Authors
- Hayes, Nicholas MBBS
Abstract
Review question/objective: 1. What are safe and effective interventions for the management of distal femoral growth plate fractures in children in terms of rates of growth deformity and rates of growth arrest?
More specifically, the objectives are to compare:
1 different methods of surgical treatments in the acute management of distal femoral growth plate fractures in children and adolescents;
2 different methods of non-surgical treatments in the acute management of distal femoral growth plate fractures in children and adolescents;
3 surgical versus non-surgical treatments in the acute management of distal femoral growth plate fractures in children and adolescents; and
4 different outpatient follow-up strategies, in particular, frequency of visits, frequency of radiographic evaluation and longevity of patient follow-up, following treatment of distal femoral growth plate fractures in children.
Surgery will be defined as treatment either by incision or physical manipulation by a surgical doctor.
Background: Description of the condition
The growth plate, or physis, is located between the epiphysis and metaphysis at the end of long-bones in children and young adults. It is the region of the bone where tightly-regulated endochondral ossification is responsible for longitudinal growth.1,2 The distal femoral physis is anatomically significant in that it contributes 70% of the longitudinal growth of the femur, equating to approximately 40% of the length of the lower extremity.3-6 Previous studies analyzing growth plate fractures found that physeal fractures account for approximately 15-30% of pediatric fractures and up to 4% of total pediatric fractures involve the distal femoral physis.7,8 At the distal femoral physis, major anatomical structures are the lateral notch, anteromedial notch, central ridge, lateral ridge, and medial peak.9 During childhood bony development, the central ridge has the most pronounced decrease in height and surface area, whilst the lateral notches deepen.9
From birth, there are three distinct periods of growth velocity.10 They are from birth to five years of age, from five years of age to puberty, and from puberty onwards. The most accelerated phase of childhood growth occurs at puberty.10,11 As skeletal maturity approaches, the central ridge has the highest relative decrease in size. This change in morphology accounts for a decrease in mechanical stability and therefore predisposes the physis to injury.9 With growth, the epiphysis becomes less cartilaginous.12 Riseborough et al. observed distal femoral physeal injuries in children, noting a greater distribution of higher energy injuries in the younger of these, hypothesizing a thicker periostium protects the physis from the lesser forces.13
The physis of the distal femur is inherently weaker than the ligaments of the knee. Thus, if an injuring force is applied to this area, a physeal fracture will more readily be produced rather than a disruption to these ligaments.14,15 A fracture to the distal femoral epiphyseal plate injury is frequently the result of a high energy injury. Common mechanisms of injury include motor vehicle accidents (including pedestrians and cyclists), sports-related injuries, and falls.16-18 Historically, when wagons and carts were common transportation vehicles, a child's foot lodging in a spoke would readily result in a distal femoral physeal fracture causing significant morbidity and mortality.19 Abduction, adduction, hyperflexion and hyperextension are known mechanisms of distal femoral physeal fractures.5
A distal femoral physeal injury is fraught with numerous potential complications.3,5,17,20,21 Complete or partial growth arrest is commonly seen, which may manifest clinically in leg length discrepancy and angulation deformity.5 Additionally, limitation on knee motion, quadriceps atrophy, osteomyelitis or osteoarthritis may result from this injury.5,22,23 A meta-analysis by Baesner studying distal femoral physeal fractures reported an incidence of 52% in growth disturbance with 22% of the growth disturbance greater than 1.5cm.21 Arkader et al. reported a complication rate of 40% with growth arrest the most common.20
It has been suggested that growth disruption and angular deformity follows peripheral bridging as a result of disruption to the zone of Ranvier.5,15 A radiological study proposed a graduation of the physeal injury, which may begin as an incomplete bridge at the central area with dense, sclerotic core causing continued disruption remaining.24
It has been postulated that fracture type, fracture mechanism, direction of injury, displacement, nature of physis, and the treatment mode may correlate with the clinical outcome of a distal femoral physeal injury.11,17,21,25,26 Some authors have suggested follow up until skeletal maturity as potential for late complications may exist.3,17,26
For epiphyseal fractures of the distal femur, modes of diagnosis of and further evaluation include plain radiography and computed tomography. Magnetic resonance imaging is able to give gradient sequences to highlight the physis and is the most suitable method for detecting bone-bridge formation.27,28
Numerous classification systems for physeal fractures have been proposed and developed since Foucher's grading in 1863. More contemporarily, in perusing the literature, the Salter Harris (SH) Classification, described in 1963, is most commonly used.17,21,29 It was developed to correlate mechanism of injury to the appearance of the fracture lines, repair and growth prognosis.30,31 Additions and further suggestions to the SH Classification have been made in recent years.15,32-35
A SH I fracture is considered to involve the cartilage of the growth plate. SH II involves bony disruption from the metaphysis to the growth plate. A SH III fracture is from the epiphysis to the growth plate. The SH IV injury is through the metaphysis, physis and epiphysis, whereas a SH V fracture is a crush injury to the physis.
For growth plate fractures, the aim of management is to keep the metaphysis, epiphysis and physis separate so that the physeal cartilage is able to grow in between to separate them.36 Management decisions regarding these injuries are generally constructed around the degree of displacement and SH grading.17,20,21,23,29
In a search of available literature, there was no systematic literature review evaluating the most effective treatment methods for distal femoral physeal fractures. Published studies show a degree of inconsistency in treatment methods for similar fractures and presentations.
