EpiphysEal Growth platE FracturEs

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EpiphysEal Growth platE FracturEs

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Hamlet A. Peterson

Epiphyseal Growth plate Fractures

With 1983 Figures and 95 Tables

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Library of Congress Control Number:

2006931258

ISBN 978-3-540-33801-7

Springer Berlin Heidelberg New York

Hamlet A. Peterson, MD, MS

Emeritus Consultant, Department of Orthopedic Surgery and Emeritus Chair

Division of Pediatric Orthopedic Surgery Mayo Clinic

Emeritus Professor of Orthopedics Mayo Medical School, Mayo Clinic College of Medicine

200 First St. SW

55905 Rochester, Minnesota USA

This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, spe- cifically the rights of translation, reprinting, reuse of illustra- tions, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag, except for Mayo Founda- tion copyrighted artwork to which inquiries should be ad- dressed to Scientific Publications, Plummer 10, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. Violations are liable for prosecution under the German Copyright Law.

Springer is a part of Springer Science+Business Media springer.com

The use of general descriptive names, registered names, trade- marks, etc. in this publication does not imply, even in the ab- sence of a specific statement, that such names are exempt from the relevant protec-tive laws and regulations and therefore free for general use.

Editor: Gabriele Schröder, Heidelberg, Germany Desk Editor: Irmela Bohn, Heidelberg, Germany Production: LE-TEX Jelonek, Schmidt & Vöckler GbR, Leipzig, Germany

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Dedication

I thank my family for their positive influences on me throughout my formative years, which continue to this day. To my wife, Suzanne, to whom this book is dedicated, I owe the most by far. She is editor-in-chief.

Her spirit never flags. She holds a steady course and is a lady in all seasons. The book would never have been completed without her encouragement and help.

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introduction

The subspeciality of Pediatric Orthopedics is distin- guished from adult orthopedics in many ways. The two most prominent differences are the small size of the patients and the presence of growth plates (physes). Physes may be injured in various ways, the most

common of which is fracture. This textbook is an overview of fractures of the physis, and is divided into three parts: general considerations, anatomic sites of fracture, and premature partial physeal arrest, the most common and onerous complication.

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preface

Textbooks are the medium where knowledge is accu- mulated, evaluated, and stored, and where, hopefully wisdom grows. Assembling facts, made known by preceding observers, investigators, and authors, ad- vances the science. Through their effort and insight, we benefit.

The creation of any medical textbook begins with a labor of love, but rapidly takes on a life of its own.

This text was no exception and has been a “work in progress” over my entire 30-year practice of pediatric orthopedics at Mayo Clinic. Throughout this period, I was challenged with difficult cases, have lectured extensively, have written multiple journal articles and book chapters on growth plate injuries, and have been collecting illustrative cases with the intention of someday writing this text.

Poland’s monumental and classic work, “Traumat- ic Separation of the Epiphysis” (Smith, Elder and Company, London, 1898), brought needed attention to the subject of growth plate injuries. He was the first to classify growth plate fractures. His textbook included references from several languages and, as far as I can tell, included all of the literature on the subject to that date. There has been no subsequent similar textbook.

I retired from active practice in February 1997. It was my intention to review all of the literature relative to growth plate fractures from the twentieth century, thereby supplementing the work of Poland. As articles in 2000 and 2001 journals appeared they were included. However, it also became apparent that if new material was included each year, the manuscript would never be completed. Thus, the literature review ends December 2001. In this goal of evaluating all twentieth century English language literature, I have fallen short, particularly in obtaining articles from the first decades of the century published in journals which no longer exist. Also absent are some articles in journals not available in the Mayo Clinic library. Some non- English language references are included. These include some important articles that were translated by the Mayo Language Department and by foreign

speaking Mayo orthopedic residents, and some recent articles which have English abstracts. I have person- ally read all the English articles and abstracts included in the references. In each, I have tried to find at least one bit of new, confirmatory, or contrary information or insight. I have avoided citing a bit of information attributed to one author by another author.

Excluded are abstracts followed by published articles, identical articles published in multiple publications, and works of obvious plagiarism. Some articles per- taining to animal research have been included when they have strong implications and associations with fractures of the physis in humans. Articles concerning physeal fracture in the veterinary literature are not included. Any misrepresentations or errors of interpretation or citing, are mine alone.

