MRI findings of growth plate fractures of the knee: are there age- and fracture-dependent differences?

OBJECTIVE: To investigate MRI findings in children with physeal fractures of the knee with respect to age, location, and articular involvement. METHODS: Children with physeal fractures who underwent knee MRI between 2008 and 2021 were included. Two radiologists retrospectively reviewed all examinations to determine articular involvement, findings of physeal instability (perichondral disruption, periosteal entrapment), and internal derangement (cruciate ligament injury, meniscal tear, chondromalacia). Independent samples t, Mann-Whitney U, Pearson's chi-square, and Fisher's exact tests were used to compare findings. RESULTS: Fifty-six patients (37 boys, 19 girls; mean age: 12.2 ± 2.5 years; 32 distal femur, 24 proximal tibial fractures) included 24(43%) intraarticular fractures. Fractures were more common in the tibia than the femur (67% versus 25%, p = 0.004) and intraarticular fractures were more common in older than younger children (13.1 ± 2.0 versus 11.5 ± 2.7 years, p = 0.01), to associate with chondromalacia (46% versus 12%, p = 0.02) and undergo surgery (33% versus 10%, p = 0.04) when compared to extraarticular fractures. Perichondral disruption (n = 44, 79%) and periosteal entrapment (n = 13, 23%) did not significantly differ based on location or articular involvement (p > 0.05). At a median follow-up of 17.5 months (interquartile range: 1.25-34), 3 patients (2 intraarticular, 1 extraarticular fractures) developed osteoarthritis, osteochondral lesion, and leg-length discrepancy from growth arrest, which required additional surgery. CONCLUSION: Intraarticular physeal fractures were more common with older children, associate with chondromalacia, and underdo surgical intervention when compared to extraarticular fractures of the knee. While MRI findings of physeal instability were common, no significant differences were found between fractures based on anatomic location or fracture pattern.

Olympic competition climbing: the beginning of a new era-a narrative review.

Climbing as a competition sport has become increasingly popular in recent years, particularly the sub-discipline of bouldering. The sport will debut in the Tokyo Summer Olympic Games. National and international competitions have three disciplines: lead (climbing with rope protection), bouldering (climbing at lower heights with mattress floor protection) and speed (maximum speed climbing on a standardised route in 1-on-1 mode). There is also a 'combined mode' of all three disciplines (combined) which forms the Olympic competition format; all competition formats are held on artificial walls. Existing literature describes a predominantly low injury frequency and severity in elite climbing. In comparison to climbing on real rock, artificial climbing walls have recently been associated with higher injury rates. Finger injuries such as tenosynovitis, pulley lesions and growth plate injuries are the most common injuries. As finger injuries are sport-specific, medical supervision of climbing athletes requires specific medical knowledge for diagnosis and treatment. There is so far little evidence on effective injury prevention measures in top athletes, and antidoping measures, in general, requiring further work in this field. An improved data situation regarding high-performance climbing athletes is crucial to ensure that the sport continues to be largely safe and injury-free and to prevent doping cases as extensively as possible.

Feasibility of pre- and postoperative arthroscopic assessments with internal fixation for growth plate injury of the distal tibia: three case reports and a literature review.

BACKGROUND: Inappropriate treatment of growth plate injury may cause complications such as malunion or early arrest of the growth plate. Identification of intra-articular lesions is mandatory in patients with a growth plate injury of the distal tibia. Arthroscopic assessment is useful in identifying intra-articular injury. We report three cases of intra-articular growth plate injury of the distal tibia that were treated via internal fixation with arthroscopic assessment in our hospital. MATERIALS AND METHODS: All three cases were performed pre- and postoperative arthroscopic assessment and open reduction and internal fixation with a cannulated cancellous screw (CCS; Meira, Japan). All patients were then examined for postoperative complications, functional recovery, at the end of the final follow-up consultation. RESULTS: Intraoperatively, a small cartilage injury was found in the non-fracture area in two cases; the remaining case had a reversed cartilage fragment at the talus, which was arthroscopically removed. CONCLUSIONS: Arthroscopic assessment followed by internal fixation is a useful minimally invasive method for the identification of intra-articular lesions such as osteochondral injury or free bodies.

