tted through the posteri or capsul e of the
knee j oi nt. The mechani sm i s si mi l ar to that of knee di sl ocati ons i n adul ts. There i s an
i ncreased ri sk of neurovascul ar i njury. Posteri or di spl acement of the epi physi s on the
femur i s uncommon. It has been reported i n bi rth i njuri es and i n ol der chi l dren struck on
the front of the fl exed knee. Reducti on i s obtai ned and mai ntai ned by extendi ng the
knee. Medi al /l ateral di spl acement currentl y i s most common, usual l y wi th an associ ated
fracture of the adjacent metaphysi s (Sal ter -Harri s type II).

Classification According to Age
Separati ons of the di stal femoral epi physi s i n i nfants may be associ ated wi th breech
bi rth or chi l d abuse (Fi g. 23-9). Most are Sal ter-Harri s type I i njuri es. Cl i ni cal l y
di fferenti ati ng between an epi physeal separati on and hematogenous osteomyel i ti s may
be di ffi cul t. Ul trasonography or MRI (25) may be used to confi rm fracture.

In most recent revi ews, approxi matel y two thi rds of di stal femoral epi physeal
separati ons occur i n adol escents, often from contact sports (4,26). The most common
patterns are Sal ter-Harri s types I and II. The potenti al for growth di sturbance i s l owest
i n thi s group. Ol der chi l dren and preadol escents usual l y are i njured i n sports whereas
younger chi l dren are often i nvol ved i n hi gh-energy acci dents, such as a fal l or bei ng hi t
by a vehi cl e (4). Associ ated muscul oskel etal and vi sceral i njuri es are common i n the
l atter group.

Imaging
Because the physi s normal l y i s radi ol ucent, i njury i s di agnosed by di spl acement,
wi deni ng, or adjacent bony di srupti on. However, a nondi spl aced Sal ter -Harri s type I or
III fracture wi thout separati on can be easi l y overl ooked (23). Obl i que vi ews of the di stal
femur may reveal an occul t fracture through the epi physi s or metaphysi s (Tabl e 23-3).
It has been suggested i n the previ ous edi ti on of thi s text that stress vi ews shoul d be
consi dered i f mul ti pl e pl ai n fi l ms are negati ve i n a pati ent wi th an effusi on or tenderness
l ocal i zed to the physi s (Fi g. 23-10). Another opti on i s an MRI, whi ch shoul d be
di agnosti c i n uncl ear cases. For many reasons ti mel y MRI scans may have l i mi ted
avai l abi l i ty. Stress x-rays may be fal sel y negati ve i f there i s associ ated muscl e spasm.
(Pl ease see Controversi es secti on of thi s chapter for more di scussi on of stress vi ews.)
Di stal femoral physeal fractures have such a si gni fi cant ri sk of growth di sturbance, and
may i nvol ve the arti cul ar surface of a wei ght -beari ng j oi nt. Thus, one shoul d have a l ow
threshol d i n orderi ng a CT scan to hel p determi ne i f there i s suffi ci ent di spl acement to
warrant surgi cal treatment and best vi sual i ze the fracture pattern.
A verti cal fracture l i ne extendi ng from the arti cul ar surface of the di stal femoral
epi physi s i nto the radi ol ucent physi s i s usual l y di agnosti c of a Sal ter -Harri s type III
fracture. The epi physeal fracture l i ne i s often best seen on an anteroposteri or vi ew
because i t i s ori ented i n the sagi ttal pl ane. The degree of di spl acement i n thi s fracture
pattern may be di ffi cul t to measure on pl ai n fi l ms unl ess the radi ographi c proj ecti on i s
preci sel y i n l i ne wi th the pl ane of fracture. A fracture l i ne extendi ng from the epi physeal
surface across the physi s and up through the metaphysi s i s char acteri sti c of a Sal ter-
Harri s type IV i njury. Even 1 to 2 mm of di spl acement i s si gni fi cant (27).

Anteri or or posteri or di spl acement of the epi physi s i s best appreci ated on the l ateral
proj ecti on. The anteri orl y di spl aced epi physi s i s usual l y ti l ted so that the di stal arti cul ar
surface faces anteri orl y. The posteri orl y di spl aced epi physi s i s rotated so that the di stal
arti cul ar surface faces the popl i teal fossa.
Separati on of the di stal femoral epi physi s i n an i nfant i s di ffi cul t to see on i ni ti al x-rays
unl ess there i s di spl acement because onl y the center of the epi physi s i s ossi fi ed at bi rth.
Thi s ossi cl e shoul d be i n l i ne wi th the axi s of the femoral shaft on both anteroposteri or
and l ateral vi ews. Comparati ve vi ews of the opposi te knee may be hel pful . MRI (25),
ul trasonography, or arthrography of the knee may hel p to i denti fy a separati on of the
rel ati vel y unossi fi ed femoral epi physi s.
When MRI i s used to vi sual i ze the physi s, fat-suppressed 3D spoi l ed gradi ent-recal l ed
echo sequences have reportedl y al l owed best vi sual i zati on (28). In a revi ew of MRI scans
i n 315 chi l dren wi th traumati c knee i njuri es, physeal i njuri es of the di stal femur was
di agnosed i n 7 pati ents and of the proxi mal ti bi al i n 2 pati ents. Pl ai n fi l ms avai l abl e on 8
pati ents showed si gns of fracture i n 7 pati ents, but was onl y cl earl y del i neated i n one
pati ent (29).

Surgical and Applied Anatomy
The epi physi s of the di stal femur i s the fi rst epi physi s to ossi fy. From bi rth to skel etal
maturi ty, the di stal femoral physi s contri butes 70% of the growth of the femur and 37%
of the growth of the l ower extremi ty. The annual rate of growth i s approxi matel y 3/8 i n.
or 9 to 10 mm. The growth rate sl ows at a mean skel etal age of 13 years i n gi rl s and 15
years i n boys (30).