Generally however, for distal femoral physeal fractures, non-displaced SH I fractures are managed conservatively in a full length leg cast or hip spica. If displacement does exist, closed manipulation with a cast may be used. Internal fixation involving K wires or pinning through the epiphysis offers another option for this fracture type. Non-displaced SH II fractures may be managed non-operatively but must be monitored closely for loss of reduction. Displaced SH II as well as well as SH III and IV have been managed operatively, although exact methods of surgical approach and devices vary.17,20,21,23,29
Whilst in some cases, surgery has shown less risk of re-displacement of the facture, this is a treatment not without risks.26 Potential surgical complications include osteomyelitis, injury of surrounding structures including vascular injury, nerve injury and growth plate injury.5,16,26
The decision regarding the exact management of these fractures is made by the treating specialist. It may be influenced by factors such as knowledge-base, experience, comfort level of the surgeon and available resources.
The purpose of this review is to synthesize the best available evidence regarding the effectiveness of these interventions.
Article Content
Inclusion criteria
Types of participants
This review will consider studies which include male and female children, younger than or equal to 18 years of age, with a distal femoral physeal fracture treated either operatively or conservatively, within 72 hours of presentation to hospital. Children may have a single or multiple injuries. The distal femoral physeal fractures considered may be open or closed injuries. Studies which follow-up these patients in the outpatient setting will also be reviewed to evaluate the incidence or detection rates of the later-appearing complications.
This review will not consider children with osteochondritis dissecans, Blount's disease, or children with other comorbidities adversely affecting the repair of a growth plate fracture.
Types of interventions
This review will consider studies which evaluate surgical and conservative treatments for distal femoral growth plate fractures in the acute hospital setting. Following the initial treatment, this review will also consider studies that evaluate different follow-up strategies for these patients in the outpatient setting. In particular, the frequency of outpatient follow-up visits, intervals between radiographic evaluation and the longevity of patient follow-up will be evaluated to determine the detection rate or incidence of outcomes such as growth arrest.
Types of outcomes
This review will consider studies that include the following outcome measures;
Primary outcomes:
* Rates of growth of the distal femur with different treatment strategies. This may be determined by the presence or absence of Harris growth arrest lines on X-Ray or measured by an absolute or relative leg length discrepancy.
* Angular or rotational deformity, measured radiographically in accordance with the appropriate technique described by Dror Paley.37
* The incidence of complications such as growth disturbance for different outpatient follow-up strategies, in particular, frequency of visits and longevity of patient follow-up, following treatment of distal femoral fractures in children.
Secondary outcomes:
* Patient factorsReturn of function in terms of pain control or absence of pain, walking ability, knee range of motion, return to sport, muscle atrophy, and ligamentous laxity.
* Treatment factorsFailure of treatment including non-union, mal-union, re-displacement, varus or valgus leg deformity and need for subsequent treatments or surgery. Complications of surgery or other treatments may include vascular injury, nerve injury, infection, thromboembolic disease, compartment syndrome or other secondary injury from the treatment.
* Hospital factorsLength of stay in hospital and a comment on resources required to perform certain treatments.
Outcomes will be categorized between immediate (occurring less than 2 weeks from injury) and non-immediate. The outcomes considered will be evaluated to determine if a relationship exists with the age, sex, and mechanism of injury, premorbid function and the comorbidities of the child. Injury factors such as SH classification, initial length discrepancy, as well as associated primary injuries including vascular injury, nerve injury, compartment syndrome, other bony injuries, will be considered. The experience level of the primary surgeon selecting and performing the chosen initial treatment will be considered.
Types of studies
Priority will be given to higher evidence-level study designs. This review will first consider randomized controlled trials (RCTs). In the absence of RCTs, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, and case control series will be considered. This review will also consider descriptive epidemiological study designs, including case series and case reports for inclusion.
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed and EMBASE will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The studies may be from any country with the article to be available in English. Studies published from 1970 onwards will be considered for inclusion in this review to ensure comparable treatment modalities.
The databases to be searched include: PubMed, EMBASE and Scopus. Grey literature will be searched through the Scirus database. Papers which meet inclusion criteria presented at conferences or meetings hosted by State or National Orthopedic Associations will also be considered for inclusion, available through the relevant Association website or on request.
An example of a search strategy that will be used when searching the PubMed database include:
femur[mh] OR femur[tw] OR femoral[tw]
AND
epiphyses[mh] OR epiphys*[tw] OR growth plate*[tw] OR physe*[tw] OR physis[tw]
AND
wounds and injuries[mh:noexp] OR injur*[tw] OR fractur*[tw] OR fractures, bone[mh:noexp]
Assessment of methodological quality
Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I ). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data collection
Quantitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II ). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis
Quantitative papers, where possible, will be pooled in statistical meta-analysis using the JBI MAStARI software. All results were subjected to double data entry to minimize the risk of error during the data entry. Where appropriate, Relative Risks and/or Odds Ratios and their associated 95% confidence interval will be calculated for analysis of categorical data. For continuous data that were collected using the same scale, the weighted mean differences (WMD) will be calculated; for data collected using different scales, the standardized mean differences (SMD) will be calculated. Heterogeneity will be assessed using standard Chi square test and if found will be investigated prior to any further analysis. Where appropriate, meta-analysis will be conducted using JBI MAStARI. Where statistical pooling is not possible, the findings are presented in narrative form.
Conflicts of interest
The authors declare no conflicts of interest.
Acknowledgements
The authors would like to acknowledge Dr William Cundy, Associate Professor Edoardo Aromataris and Dr Catalin Tufanaru for their expert advice and suggestions regarding inclusion criteria, outcome measures and in the refinement of this protocol. Further acknowledgement to Maureen Bell for her input and feedback regarding the search strategy.
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Appendix I: Appraisal Instruments
MAStARI appraisal instrument[Context Link]
Appendix II: Data extraction instruments[Context Link]
Keywords: Physical injury; fracture; femur; growth plate; distal femur; children