There are several excellent chapters in existing textbooks (referenced in Chapter 1) which contain vast amounts of information on all aspects of physeal fractures. Material contained in these chapters is referenced in appropriate chapters in this text, when the information is unique. Most information in textbook chapters is an accumulation of then-known knowledge. This general knowledge information in these chapters is not routinely referenced, to avoid repeti- tious referencing.

This textbook is divided into three major parts:

General Considerations, Anatomic Sites, and Prema- ture Partial Physeal Arrest. In each part, emphasis on the fundamentals of diagnosis and treatment of physeal fractures is supplemented with sections on anatomy, prognosis, and complications, so that the subject is covered from a clinical perspective. This design is intended for easy quick reference to any specific, and particularly any uncommon, growth plate problem.

There is an effort to connect the thoughts, concepts, and practices of earlier times with current thinking.

The reader will learn “when” and “how” to institute treatment, as well as the “what” and “why.” Since my aim was to be both practical and didactic, sections on classification and epidemiology are included to sys- tematize and emphasize basic understanding.

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Nearly all the cases illustrated in this text were patients seen and treated at Mayo Clinic. Some were from Olmsted County, the county in Minnesota where Mayo Clinic resides. Some were referred from elsewhere for initial care, but most cases were referred in various stages of healing, usually including an anticipated or established complication. A few cases were reviewed by correspondence and were not seen at Mayo. Credit for these cases has been given to the corresponding physician when appropriate.

The greatest impediment to advancing the science of growth plate fractures is the paucity of long term follow-up. Thus, where possible, illustrative cases have been chosen in which long follow-up was available. These long term follow-up cases were available due to several factors. First, there was a concerted effort by the pediatric orthopedic staff to obtain them.

Second, was the nature of the practice. Each Mayo patient has one medical history, which includes all outpatient, inpatient, surgical, and emergency room visits. In many instances a patient would not return for the requested follow-up. However, when the patient returned to the clinic months, years, or even decades later for another medical problem, the inter-

viewing physician would often obtain the requested history and roentgenograph. And third, the Mayo adult orthopedic staff would usually inform the pediatric orthopedist, or record in the history, concerning any relevant follow-up information.

The book was written with the practicing pediatric orthopedist in mind – the surgeon who needs to ex- tract information as quickly and easily as possible.

The book is an excellent source of information for residents in the emergency room who are encountering physeal fractures for the first time. The exhaus- tive reference list encompassing the twentieth century should also serve the academic surgeon as a resource of published information on the subject of physeal fractures, as well as to identify unknown aspects. A conscious effort was made to keep each chapter brief, but the importance of the subject matter mandated the amount of information included. It is my hope that the reader, who might be any pediatric orthopedist, orthopedist-in-training, general orthopedist, or traumatologist, will find the information in this book, and its presentation, useful.

Hamlet A. Peterson

preface

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acknowledgments

The genesis of this book began many years ago while encountering a wide variety of interesting patient problems. The collection of data from these patients and periodic publishing of related articles, supplemented by a review of the literature, forms the basis of the book. In this regard I am indebted to Mayo Clinic, and in particular to its related Departments of Ortho- pedic Surgery, Pediatric and Adolescent Medicine, and Radiology, the Divisions of Biostatistics, and Me- dia Support Services, the Section of Scientific Publi- cations, the Mayo Clinic Library, the Legal Depart- ment, and the Emeritus Staff Center. Also, the liberal Mayo Clinic travel policy allowed me to attend frequent meetings, symposia, and seminars to keep abreast of ongoing developments in all aspects of pediatric orthopedics.

Nearly the entirety of my 30-year career at Mayo was spent with pediatric orthopedic colleagues Drs.

Tony Bianco and Rudi Klassen. For 19 of those years we saw patients in the same clinic area and operated in adjacent operating rooms on the same days. This sharing of patient experiences, trials, tribulations, successes, and failures, and their counsel and friend- ship have been invaluable not only for accumulating the data in this book, but also for my professional development and insight into the material presented herein. In more recent years this was supplemented by wise counsel and patient follow-up information by pediatric orthopedic colleagues Drs. Bill Shaughnessy and Tony Stans, and by all the adult orthopedic staff who kept me informed about our former patients.

A monetary award from the Huene Foundation was instrumental in the initial start up, by funding a personal computer and underwriting the cost of manuscript transcription. For a book of this magnitude, an enormous amount of skilled support was required.