Bony Anatomy
Immedi atel y above the medi al border of the medi al condyl e, the metaphysi s of the di stal
femur wi dens sharpl y to the adductor tubercl e. In contrast, the metaphysi s fl ares
mi ni mal l y on the l ateral si de to produce the l ateral epi condyl e. A l i ne tangenti al to the
di stal surfaces of the two condyl es (the joi nt l i ne) i s approxi matel y hori zontal i n an
upri ght stance. The l ongi tudi nal axi s of the di aphysi s of the femur i ncl i nes medi al l y
downward, wi th an angl e of 9 degrees from verti cal . The mechani cal axi s of the femur i s
formed by a l i ne between the centers of the hi p and knee j oi nts (Fi g. 23-11).
A l arge part of the surface of the di stal femoral epi physi s i s covered by carti l age for
arti cul ati on wi th the proxi mal ti bi a and patel l a. The anteri or or patel l ar surfac e has a
shal l ow mi dl i ne concavi ty to accommodate the l ongi tudi nal ri dge on the undersurface of
the patel l a. The di stal or ti bi al surface of each condyl e extends on ei ther si de of the
i ntercondyl ar notch far around onto the posteri or surface. Here, the arti cul ar carti l age
nearl y reaches the posteri or margi n of the physi s.
There i s a di sti nctl y quadrupedal confi gurati on of the di stal femoral physi s, undul ati ng
from si de to si de and front to back. The fact that the physi s i s not fl at may hel p to resi st
shear and torsi on. However, when subj ect to trauma si gni fi cant enough to cause fracture,
however, the epi physeal ri dges may gri nd agai nst the metaphyseal proj ecti ons and
damage germi nal cel l s. Wi th a nonpl aner physi s, i t i s hypothesi zed that the fracture l i ne
may extend through mul ti pl e regi ons of the growth pl ate (4). Ani mal studi es report that
i f a fracture l i ne extends i nto the epi physeal physeal border, there was a greater
l i kel i hood of subsequent physeal bar formati on (31). Note that the cl i ni cal outcome of
the di stal femoral physi s i s qui te di fferent from the rel ati vel y pl aner di stal radi us physi s
i n whi ch growth pl ate di sturbances are rare.

Soft-Tissue Anatomy
The di stal femoral physi s i s compl etel y extra-arti cul ar. Anteri orl y and posteri orl y, the
synovi al membrane and j oi nt capsul e of the knee attach to the femoral epi physi s cl ose to
the di stal femoral physi s. Anteri orl y, the suprapatel l ar pouch bal l oons proxi mal l y over
the anteri or surface of the metaphysi s. On the medi al and l ateral surfaces of the
epi physi s, the proxi mal attachment of the synovi um and capsul e i s bel ow the physi s and
separated from the physi s by the i nserti ons of the col l ateral l i gaments.
The strong posteri or capsul e, as wel l as al l major supporti ng l i gaments of the knee, i s
attached to the epi physi s of the femur di stal to the physi s. Both cruci ate l i gaments
ori gi nate i n the upward-sl opi ng roof of the i ntercondyl ar notch di stal to the physi s.
Compressi on and tensi on forces can be transmi tted across the extended knee to the
epi physi s of the femur by taut l i gaments.

The medi al and l ateral head of the gastrocnemi us ori gi nate from the di stal femur,
proxi mal to the j oi nt capsul e (32,33). Thus muscl e pul l woul d theoreti cal l y not seem to
be as much of a factor as the pul l of the l i gaments i n the i ni ti al di spl acement of the
epi physi s at the ti me of i njury.

Vascular Anatomy
The popl i teal artery i s separated from the posteri or surface of the di stal femur by onl y a
thi n l ayer of fat. Di rectl y above the femoral condyl es, the superi or geni cul ate arteri es
pass medi al l y and l ateral l y to l i e between the femoral metaphysi s and the overl yi ng
muscl es. As the popl i teal artery conti nues di stal l y, i t l i es on the posteri or capsul e of the
knee j oi nt between the femoral condyl es. At thi s l evel , the mi ddl e geni cul ate artery
branches di rectl y forward to enter the posteri or aspect of the di stal femoral epi physi s.
The popl i teal artery and i ts branches are vul nerabl e to i njury from the di stal femoral
metaphysi s at the ti me of hyperextensi on i njury. It i s unl i kel y that the di stal femoral
epi physi s woul d be compl etel y shorn of i ts bl ood suppl y because of the ri ch anastomosi s
suppl i ed, i n part, by the superi or geni cul ate branches. Cl i ni cal l y osteonecrosi s (ON) of
the epi physi s i s not a commonl y recogni zed sequel a of even severe fractures about the
epi physi s.
Above the popl i teal space, the sci ati c nerve di vi des i nto the peroneal and ti bi al nerves.
The peroneal nerve descends posteri orl y between the bi ceps femori s muscl e and the
l ateral head of the gastrocnemi us muscl e to a poi nt just di stal to the head of the fi bul a.
Thus, there i s i nterposed muscl e protecti ng the nerve from the potenti al l y sharp edges
of a physeal fracture. The nerve i s subj ect to stretch i f the di stal femoral epi physi s i s
ti l ted i nto varus or rotated medi al l y.



Current Treatment Options
Rationale
The obj ecti ves of treatment of separati on of the di stal femoral epi physi s are to obtai n
and mai ntai n sati sfactory reducti on, to regai n a functi onal range of moti on and strength,
and to avoi d further damage to the physi s whi l e addressi ng associ ated neurovas cul ar
i njuri es (34). Anatomi c reducti on of a di spl aced separati on of the di stal femoral
epi physi s i s desi rabl e to mai ntai n normal mechani cal al i gnment of the l i mb, to hel p
prevent growth di sturbance, and mi ni mi ze arthri ti s from j oi nt i ncongrui ty.
In terms of remodel i ng, the cl oser the pati ent i s to skel etal maturi ty, the greater the
need for exact real i gnment. In contrast, i n terms of future growth di sturbance, skel etal l y
i mmature chi l dren wi th growth remai ni ng wi l l devel op si gni fi cant deformi ty wi th a growth
di sturbance. Resi dual varus or val gus deformi ty after reducti on remodel s much l ess than
remodel i ng i n the pl ane of j oi nt moti on. The remodel i ng potenti al i n i nfants i s so great
that consi derabl e di spl acement can be accepted. Most i nfants can be treated by
supporti ve tracti on or spl i nti ng, no matter how great the di spl acement.
Al though growth may be adversel y affected by the i njury i tsel f, further damage to the
physi s shoul d be avoi ded duri ng di agnosti c stress x-rays, cl osed reducti on, or open
reducti on. The use of general anesthesi a decreases the forces across the physi s.
At the ti me of i ni ti al eval uati on and treatment pl anni ng, the short - and l ong-term
probl ems and compl i cati ons are expl ai ned to the pati ent and parents. The need for l ong-
term fol l ow-up i s stressed from the begi nni ng of treatment. The fami l y i s better abl e to
accept the l i kel i hood of growth di sturbance, deformi ty, and need for further surgery i s
thi s i s di scussed at the i ni ti al consul tati on.