[Update: transitional fractures : Osseous injuries in growing up adolescents-correct nomenclature, radiological diagnostics and treatment]. / Update: Übergangsfrakturen : Knöcherne Verletzungen heranwachsender Jugendlicher ­ richtige Nomenklatur, radiologische Diagnostik und Therapie.

Transitional fractures are special forms of epiphyseal injuries in adolescents in whom the growth plate is already partially closed. Due to the partial ossification specific stereotypical fracture patterns can develop, which can be differentiated into twoplane, triplane I and triplane II fractures, depending on the involvement of the metaphysis and the number of fragments. At the beginning of the diagnostics conventional projection radiography in two planes is used; however, due to the complex fracture patterns computed tomography (CT) is often indicated, also for preoperative planning. The treatment depends on the extent of the fracture dislocation, which should be an integral part of the radiological findings, as dislocation of fragments less than 2 mm in size are usually treated conservatively. Prognostically relevant is above all the reconstruction of the joint surfaces, as early arthrosis can be a threat if the incongruity remains-relevant growth disturbances in the case of growth joint closure that has already begun are usually no longer expected.

Are classic metaphyseal lesions pathognomonic for child abuse? Two cases of motor vehicle collision-related extremity CML and a review of the literature.

Long bone fractures at the infant growth plate, known as classic metaphyseal lesions (CMLs), raise a strong suspicion for abusive injury. CMLs persist as a hallmark for inflicted injury although a handful of documented cases of CMLs created by other, non-abusive mechanisms within various healthcare settings are scattered throughout the past few decades of medical literature. The forces required to sustain a CML are typically defined as a combination of tensile, compressive, or rotational energy applied to the metaphyseal regions of an infant's long bones. Recently, two separate child protection teams each encountered a case of CML discovered after reported motor vehicle collisions (MVC). This provoked a critical appraisal of the medical literature to inform clinical practice regarding MVCs as a potential mechanism for this fracture type and to remind clinicians that there is no single injury pathognomonic for abuse.

Growth Disturbance Following Intra-articular Distal Radius Fractures in the Skeletally Immature Patient.

INTRODUCTION: The purpose of this study was to characterize the incidence of growth disturbance following intra-articular distal radius fractures in skeletally immature patients and to assess early radiographic and functional outcomes. METHODS: A retrospective investigation of pediatric patients with intra-articular distal radius fractures between 1997 and 2012 at a single institution was performed. Pathologic fractures and fractures in patients with closed physes were excluded. In total, 28 patients (24 males, 4 females), with a mean age of 13.8 years and mean follow-up of 31.7 months, met inclusion criteria. Fractures were categorized according to the Salter-Harris classification, and all radiographs were assessed for evidence of physeal disturbance. Information regarding treatment and early clinical results were obtained from a medical record review. Functional outcomes using the Disabilities of the Arm, Shoulder, and Hand (DASH) and Modified Mayo Wrist Score (MMWS) were collected. Fisher exact test was used to compare the incidence of physeal arrest in the study population to previously published rates of physeal arrest in extra-articular fractures involving the distal radius. Because the data were not parametrically distributed, the Mann-Whitney-Wilcoxon test was used to compare those who did and did not develop physeal arrest. RESULTS: Of the 28 patients, 9 (32%) sustained Salter-Harris III fractures and 19 (68%) sustained Salter-Harris IV fractures. Growth disturbance occurred in 12 (43%) patients, comprised of 3 Salter-Harris III fractures and 9 Salter-Harris IV fractures; 7 of these patients underwent surgical intervention to address deformity. All 4 children age 10 years or younger had growth arrests that underwent subsequent procedures for a skeletal rebalancing of the wrist. No significant differences in DASH or MMWS were seen in the short term between patients who did or did not have physeal arrest. CONCLUSIONS: Intra-articular distal radius fractures in skeletally immature patients have a considerably higher rate of physeal growth arrest than extra-articular physeal fractures. Following acute management aimed at restoring and preserving anatomic physeal and articular alignment, follow-up radiographs should be obtained to evaluate for physeal arrest in skeletally immature children. Patients and families should be counseled regarding the high rate of growth disturbance and the potential need for deformity correction in the future, particularly in younger children. LEVEL OF EVIDENCE: IV-case series.

