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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.