Closed Reduction and Immobilization
A nondi spl aced separati on i s i mmobi l i zed to prevent di spl acement and rel i eve pai n. If
there i s tense effusi on of the knee j oi nt, aspi rati on under steri l e precauti ons may be
done for pai n rel i ef. A wel l -mol ded l ong l eg cast i s appl i ed wi th the knee i n
approxi matel y 15 degrees to 20 degrees of fl exi on wi th the i ntact peri osteal hi nge
ti ghtened. Thus, i f the metaphyseal fragment of a nondi spl aced Sal ter -Harri s type II
separati on i s on the l ateral si de of the metaphysi s, the cast i s appl i ed wi th three-poi nt
mol di ng i nto sl i ght varus. Al ternati ve methods of i mmobi l i zati on i ncl ude a posteri or
spl i nt, cyl i nder cast from hi gh thi gh to supramal l eol ar l evel , or a si ngl e hi p spi ca cast.
The more secure form of i mmobi l i zati on shoul d be used i f the pati ent i s obese or of
uncertai n rel i abi l i ty. It must be stressed that there i s a hi gh chance of l oss of reducti on
i f a di spl aced fracture i s reduced and not i nternal l y fi xed (16). X-rays are made 1 week
after i mmobi l i zati on to ensure that di spl acement has not occurred, and more frequentl y
based on cl i ni cal suspi ci on of i nstabi l i ty.
Cl osed reducti on usual l y can be performed i n ol der chi l dren up to 10 days after i njury.
Parti al wei ght-beari ng on crutches wi th touchdown gai t may be started 2 to 3 weeks
after i njury. By 4 to 8 weeks after i njury, dependi ng on the x-rays, pati ent' s age, and
soci al si tuati on, the cast i s removed and may be converted to knee i mmobi l i zer for
conti nued protecti on. Even wi th a nondi spl aced fracture, growth i nhi bi ti on may be
caused by a compressi on force at the ti me of i njury, and the pati ent shoul d be fol l owed
for 12 to 24 months.
Seri es have reported rates of 43% to 70% of di stal femoral fractures treated wi thout
i nternal fi xati on have di spl aced (16,36). Unl ess a fracture i s trul y nondi spl aced and
stabl e, i mmobi l i zati on wi thout fi xati on i s no l onger the treatment of choi ce (26).

Closed Reduction and Fixation
A basi c pri nci pl e i s that fi xati on devi ces shoul d avoi d crossi ng the physi s i f adequate
fi xati on can be achi eved. In Sal ter-Harri s type III and IV separati ons, pi ns or screws
may be pl aced transversel y across the epi physi s. In Sal ter -Harri s type II and IV
separati ons, pi ns or screws are pl aced transversel y across the metaphysi s, engagi ng the
tri angul ar fragment i f i t i s l arge enough (2 to 3 cm tal l ; Fi g. 23-6B). Washers shoul d be
used wi th compressi on screws as the bone i n the metaphysi s and epi physi s i s not
corti cal , and a screw head wi thout a washer may mi grate i nto the metaphysi s.
If traversi ng the physi s i s unavoi dabl e, smooth pi ns are used. Pi ns shoul d be wi del y
separated at the fracture si te (Fi g. 23-5C), whi ch i s general l y easi est to achi eve by
crossi ng the pi ns proxi mal to the physi s. Al though i t may not be possi bl e to tel l wi th
100% certai nty i f a subsequent growth di sturbance arose from the i njur y or pi ns crossi ng
the physi s, cl i ni cal experi ence suggests smooth pi ns crossi ng a physi s are exceedi ng
unl i kel y to cause a growth di sturbance. The treatment of supracondyl ar humerus
fractures supports thi s bel i ef. A rabbi t model found a 2.5 mm dri l l hol e (4% to 5% of the
physeal area) across the di stal femoral growth pl ate di d not cause a growth di sturbance
(37). In Sal ter I fractures, as wel l as Sal ter II fractures wi th smal l metaphyseal
fragments crossi ng the physi s may be necessary. It i s i mportant to obtai n adequate
fi xati on and avoi d l oss of reducti on i n the postoperati ve peri od.
The techni que of cl osed reducti on depends on the di recti on and degree of di spl acement
of the epi physi s (Fi g. 23-12A, B). General anesthesi a often i s hel pful to decrease
associ ated muscl e spasm and di mi ni sh the ri sk of further i njury to the physi s. Joi nt
aspi rati on may precede mani pul ati on. Remember that the peri osteum i s usual l y i ntact on
one si de=mthe si de of the metaphyseal fragment i n a Sal ter II fracture, and the
di recti on of di spl acement of the di stal fragment i n most Sal ter fractures. The fi rst
pri nci pal i n reducti on i s do no harm to the physi s. The maneuver shoul d be 90% tracti on
and 10% l everage. The fi rst maneuver i ncreases the deformi ty sl i ghtl y wi th tracti on. The
proxi mal edge of the di spl aced epi physi s can then be brought to the edge of the
metaphysi s on the same si de of the peri osteal tether. Reducti on i s then compl eted by
real i gnment of the angul ar deformi ty. Gri ndi ng of the physeal carti l age agai nst the
metaphysi s i s thereby avoi ded. The sequence of events i s to pul l , ti p, and cl ose the
separati on.

Medial or Lateral Displacement
The pati ent i s pl aced supi ne. The l eg i s grasped wi th the knee i n extensi on and the hi p i n
sl i ght fl exi on. The thi gh i s fi xed by an assi stant. Moderate l ongi tudi nal tracti on i s
exerted by a handhol d on the l eg above the ankl e. If the di spl acement of the epi physi s i s
medi al , varus i s i ncreased gentl y and cauti ousl y to avoi d stretchi ng the peroneal nerve.
Wi th one hand hol di ng tracti on on the l eg, the pal m of the other hand i s pl aced agai nst
the concave surface of the angul ated di stal femur. The epi physi s i s pushed toward the
metaphysi s as the l eg i s real i gned wi th the thi gh. Once reducti on i s obtai ned,
l ongi tudi nal tracti on i s rel eased. A l ong l eg cast or hi p spi ca cast i s then appl i ed, wi th
the knee i n sl i ght fl exi on. Ext ernal i mmobi l i zati on i s conti nued for 5 to 6 weeks.
Thereafter, the care i s si mi l ar to that for a nondi spl aced separati on.