Clinical Outcomes of Triplane Fractures Based on Imaging Modality Utilization and Management: A Systematic Review and Meta-analysis.

BACKGROUND: Because of the complex nature and relatively rare prevalence of triplane fractures, ideal imaging and optimal treatment remain controversial. The purpose of this investigation was to systematically review and compare clinical outcomes in skeletally immature patients with triplane fractures on the basis of imaging modalities [radiography alone vs. radiography+computed tomography (CT)] and fracture management (operative vs. nonoperative). METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement using a PRISMA checklist. All the literature related to skeletally immature patients with triplane fractures published from January 1988 to March 2020 were identified. Inclusion criteria consisted of skeletally immature patients with triplane fractures with reported imaging modality performed during diagnosis, fracture management, and postoperative outcomes on the basis of functional scores and the incidence of any complications. RESULTS: A total of 11 articles met inclusion criteria, comprising a total of 203 skeletally immature patients with 203 documented triplane fractures. Male individuals were significantly older at the time of injury (14.2±0.6 y) when compared with female individuals (12.6±0.9 y) (P=0.006). Fracture diagnosis and management were evaluated using radiography+CT in 63% (128/203) of patients, whereas 37% (75/203) underwent radiography only. No significant differences in good/excellent Modified Weber Protocol scores were reported in patients treated nonoperatively versus those undergoing operative treatment (P=0.78), whereas Modified Weber Protocol scores were significantly higher in patients using radiography alone (P=0.02). No significant difference in complication incidence was reported on the basis of management type (nonoperative, 16%; operative, 15%; P=0.47). CONCLUSIONS: Patients undergoing operative management of triplane fractures achieved comparable functional outcomes scores without an increased incidence of complications when compared with patients undergoing nonoperative treatment. Further investigations analyzing outcomes at middle and long-term follow-up are necessary to determine the clinical utility of CT and various treatment modalities for the management of triplane fractures. LEVEL OF EVIDENCE: Level IV-Systematic review.

Comparison of mesenchymal stem cell sheets and chondrocyte sheets in a rabbit growth plate injury model

Background/aim: The treatment of posttraumatic deformities and differences in length between the extremities resulting from physeal injury remains controversial. The aims of this study were to compare the efficacy of tissue-engineered, monolayer, and allogeneic mesenchymal stem cell sheets and chondrocyte sheets for physeal arrest treatment and to investigate cell sheet technology as a novel method for cell transplantation in physeal cartilage repair. Materials and methods: A proximal tibial physeal injury was induced in New Zealand rabbits. Allogeneic mesenchymal stem cells (MSCs) and chondrocytes were cultured in temperature-responsive culture dishes and applied to the iatrogenic partial growth plate defects in single-sheet grafts (cell sheets). Treatment efficacy was determined using radiological measurements, as well as histological and immunohistochemical staining. Results: Treatment with MSCs and chondrocytes prevented endochondral ossification in the physeal plate, and bone growth resumed after treatment in both the MSC and chondrocyte cell groups. We found significant differences in radiological evaluations between pre- and posttreatment measurements in both MSC and chondrocyte groups. Transplanted cells were observed in the damaged area in both of the groups, which differentiated in the direction of growth plate cartilage. Conclusion: Our results support the hypothesis that MSC or chondrocyte transplantation using the cell-sheet technique described in the present study aids in the regeneration of cartilage tissue during physeal arrest after growth plate damage.

A Salter-Harris II Distal Radius Fracture Irreducible by Closed Methods.

