Physeal injuries are common and unique features of children’s bony injuries.
Physis or growth plate provides longitudinal growth of children long bone.
Causes of physeal injuries are as follows –
Trauma – Direct injury due to fracture involving the physis. An indirect injury like compression forces or ischemia can result in physeal injuries.
Infection – Long bone osteomyelitis or septic arthritis of the shoulder, hip, and knee results in either physeal growth disturbance or frank growth arrest.
Tumour – Benign (Olliers disease – Multiple enchondromatosis), Malignant tumours, and tumour like disorder (Unicameral bone cyst).
Vascular insult – Common site is tibial tubercle and distal femur physics
Repetitive stress – The most common locations are distal radius or ulna in gymnasts, proximal tibia in runners, kicking sports such as soccer, and proximal humeral physis in baseball pitchers.
Miscellaneous – Irradiation, thermal injury, electrical, unrecognized trauma, or infection.
Acute direct physeal injuries will present with sudden onset of pain and swelling over the injured extremity.
Acute signs of direct injuries such as ecchymosis, swelling, tenderness, and a restricted range of motion will present.
Whereas physeal injuries due to indirect trauma and other causes will present with angular deformity of the extremity and limb length discrepancy.
Signs indirect injuries such as scar marks of an old injury, healed sinus tract, signs of benign tumors will be present.
Acute direct physeal injuries are evaluated with plain radiographs.
Radiographs should be taken in a true orthogonal view and include the joint above and below. Oblique radiographic may be of value in assessing minimally displaced injuries.
Ultrasonography is useful in identifying epiphyseal separation in infants and intra-articular effusion. Magnetic resonance imaging is excellent for demonstrating soft tissue lesions and minor osseous injuries.
Indirect physeal injuries or late sequelae of physeal injuries need multimodal evaluation with radiographs, computed tomography scan, and magnetic resonance imaging.
The radiographic evaluation includes an orthogonal view of the affected part and standing alignment view for lower limb physeal injuries.
Computed tomography scans provide an excellent definition of bony anatomy and bony physeal bar, particularly using the reconstructed images.
Magnetic resonance imaging helps in mapping the physeal bar and assessment of the healthy physis.
Acute direct physeal injuries should be dealt with gently with careful reduction and minimal implants crossing the physis.
Late presenting physeal injuries with angular deformity and limb length discrepancy are dealt with following options –
Physeal bar resection
Physeal bar resection with corrective osteotomy for angular deformities
Repeated osteotomies with limb lengthening
Complete epiphysiodesis and limb lengthening.
Long term consequences of physeal injuries are growth disturbances leading to angular deformities, limb length discrepancies, and joint distortion.