Anterior Displacement
Anteri or di spl acement of the epi physi s can be reduced wi th the pati ent ei ther supi ne or
prone. Wi th the pati ent supi ne, the hi p i s fl exed approxi matel y 60 degrees and the thi gh
i s fi xed by an assi stant. Longi tudi nal tracti on i s appl i ed, wi th the knee i n parti al fl exi on.
Posteri or pressure on the epi physi s i s exerted manual l y. Wi th conti nui ng tracti on on the
l eg, the knee i s fl exed 45 degrees to 90 degrees. Prone reducti on requi res fewer
assi stants. If the surgeon chooses to perform the reducti on wi th the pati ent prone,
tracti on i s appl i ed to the l i mb, an assi stant pushes down on the posteri or aspect of the
proxi mal femur, and the knee i s fl exed further unti l approxi matel y 110 degrees of fl exi on
i s reached. Thi s sequence i s si mi l ar to that for reducti on of a supracondyl ar humerus
fracture of the el bow.
After reducti on of an anteri orl y di spl aced epi physi s, i t i s i mpor tant to check the pul ses i n
the foot and ankl e. Fl exi on of a swol l en knee to beyond 90 degrees may compromi se the
popl i teal vessel s. If reducti on i s adequate, the knee may be i mmobi l i zed i n fl exi on by a
l ong l eg or hi p spi ca cast. Gri swol d (38) noted di ffi cul ty regai ni ng extensi on of the knee
after prol onged i mmobi l i zati on i n fl exi on. In addi ti on, judgment of frontal pl ane
al i gnment i s di ffi cul t i n the fl exed knee. For these reason, pi nni ng the knee i n the
reduced posi ti on, and casti ng i n mi l d knee fl exi on of 20 degrees to 30 degrees may be
preferabl e. If casti ng i n fl exi on wi thout fi xati on i s chosen, i t i s i mportant to i ncrease the
range of extensi on gradual l y duri ng the 6-to-8-week peri od of i mmobi l i zati on wi th cast
changes.

Posterior Displacement
To reduce posteri or di spl acement of the di stal femoral epi physi s, the pati ent i s pl aced
supi ne. The surgeon grasps the l eg and exerts downward l ongi tudi nal tracti on whi l e the
knee i s hel d partl y fl exed. Longi tudi nal tracti on i s conti nued as the l eg i s brought up to
extend the knee. An assi stant pul l s up di rectl y under the di stal femoral epi physi s wi th
one hand and pushes down on the di stal metaphysi s of the femur wi th the other. Such
fl exi on type i njuri es may be i mmobi l i zed i n extensi on (39).

Pin Fixation
The l arger the metaphyseal fragment and the greater the di spl acement, the l ess stabl e
the cl osed reducti on. If the metaphyseal fragment i s l arge enough, threaded pi ns or
screws can be di rected transversel y across the metaphysi s after reducti on (Fi g. 23-13;
see al so Fi g. 23-6C). In the absence of a substanti al metaphyseal fragment, smooth pi ns
are di rected through the si de of each condyl e to cross i n the metaphysi s proxi mal to the
physi s. The cl oser the pi ns are to crossi ng at the fracture si te, the l ess stabl e they are.
To make the pi ns cross at a poi nt proxi mal to the fracture si te, they shoul d come i n at a
hi gh angl e, l ess than 45 degrees to the l ong axi s of the femur. The pi ns may be
cut off under the ski n before appl i cati on of the cast or l eft perc utaneous. Infecti on i s
frequent i f pi ns i n thi s regi on are l eft out through the ski n for greater than 4 to 6 weeks,
and i ntra-arti cul ar pi ns may l ead to a septi c knee. The use of sel f -rei nforced pol ygl ycol i c
aci d pi ns has been reported i n fi xati on of di stal femoral physeal fractures i n a rabbi t,
wi th good heal i ng and no growth di sturbance at 28 weeks, though thi s short -term ani mal
study can not necessari l y be transl ated to use i n humans (40).

Open Reduction of Physeal Fractures
Open reducti on i s i ndi cated for di spl aced Sal ter-Harri s type III or IV fractures, for al l
other types i n whi ch sati sfactory al i gnment cannot be obtai ned by cl osed means, open
fractures, or when associ ated i njuri es mandate i t (i .e., a fl oati ng knee or
l i gament i njury). A tourni quet around the proxi mal thi gh may be used for temporary
hemostasi s i f i t i s pl aced proxi mal l y enough to avoi d bi ndi ng the thi gh muscl es under the
i nfl ated tourni quet. Al though some fracture mal al i gnment may be tol erated i n Sal te r I
and II i njuri es wi th subsequent remodel i ng (Fi g 23-14), gi ven the hi gh rate of growth
di sturbance for these fractures, we do not recommend acceptance of cl earl y di spl aced
fractures, and prefer open reducti on i n these i nstances.

How much of a fracture gap of a Sal ter II fracture i s acceptabl e i s open to
debate. The si mpl e presence of i nterposed peri osteum i s not an absol ute i ndi cati on for
an open reducti on. We know from ani mal studi es that i nterposed peri osteum i n a Sal ter
fracture, i n the absence of i ntenti onal physeal abl ati on, does not l ead to a growth
di sturbance. In these ani mal s the peri osteum was degraded or forced toward the
metaphysi s wi th normal growth. Onl y i n ani mal s where the physi s was parti al l y abl ated
di d a physeal bar occur (41).
For a Sal ter-Harri s type II separati on i n the coronal pl ane, a l ongi tudi nal i nci si on
opposi te the metaphyseal fragment gi ves di rect exposure of any obstacl es to reducti on
and avoi ds di srupti on of the peri osteal hi nge. If the di spl acement i s anteri or, the
procedure i s done wi th the pati ent prone. After i nci si on of the deep fasci a di ssecti on i s
conti nued, extendi ng the pl ane of i njury bl untl y by spreadi ng the muscl e fi bers to expose
the end of the metaphysi s. Irri gati on and careful removal of cl otted bl ood permi t better
i nspecti on of the separati on. An i nterposed fl ap of peri osteum may be i denti fi ed between
the epi physi s and metaphysi s and removed. Speci al care i s taken to avoi d any addi ti onal
damage to the physi s. Once the muscl e and peri osteal fl ap are removed, reducti on i s
carri ed out pri mari l y wi th tracti on accompani ed by gentl e real i gnment. To avoi d damage
to the physi s, i nstruments shoul d not be pl aced i n the physeal i nterval . Fi xati on shoul d
be performed as needed. After cl osure of the wound, a l ong l eg or hi p spi ca cast i s
appl i ed.