CASE: A 10-year-old boy presented with a Salter-Harris II distal radius fracture that was irreducible by closed methods. An open reduction was performed in the operating room where a sleeve of periosteum was found interposed between the fracture fragments. Successful reduction was performed without difficulty after the periosteum was removed from the fracture. CONCLUSION: Soft-tissue interposition must be kept in mind when having difficulty performing closed reductions of pediatric distal radius physeal fractures to avoid excessive reduction attempts.

Traumatic Posterior Hip Dislocation and Epiphysiolysis in a High School Football Player with Successful Outcome at 4 Years Follow-up: A Case Report.

CASE: We describe a case of posterior hip dislocation in a 13-year-old boy after a contact football injury with attempted closed reduction resulting in complete separation of the epiphysis from the femoral neck metaphysis with associated femoral head fracture and posterior dislocation of the femoral head. Treatment was emergently performed with a greater trochanteric osteotomy, open reduction internal fixation using cannulated screws, and additional small diameter drill holes in the femoral head to promote blood flow. The patient did well postoperatively and at over 4 years follow-up had no evidence of avascular necrosis and returned to full athletics participation. CONCLUSION: Particular attention should be taken when reducing hip dislocations in the adolescent population who may be predisposed to epiphysiolysis. Preservation of periosteal soft-tissue attachments and the use of small diameter drill holes to promote femoral head blood flow may have contributed to the excellent outcome.

Status of growth plates can be monitored by MRI.

BACKGROUND: Growth plate injuries and disorders cause premature closure, resulting in shortened or deformed limbs. Quantitative assessment by MRI might monitor the status of the growth plate and may assist in the prediction of these deformations. PURPOSE: To investigate whether the status of the growth plate can be monitored by quantitative evaluation using MRI of the noninjured region of the growth plate in a physeal injury model. STUDY TYPE: Prospective, longitudinal. ANIMAL MODEL: A 3.0-mm drill was used to create an injury to the central region of the right proximal tibial growth plate in 5-week-old male Japanese white rabbits (N = 18). The left tibia served as the control. FIELD STRENGTH/SEQUENCE: 7.04T, T2 -weighted imaging, diffusion-weighted imaging. ASSESSMENT: Eight of 18 rabbits underwent MRI, proton density-weighted imaging, and T2 -weighted and diffusion-weighted imaging. T2 and apparent diffusion coefficient (ADC) maps were generated for each image. The growth plate height and the T2 and ADC values of the noninjured region were measured. Two rabbits were sacrificed at 2, 4, 6, 8, and 10 weeks postinjury. Proximal tibial bones were evaluated using microcomputed tomography, histological, and immunohistological methods. STATISTICAL TESTS: Data were compared using repeated-measures analysis of variance followed by Tukey post-hoc multiple comparison. RESULTS: Growth plate height decreased at 10 weeks postinjury (P = 0.018) on the injured side. T2 values were greater at 2 weeks postinjury (P = 0.0478) and decreased at 8 and 10 weeks (P = 0.0226, P = 0.0470, respectively) on the injured side. ADC values increased at 6 weeks on the lateral side (P = 0.0304) and decreased at 8 weeks and 10 weeks postinjury (P < 0.01) on the medial and injured sides, respectively. DATA CONCLUSION: Quantitative MRI can help monitor the status of the growth plate and capture its changes early. LEVEL OF EVIDENCE: 1 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:133-143.

Concurrent Ipsilateral Tibial Shaft and Distal Tibial Fractures in Pediatric Patients: Risk Factors, Frequency, and Risk of Missed Diagnosis.

