The Hip: Preservation, Replacement and Revision

Salter Harris Type II: Distal Femoral Physeal Fractures

- Salter Harris Type II Fractures:
     - 80% of type II fractures can be managed non operatively;
     - displaced SH type-I or II frx are reduced closed w/ pt under GEA;
     - reduction is obtained mainly by traction rather than manipulation;
            - 90 % traction, 10 % manipulation;
     - knee may require flexion for reduction, however, too much flexion may risk vascular comprimise;
     - anterior displacement:
            - may be associatted w/ vascular insufficiency, as the popliteal artery is injured by the distal femoral metaphysis;
            - reduction of these frx is facilitated by having patient in the prone position and flexion of knee to 90 deg, utilizing the intact anterior periosteum;
            - treated w/ single leg spica cast in slight to moderate knee flexion for 6 weeks;
     - posterior displacement is treated w/ single leg spica cast in extension;
            - note that casting the patient in extension may be more painful than flexion, and therefore, if adequate reduction is achieved w/ slight flexion, then casting in extension is not necessary;
     - if reduction is not possible, consider interposed soft tissue;
     - following reduction of a displaced frx, determine whether frx is stable or unstable (as determine from flouroscopy);
     - if the fracture is unstable then some form of fixation is necessary;

- Operative Rx: SH II Frx:
     - percutaneous screw fixation:
             - mainly indicated for type II fractures with a large Thurstan Holland metaphyseal spike, which will accomodate one or two screws;
             - obviously screws cannot cross the fracture site;
     - percutaneous pinning w/ smooth Steinmnan pins placed through metphyseal fragment, parallel to the
             epiphysis is recommended for displaced or angulation frx;
             - optimally fixation will not cross the physis, however, transmetaphyseal pins may be required for unstable type I frx or type II frx w/ a short metaphyseal fragment;
                    - in this case, pins should be directed through the center of the physis in order to minimize any angulatory deformity that might result from physeal bar formation;
             - in general, pins are cut beneath the skin inorder to avoid infection and subsequent joint sepsis;
     - if acceptable reduction is not possible, then ORIF is required;
             - the block to reduction may be a medial periosteal flap;
     - following internal fixation, a long leg cast is applied with slight flexion;

     - case example:
             - 9 year old female who was pinned between a car bumper and a brick wall, sustaining bilateral distal femoral physeal frx;
             - open reduction was required along w/ internal fixation w/ Steinman pins;



- Complications: Growth Plate Arrest:
     - limb length descrepancy of more than 1 cm may occur in over 40%.
     - angular deformities may occur in a third of patients

Traumatic injuries of the distal femoral physis. Retrospective study on 151 cases.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, September 13, 2012 1:08 pm