For open reducti on and i nternal fi xati on of a di spl aced Sal ter -Harri s type III or IV
separati on, an anteromedi al or anterol ateral l ongi tudi nal i nci si on i s used (Fi g. 23-15). In
severel y commi nuted fractures an anteri or i nci si on may be used wi th a total knee
repl acement i n mi nd for the future. The anteri or physeal and arti cul ar margi ns of the
fracture are exposed. Reducti on i s checked by noti ng the apposi ti on of the arti cul ar
surfaces, the physeal l i ne anteri orl y, and the fracture pattern (Fi g. 23-15) and can be
confi rmed wi th fl uoroscopy. The gastrocnemi us has been reported as an obstacl e to
reducti on i n a Sal ter III fracture of the medi al femoral epi physi s (42). Provi si onal
stabi l i zati on i s obtai ned wi th Ki rschner gui de wi res. When reducti on i s accompl i shed,
screws are di rected transversel y across the epi physi s i n Sal ter -Harri s type III
separati ons or across the metaphysi s and epi physi s i n Sal ter -Harri s type IV i njuri es
(Fi gs. 23-15 and 23-16) If crossi ng the physi s wi th fi xati on i s unavoi dabl e, smooth pi ns
or wi res shoul d be used. After reducti on and fi xati on are checked by i ntraoperati ve x-
rays, the knee j oi nt i s thoroughl y i rri gated and i nspected for other fractures and
l i gament di srupti on. After surgery, the reducti on i s prot ected by a l ong l eg or hi p spi ca
cast. The use of i ndomethaci n to reduce the i nci dence of growth di sturbance i n a rabbi t
di stal femoral fracture model has been reported wi th equi vocal resul ts (43).
Recommendati on for thi s treatment i n humans i s premature.
If an associ ated col l ateral l i gament i njury i s found, i t can be repai red at the ti me of open
reducti on. Internal fi xati on i s used to al l ow earl y mobi l i zati on and rehabi l i tati on of both
the physeal separati on and the l i gamentous i njury.
If vascul ar repai r i s i ndi cated, a posteri or modi fi ed S-shaped i nci si on or posteromedi al
i nci si on i s used to fol l ow the course of the femoral artery. Care shoul d be taken duri ng
i nci si on because the vessel may be superfi ci al beneath the ski n, parti cul arl y i n an
anteri orl y di spl aced fracture. The hamstri ng tendons may be bowstrung around
the femoral metaphysi s. The artery may be i n spasm, occl uded by i nti mal tear, or torn.
After the vascul ar structures are i denti fi ed, the fracture i s reduced and stabi l i zed before
vascul ar repai r, except as noted above i n the associ ated i njuri es secti on on vascul ar
i njury.

Open separati ons of the di stal femoral epi physi s usual l y are caused by hyperextensi on,
wi th anteri or di spl acement of the epi physi s. A wound may be present i n the popl i teal
fossa, overl yi ng the posteri or protrudi ng end of the metaphysi s. The pati ent i s pl aced
prone wi th the knee sl i ghtl y fl exed and the ski n i s thoroughl y i rri gated and debri ded. The
wound i s enl arged to al l ow i nspecti on of the contents of the popl i teal foss a. Muscl e or
peri osteum or both may be i nterposed i n the fracture si te. Because the pati ent i s prone,
reducti on i s obtai ned by bri ngi ng the l eg up agai nst downward pressure on the di stal end
of the femoral shaft, whi l e mai ntai ni ng l ongi tudi nal tracti on. Internal fi xati on i s used to
stabi l i ze the fracture, especi al l y i f vascul ar or l i gamentous repai r i s to be done. The knee
i mmobi l i zed i n sl i ght fl exi on wi th a l ong l eg or hi p spi ca cast.

External Fixation
In cases of si gni fi cant soft-ti ssue i njuri es i n whi ch dressi ng changes or staged surgeri es
are pl anned, or i n severel y commi nuted fractures, external fi xati on may be i ndi cated.
Because of the danger of secondary knee j oi nt i nfecti on, external fi xati on i s general l y
not i ndi cated for most di stal femoral physeal fractures (44).

Rigid Plate Fixation
Ri gi d pl ate fi xati on across the physi s wi l l stop al l remai ni ng growth. Thus, thi s opti on i s
reserved onl y for adol escents near the end of growth and/or chi l dren wi th severe i njuri es
i n whi ch severe growth di sturbance i s bel i eved to be i nevi tabl e. Growth remai ni ng for an
i ndi vi dual i s di ffi cul t to predi ct, and fami l y growth patterns and si ze shoul d be careful l y
consi dered before taki ng thi s i rreversi bl e step (Tabl e 23-4).

AUTHOR'S PREFERRED TREATMENT
Surgical Procedure
Nondisplaced Fractures

Trul y nondi spl aced fractures may be pl aced i n a l ong l eg cast for 6 weeks (Fi g. 23-8). If
there i s any concern of fracture di spl acement, parti cul arl y i n Sal ter type III and IV
i njuri es a CT scan i s obtai ned. The cast must be hi gh on the thi gh to avoi d a l arge
moment arm at the fracture, and short or obese chi l dren may requi re a hi p spi ca cast.
Wei ght-beari ng i s started i n Sal ter I and II fractures at 2 to 3 weeks i f there i s no
di scomfort.
In the rare case of a nondi spl aced di stal femur fracture that cannot be di fferenti ated
from a col l ateral l i gament i njury on physi cal exami nati on or x-rays, I pl ace the pati ent i n
a knee i mmobi l i zer and reexami ne i n 10 to 14 days, i ncl udi ng x-rays to l ook for
peri osteal new bone formati on i ndi cati ve of a heal i ng facture.