BACKGROUND: The purpose of this study was to determine the frequency of concurrent ipsilateral distal tibial fractures with tibial shaft fractures in the pediatric population; to identify patient and fracture characteristics that increase the likelihood of a concurrent fracture; and determine if any of these concurrent distal tibial fractures were missed on initial radiographic examination. METHODS: Retrospective chart review was done to identify patients 5 to 17 years old who were treated for a tibial shaft fracture at a large, Level 1 free-standing children's hospital and an outpatient orthopaedic practice between 2008 and 2016. Patient and fracture characteristics were recorded. RESULTS: Of 517 fractures (515 patients), 22 (4.3%) had concurrent ipsilateral distal tibial fractures: 11 triplane, 5 medial malleolar, 3 bimalleolar, and 2 Tillaux (Salter-Harris III) ankle fractures, and 1 Salter-Harris II distal tibial fracture. Age was the only patient characteristic significantly associated with a second, more distal fracture: patients with both fractures were older (12.7 y) than those with an isolated tibial shaft fracture (11 y). There was no difference in the rate of distal tibial fractures between high-energy and low-energy mechanisms of injury and no differences in the rate of open injuries or the presence of a fibular fracture. Patients with a tibial shaft fracture at the junction of the middle and distal thirds were significantly more likely to have a concurrent distal tibial fracture; oblique and spiral fracture patterns were more frequent in the group with concurrent distal tibial fractures than in the isolated tibial shaft fracture group. CONCLUSIONS: In our series, 36% of the concurrent distal tibial fractures were not diagnosed until chart review for this study, which suggests the need for ankle-specific imaging in certain patients. We recommend ankle-specific imaging when an oblique or spiral tibial shaft fracture is located at the junction of the middle and distal thirds of the tibia or in patients in whom a distal tibial fracture is suspected because of pain, swelling, or bruising. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Physeal bridges: causes, diagnosis, characterization and post-treatment imaging.

The cartilaginous primary physis, or growth plate, at the end of long bones in children allows for longitudinal bone growth. A variety of insults to the physis can lead to physeal bridge formation, which in turn can lead to limb-shortening and angular deformities. This paper begins with a description of the causes, risk factors and mechanisms by which bridges form. Then it reviews the use of imaging in the diagnosis and characterization of bridges and in the evaluation of treatment and post-treatment complications. It is important for radiologists taking care of children to be aware of the indirect and direct imaging findings of physeal bridges to aid in their diagnosis, to be able to characterize bridges as part of preoperative planning, and to know the imaging finding of post-resection complications.

Displaced Salter-Harris I fracture of the distal ulna physis.

A 10-year-old girl presented to the emergency department having sustained a fall onto an outstretched left hand while playing soccer. Clinical and radiographical assessment identified a Salter-Harris I distal ulna fracture, as well as a buckle fracture of the distal radius. The injury was closed, and she had no neurovascular deficits on examination. She was brought to the operating theatre the following morning for closed reduction under general anaesthesia. Image intensification was used to confirm anatomical reduction, and an above-elbow moulded plaster-of-paris cast was applied. Follow-up clinical assessment at 6 weeks confirmed healing of the fracture, and she proceeded to make a full recovery. This case describes the anatomy and physiology of such rare injuries and outlines treatment principles and potential pitfalls based on best available evidence.

Distal femoral physeal fractures after neonatal osteomyelitis: A case report.

RATIONALE: The physeal separations and septic osteomyelitis in newborns are unusual, which represents a challenging problem in diagnosis and treatment. PATIENT CONCERNS: A 2-day-old mature male suddenly complained by parents about minimal swelling around the left knee, decreased left extremity motion and no fever. DIAGNOSIS: Preliminary x-rays of the lower extremities demonstrated a displaced distal femoral physeal, Laboratory investigation indicated infection. Magnetic resonance imaging and ultrasound showed displaced distal femoral physeal. A needle aspiration confirmed the diagnosis. INTERVENTION: Debridement and ultrasound guide reduction with pinning of physeal separations was performed. OUTCOME: At 5 years later, his last follow-up showed that there was only 1.6 cm limb-length discrepancy without angular deformity, the child did not report any pain and was perfectly able to perform his daily activities. LESSONS: Distal femoral physeal fractures after neonatal osteomyelitis requires immediate and reliable decision for management. We point out the important role of the application of sonography, which is helpful to make an early diagnosis and guide reduction and percutaneous pinning of distal femoral physeal fractures.

Management of ankle fractures in children.

Ankle fractures are a common injury in children and adolescents - 1 in 1000 children will sustain an ankle fracture each year. Understanding the diagnosis and management of these injuries is vital for any doctor or clinician working in the emergency department, orthopaedics or providing community care. This review identifies the important features of high- and low-risk ankle fractures, how to prevent the use of unnecessary radiation and the management of these injuries. Fractures may be at high or low risk of instability and are managed accordingly. Many can be treated with conservative management in a cast, including unstable injuries following reduction. However, particular fracture patterns associated with the tibial growth plate need careful assessment of fracture reduction with cross-sectional imaging before committing to conservative management.

Salter-Harris Type III Fracture in a Football Player.

A 15-year-old high school football player sustained direct impact to his anteromedial left knee by a teammate's helmet during practice. The physician referred the athlete immediately to an after-hours clinic for imaging to rule out a fracture. Radiographs of the knee showed a nondisplaced Salter-Harris type II fracture. The treating physician also ordered magnetic resonance imaging, the results of which allowed for a more specific diagnosis of the fracture as a Salter-Harris type III fracture of the left femur.J Orthop Sports Phys Ther 2019;49(3):209. doi:10.2519/jospt.2019.7984.

Pathogenesis And Radiological Findings In Rare Case Of Salter Harris Type I Distal Tibial Fracture With Associated Osteonecrosis In The Paediatric Population.

Salter-Harris type I fractures of the distal tibia are commonly seen in paediatrics and management of such fractures follows an algorithm established in the literature. Despite this, osteonecrosis of the distal tibia can subsequently develop. Osteonecrosis or avascular necrosis is cell death that occurs secondary to trauma, metabolic disturbances, sickle cell disease, or medication side effect. It most frequently affects the femur, talus, or humerus, and rarely the tibia. Radiographs and MRI are pivotal in making a timely diagnosis in order to minimize patient discomfort. To the best of our knowledge, there has only been one previous documented case of osteonecrosis following a Salter Harris Type I distal tibial fracture. Here, we present the second such case.

Salter-Harris Fracture of the Proximal Humerus in an Adolescent Gymnast.

A 13-year-old male gymnast presented via direct access to physical therapy with a chief complaint of insidious-onset right anterolateral shoulder pain that occurred only when performing on the rings and high bar. Following physical examination, the patient was advised to avoid any gymnastic activities that might cause pain while completing stretching and neuromuscular training over the following 2 weeks. Due to continued symptoms, the patient was then referred to an orthopaedist. Radiographs were performed, followed by magnetic resonance imaging without contrast. The patient was diagnosed with a type 1 Salter-Harris fracture. J Orthop Sports Phys Ther 2018;48(9):729. doi:10.2519/jospt.2018.7296.

Outcome of 3.5-mm Anatomical Locking Plates for the Treatment of Proximal Tibia Fractures Involving the Meta-Diaphyseal Junction.

The clinical and radiological outcomes of proximal tibia fractures involving the meta-diaphyseal junction treated with unilateral 3.5-mm locking precontoured anatomical plates are reported. Thirty-nine patients (41 proximal tibia fractures) who had proximal tibia fractures with complete meta-diaphyseal dissociation were enrolled in the study. For all patients, immediate postoperative and final follow-up simple radiographs were evaluated to determine the quality of the reduction by assessing coronal and sagittal alignment. In cases of intra-articular involvement, articular reduction quality and condylar width were additionally assessed. Clinical outcomes were assessed by knee range of motion and Lysholm knee score at final follow-up. Immediate postoperative radiographs showed satisfactory results: medial proximal tibial angle within 87°±5° in 87.8% (36 of 41), posterior tibia slope within 9°±5° in 85.4% (35 of 41), less than 2-mm articular step or gap in 79.3% (23 of 29), and a condylar width difference within 5 mm compared with the femoral condyles in 93.1% (27 of 29). All reductions but 1 were found to have satisfactory maintenance of the initial reduction. At final follow-up, the mean knee range of motion and Lysholm knee score were 122.5° (range, 100°-135°) and 75.8 (range, 50-100), respectively. A single lateral 3.5-mm plate fixation for proximal tibia fractures involving the meta-diaphyseal junction offers mechanically stable fixation with satisfactory clinical and radiological outcomes. [Orthopedics. 2018; 41(6):e777-e782.].