Salter I and II Fractures
For di spl aced Sal ter I and II fractures, cl osed reducti on and percutaneous fi xati on i s
performed under general anesthesi a. In Sal ter I fractures, smooth pi ns, 2.0 to 3.2 mm i n
si ze i s used i n a cross pi n confi gurati on. Pi ns are bent to prevent mi grati on, and the ski n
protected by steri l e i n. thi ck fel t (Fi g. 23-5). We attempt to maxi mal l y separate the
pi ns at the fracture si te for stabi l i ty. In thi n chi l dren, the pi ns may be brought out of the
ski n proxi mal l y to avoi d the possi bi l i ty of a pi n i nfecti on l eadi ng to a septi c knee.
In Sal ter II fractures, i f the metaphyseal fragment i s l arge enough, one or two
cannul ated cancel l ous screws are pl aced under compressi on usi ng washers (Fi g. 23-6).
At l east two gui de wi res are pl aced before dri l l i ng and tappi ng to prevent rotati on of the
fragment. Di fferent si zed screws, such as a 7.3 mm screw i n the bottom of the
metaphyseal fragment and a 4.5 mm screw i n the smal l er upper porti on, may be used.
Ti tani um screws wi l l i mprove the qual i ty of MRI scans i n t he future of the growth pl ate i f
a physeal bar i s suspected, but i magi ng wi th steel screws may be effecti ve at vi sual i zi ng
the physi s i f they are suffi ci entl y far from the physi s (Fi g. 23-6E).

In chi l dren younger than 10 years of age, as much as 20 degrees of posteri or angul ati on
i s acceptabl e, but i n pati ents cl oser to adol escence, we accept onl y mi ni mal
anteroposteri or angul ati on and no more than 5 degrees of varus -val gus angul ati on. As
l ong as al i gnment i s acceptabl e, we accept a gap of up to 3 to 4 mm.
If the di spl acement i s anteri or, we perform the reducti on wi th the pati ent supi ne. An
assi stant hol ds the thi gh wi th the hi p partl y fl exed over a bol ster. The surgeon grasps
the l eg from behi nd the cal f wi th one hand and pul l s down i n l i ne wi th the thi gh as he or
she tri es to ti p and cl ose the epi physi s agai nst the metaphysi s wi th the other hand. An
above-the-knee cast i s appl i ed wi th the knee i n 5 degrees to 10 degrees of fl exi on.
A l ong l eg fi bergl ass cast i s pl aced wi th the knee i n 5 degrees to 10 of fl exi on, to
al l ow for assessment of fracture reducti on wi th postoperati ve i magi ng.

Salter III and IV Fractures
We prefer open anatomi c reducti on for al l di spl aced type III and IV fractures to prevent
the formati on of a bony bar, whi ch causes l i mb-l ength di screpancy and angul ar
deformi ty. Preoperati ve CT scans are hel pful i n the di agnosi s and preoperati ve pl anni ng
for these fractures, and may i denti fy unrecogni zed commi nuti on that wi l l i nfl uence
fi xati on. In the trul y nondi spl aced type III fracture, percutaneous screw fi xati on i s
adequate. An anteromedi al or anterol ateral approach i s performed based upon the
l ocati on of the fracture. The fracture l i ne, the physi s, and the j oi nt surface are observed
to confi rm anatomi c reducti on (Fi g. 23-16). Cannul ated screws are then i nserted wi th
ei ther an open techni que or percutaneousl y wi th the ai d of i mage i ntensi fi cati on, usi ng
the above pri nci pal s (Fi g. 23-15). Large osteochondral fragments may be fi xed wi th
headl ess screws (such as Herbert screws) i n a subchondral posi ti on i n the unusual
i nstance where extra-arti cul ar fi xati on i s not possi bl e. Ti tani um screws wi l l i mprove the
qual i ty of MRI scans i n the future of the growth pl ate i f a physeal bar i s suspected.
Every effort i s made to achi eve ri gi d fi xati on to al l ow earl y moti on i n about 6 weeks. A
l ong l eg fi bergl ass cast i s pl aced wi th the knee i n 5 degrees to 10 degrees of fl exi on.
Open fractures or fractures caused by massi ve penetrati ng trauma requi re meti cul ous
debri dement. We try to save and stabi l i ze any vi abl e fragments of epi physi s or arti cul ar
surface, but total l y free fragments are removed. Debri dement i s repeated as necessary,
usual l y at 24 to 72 hours, and soft-ti ssue coverage i s accompl i shed as soon as feasi bl e.

Postreduction Care
Ambul ati on on crutches usual l y i s possi bl e wi thi n a few days. In chi l dren wi th
percutaneous pi ns, si gns and symptoms of i nfecti on shoul d be expl ai ned to the parents
and assessed at fol l ow-up vi si ts. At 1 week after reducti on, the pati ent returns for x-rays
taken through the cast. X-rays may be repeated at 2 and 3 weeks i f l oss of reducti on i s a
concern (Fi g. 23-17). Parti al wei ght-beari ng i s started at 2 to 3 weeks for Sal ter I and II
fractures. Pi ns may be removed at 3 to 4 weeks when there i s earl y heal i ng i f there i s
any concern of i nfecti on. Thi s may be done through a wi ndow i n the cast. At 6 to 8
weeks after i njury, i f x-rays taken out of pl aster show adequate heal i ng, the cast i s
di sconti nued. Scanograms are often taken shortl y fol l owi ng i ni ti al fracture care to
i denti fy a preexi sti ng l eg l ength di screpancy, because growth di sturbances are common
compl i cati ons of the fracture. Many pati ents who underwent open reducti on may benefi t
from physi cal therapy to i ncrease range of moti on and strength. At 6 mont hs after i njury,
al i gnment, l eg l ength, and gai t are eval uated wi th comparati ve x-rays of the l ower
extremi ti es. If al i gnment, l eg l ength, and gai t are wi thi n normal l i mi ts, the pati ent i s
di smi ssed from routi ne care but i s counsel ed to return for eval uati on of growth 12 and
24 months after i njury.

Pearls and Pitfalls
Reducti on i s 90% tracti on=m10% l everage (Tabl e 23-5).
For screw fi xati on, use washers=mdo not hesi tate to use 2 si zes of screws.
The l eg i s a l ong, heavy l ever arm. Protect your fi xati on wi th a cast that i s hi gh
enough, or a si ngl e l eg spi ca i f the thi gh i s short and/or wi de.
Use fi xati on for any di spl aced fracture. Li terature i s cl ear that fractures wi thout
fi xati on often l ose reducti on.
Compl i cati ons of fractures of the di stal femoral epi physi s are l i sted i n Tabl e 23-6.

Complications

Recurrent Displacement
Separati on of the di stal femoral epi physi s may be qui te unstabl e after reducti on (26). In
a seri es of 30 fractures, Thomson et al (16) showed 43% of fractures wi thout i nternal
fi xati on di spl aced, whereas no fractures wi th i nternal fi xati on di spl aced. Graham and
Gross reported that 7 of 10 pati ents treated by cl osed means l ost reducti on (36).
The use of fi xati on i n any fracture that requi res reducti on shoul d mi ni mi ze the ri sk of
recurrent di spl acement. It i s i mportant to remember that the femur and ti bi a are a l ong
l ever arms wi th forces that may overcome al most any fi xati on about the knee (Fi g. 23-
17) The use of a knee i mmobi l i zer, l ong l eg cast, or spi ca cast for pati ents wi th l arge
thi ghs wi l l further hel p mi ni mi ze the ri sk of recurrent di spl acement.

Physeal Injury
Di stal femoral physeal fractures are associ ated wi th hi gh i nci dences of growth
di sturbance, resul ti ng i n asymmetry of l ength or angul ati on, or both (4,14,16,17,26,34).
Growth di sturbance i s caused by bony bri dgi ng resul ti ng from di rect physeal trauma or
from l ack of anatomi c reducti on of the physi s. Several authors have shown that the
l i kel i hood of physeal di sturbance i s greater wi th si gni fi cant (>50% of the wi dth of the
physi s) i ni ti al di spl acement of the fracture (18,16). The compl ex contour of the physi s
makes i t possi bl e for sheari ng of the fracture l i ne to occur across several zones of the
physi s at a mi croscopi c l evel , even i n fracture patterns that are typi cal l y consi dered to
be beni gn, such as Sal ter-Harri s type I and II i njuri es.

Physeal i njury may be noted about 6 months fol l owi ng fracture heal i ng on pl ai n fi l ms
taken centered on the physi s by narrowi ng of t he physi s, or areas of osseous bri dgi ng. If
Park-Harri s growth l i nes are not paral l el , thei r convergence poi nts the area of growth
arrest. The di stance to these l i nes shoul d be greater than the di stance of the l i nes form
the adjacent proxi mal ti bi al physi s, whi ch grows more sl owl y (34). An absence of Park-
Harri s l i nes suggests compl ete physeal cl osure as there i s no growth. MRI can
demonstrate transphyseal bri dgi ng or al tered arrest l i nes i n physeal fracture before they
become mani fest on x-rays (45). T2-gradi ent-recal l ed echo or proton-densi ty sequences
wi th fat suppressi on MRI has been recommended as the best MRI techni que for di agnosi s
and fol l ow-up of the growth pl ate (Fi g. 23-18; see al so Fi g. 23-6) (46,47).

Physeal Injury with Progressive Angulation
Angul ar deformi ty fol l owi ng di stal femoral physeal i njury i s reported i n 18% to 51% of
recent seri es (4,14,16,26). Progressi ve angul ati on after separati on of the di stal femoral
epi physi s i s usual l y caused by asymmetri c growth (48) from ei ther trauma to the physi s
at the i ni ti al i njury (Sal ter-Harri s type I or II) or physeal offset wi th bony bar formati on
after heal i ng (49) (Sal ter-Harri s type III or IV). Occasi onal l y, progressi ve angul ati on
fol l ows nonphyseal fractures i n whi ch an associ ated Sal ter -Harri s type V physeal i njury
presumabl y was not noted (3). The ri sk of si gni fi cant angul ar di sturbance i s hi ghest i n
pati ents wi th si gni fi cant growth remai ni ng. If the separati on i s a Sal ter -Harri s type II
i njury, the physi s di stal to the tri angul ar metaphyseal fr agment usual l y i s spared (Fi g.
23-6). The l ocal i zed area of growth i nhi bi ti on occurs i n that porti on of the physi s not
protected by the metaphyseal fragment.

If a l ocal i zed area of premature arrest consti tutes l ess than 25% to 50% of the total
area of the physi s and i f at l east 2 years of growth remai n, exci si on of the bony bri dge
has been recommended (17,50,51,52). The bri dge can be accuratel y defi ned by MRI as
di scussed above. Hel i cal CT scans have been recommended to create a map of the
i njured physi s (24,53). Kasser recommends that si mul taneous correcti ve osteotomy
shoul d be performed when the angul ar deformi ty exceeds 20 (50).
The techni que of exci si on i s wel l descri bed by Peterson (48,52). A peri pheral bri dge can
be approached di rectl y. A central bri dge i s approached through a metaphyseal wi ndow.
The area of uni on between the epi physi s and the metaphysi s i s careful l y removed wi th a
curette and power bur. The defect i s fi l l ed wi th an i nterposi ti on materi al such as fat,
carti l age, el astomer, or methyl methacryl ate, though the superi ori ty of one over the other
i s uncl ear (50). It i s cri ti cal l y i mportant to exci se the osseous bri dge i n i ts enti rety,
whi ch can be veri fi ed by seei ng heal thy growth pl ate at al l edges of the bar resecti on. A
dental mi rror or arthroscope can be useful to vi sual i ze the growth pl ate fol l owi ng
resecti on of a central bar.
Langenski ol d reported on a seri es of 35 pati ents undergoi ng boney bri dge resecti on and
fat graft i nterposi ti on, of whi ch 18 were for the di stal femur. Fi ve pati ents requi red a
secondary procedure, and 7 had questi onabl e benefi t (52). Hasl er and Foster warn that
despi t e a standardi zed operati ve techni que and appropri ate pati ent sel ecti on for physeal
bar resecti on (a bar si ze l ess than 50% of the physi s, and a prospecti ve growth peri od
greater than 2 years) fai l ure may resul t. In thei r seri es of 22 pati ents wi th bar
resecti ons wi th i nterposi ti on of autol ogous fat, 14 pati ents had onl y fai r or poor resul ts.
Li mi ted growth because of poor functi on of the remai ni ng physi s and secondary tethers
(i ncompl ete resecti on or recurrence of the bar) may prevent reestabl i shment of growth
or l ead to i ts premature cessati on (54). Cal ci fi cati on of the provi si onal zone of the
metaphysi s shown by MRI i ndi cates poor vi abi l i ty of the physi s and has been associ ated
wi th fai l ure of bar resecti on (55).
It has been the author' s experi ence that physeal resecti on about the di stal femur has a
hi gh rate of fai l ure, and one shoul d consi der epi physi odesi s, and even contral ateral
epi physi odesi s i n ol der chi l dren. Robert suggests surgi cal epi physi odesi s at the ti me of
fracture treatment i n adol escents aged 15 years or over as a reasonabl e possi bi l i ty (26).
Hemi epi physi odesi s may be consi dered i n maturi ng adol escents wi th progressi ve varus or
val gus angul ati on associ ated wi th a central bony bri dge wi th some remai ni ng growth
medi al l y or l ateral l y. Enough growth may remai n i n the segment of physi s between the
bony bri dge and the peri meter on the same si de to correct the deformi ty. Because of the
physeal bar, thi s procedure i s unpredi ctabl e and must be fol l owed cl osel y post
operati vel y to assess for fai l ure. If hemi epi physi odesi s i s used to correct angul ar
deformi ty, ti mel y epi physi odesi s of the opposi te l i mb may be requi red to prevent
si gni fi cant l i mb-l ength di screpancy.
If the pati ent i s approachi ng skel etal maturi ty, correcti ve osteotomy i s the preferred
treatment. Openi ng-wedge osteotomy i s appl i cabl e for correcti on when the angul ar
deformi ty i s 25 or l ess and the l i mb-l ength di screpancy i s, or wi l l be, 25 mm or l ess at
maturi ty. Thi s techni que i s descri bed and i l l ustrated by Scheffer and Peterson (56). An
osteotomy i s made at the supracondyl ar l evel , paral l el to the arti cul ar surface of the
condyl es. The hi nge of the osteotomy shoul d be i n metaphyseal bone, whi ch i s better
abl e to deform pl asti cal l y than i s corti cal bone. Usual l y no more than 15 degrees of
correcti on can be obtai ned wi thout cracki ng the hi nge. The di stal fragment i s then ti l ted
to pl ace the arti cul ar surface i n hori zontal al i gnment. A tri angul ar fragment of bone graft
i s i nserted i n the openi ng. The graft and correcti on may be i nternal l y fi xed and the l eg
i mmobi l i zed.
An al ternati ve method of fi xati on for an openi ng-wedge osteotomy or for l engtheni ng and
angul ar correcti on of the di stal femur i s external fi xati on. The Il i zarov or si mi l ar
constructs are useful because the amount of l engtheni ng or angul ati on can be adjusted
postoperati vel y, and si gni fi cant angul ati on and l ength deformi ti es can be corrected (57).

Physeal Injury with Leg-Length Discrepancy
Progressi ve l eg-l ength di screpancy may fol l ow a separati on of the di stal femoral
epi physi s i f premature arrest of the physi s occurs. If the pati ent i s wi thi n 2 years of
skel etal maturi ty at the ti me of i njury, the shorteni ng probabl y wi l l be i nsi gni fi cant. If
there are more than 2 years from the ti me of i njury to skel etal maturi ty, the l eg-l ength
di screpancy may progress at a rate of 1 cm (3/8 i n.) per year (Fi g. 23-17).
Someti mes the growth di sturbance i s not a di screte bar but a parti al physeal sl owi ng.
The progressi on of l eg-l ength di screpancy i s best fol l owed by seri al exami nati ons. Every
6 months, a scanogram and bone age are obtai ned and the cl i ni cal di screpancy i s
measured. The l eg l engths can be pl otted on the Mosel ey strai ght -l i ne graph. After three
sequenti al scanograms over a peri od of 12 to 18 months, di screpancy at skel etal
maturi ty can be esti mated by extrapol ati on accordi ng to the rate of growth of each l i mb.
Al though l i mb l ength di screpancy i s a frequentl y reported compl i cati on of di stal femoral
physeal fractures (4,14,16,26), i n most cases the amount of di screpancy i s not cl i ni cal l y
si gni fi cant (39). Management of the l i mb l ength di screpancy i s wel l descri bed (58,59).

Stiffness
Li mi tati on of knee moti on after separati on of the di stal femoral epi physi s may be caused
by i ntra-arti cul ar adhesi ons, capsul ar contracture, or muscul ar contracture. Thi s shoul d
be treated wi th acti ve and acti ve-assi sti ve range-of-moti on exerci ses. Fol l owi ng
prol onged i mmobi l i zati on and osteoporosi s, peri arti cul ar fractures from overzeal ous
mani pul ati on for knee contracture has been reported (60). Drop-out casts and dynami c
braces may be of benefi t i n recal ci trant cases. For pati ents wi th sti ff knees i n whom
conservati ve treatment has fai l ed, surgi cal rel ease of contractures and adhesi ons,
fol l owed by conti nuous passi ve moti on, may regai n si gni fi cant moti on (27).

Controversies
Stress X-rays
Stani tski presents a cogent argument agai nst the use of stress vi ews to di fferenti ate
between a col l ateral l i gament i njury and a physeal fracture of the di stal femur. He
reports that thi s test may have been needed i n the past, when the treatment of a
col l ateral l i gament i njury was operati ve, and the treatment of a nondi spl aced physeal
fracture was i mmobi l i zati on. Stani tski argues the current i ni ti al treatment of both a
col l ateral l i gament i njury and a nondi spl aced femur fracture i s i mmobi l i zati on, thus the
need for an i mmedi ate di agnosi s and stress vi ews i s no l onger val i d (61). Another opti on
for earl y di agnosi s i s an MRI scan, however the addi ti onal use of heal th care resources
may be di ffi cul t to j usti fy as i t wi l l not have a si gni fi cant change i n the i ni ti al trea tment.