I would like to thank Karen Fasbender, and my wife,

Suzanne, who cheerfully typed the manuscript and its frequent revisions. Their diligence and patience is greatly appreciated. Special thanks go to secretaries MaryAnne Petersen and Kathy Grutzmacher who procured and assembled patient histories and roentgenographs. I am particularly indebted to David Fac- tor, the medial illustrator who rendered all the draw- ings and was so patient with my multiple suggestions and requests, and to Dr. Rudi Klassen for gathering the follow-up data on our physeal bar excisions as documented in Chapter 33. Dr. Joe Melton and Joanne Benson in Biostatistics were most helpful in acquir- ing, assembling, and reviewing data from the Olmst- ed County study. The professionalism of all the folks in Media Support Services, where roentgenographs were copied and graphs designed, was a wonder to behold. The expertise of Roberta Schwartz in Publi- cations and Janice Thompson in the Legal Depart- ment, were indispensable in navigating publication and legal issues. I thank Ms. Gabriele Schröder, and the staff of Springer for their skill and imagination in creating a product of the highest standard and quality.

Finally, I pay tribute to all previous authors of various aspects of physeal fractures who labored to pub- lish their observations so that we might learn to better care for pediatric patients. In particular, I salute my mentors and colleagues in the Department of Ortho- pedics at Mayo Clinic who were instrumental in my development, and for fostering in me a desire to share my experience and knowledge with others.

Despite all of this help, this book would never have reached completion without the support and encouragement of my wife, Suzanne, who was constant and relentless in urging me to stay the course and finish the race.

To all, I owe immense gratitude.

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contents

part i

physeal Fractures: General considerations

chapter 1 historical review

prior to the twentieth century.. . . 3 the twentieth century... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 5 references.. . . 6

chapter 2

anatomy and Growth

history... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 7 anatomy.. . . 7 Growth.. . . 12 references.. . . 17

chapter 3 classification

introduction.. . . 22 Bergenfeldt 1933 ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .22 aitken 1936. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..22 Brashear 1958... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .22 salter and harris 1963. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..25 rang 1969... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .27 ogden 1981. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..27 shapiro 1982. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..27 peterson 1994... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .28 anatomy.. . . 28 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .28 Fracture type, age, and site... .. .. .. .. .. .. .. .. .. .. .. .28 prognosis. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..28 complications.. . . 28

A Type 1 Fracture.. . . 30 anatomy.. . . 30 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..32 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .33 Evaluation... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .35 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .44 complications.. . . 44 B Type 2 Fracture.. . . 49 anatomy.. . . 49 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..49 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .50 Evaluation... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 51 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 51 complications.. . . 56 C Type 3 Fracture.. . . 58 anatomy.. . . 58 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..58 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .58 Evaluation... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .58 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .59 complications.. . . 64 D Type 4 Fracture. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..66 anatomy.. . . 66 classification. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..66 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .67 Evaluation... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .68 Management. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..71 complications.. . . 71 E Type 5 Fracture.. . . 72 anatomy.. . . 72 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..72 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .73 Evaluation... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .73 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .73 complications.. . . 74

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Xi contents F Type 6 Fracture.. . . 77 anatomy.. . . 77 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..77 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .77 Evaluation... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .84 Management. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..84 complications.. . . 85 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..90 references.. . . 90

chapter 4 Epidemiology

introduction.. . . 93 literature review... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .93 the olmsted county study.. . . 99 comparison of Data from the literature

and the olmsted county study. .. .. .. .. .. .. .. .. .. .. 113 conclusions. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 113 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 114 references.. . . 114

chapter 5 Evaluation

history... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 117 physical Examination... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 117 imaging. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 117 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 128 references.. . . 128

chapter 6 Management

Goals of treatment ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...131 type of Fracture . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .133 Management choices . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .134 additional concepts ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...136 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .138 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .138

chapter 7 prognosis

severity of injury ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...141 age . ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...141 site . ... . . 141 type .... . . 142

treatment .. . . ..142 Gender . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .143 remodeling .. . . ..143 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .143 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .143 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .143

chapter 8 complications

Epidemiology of complications .. . . ..145 list of complications .. . . ..150 I. Complications Occurring

At or Near the Time of Fracture. .. .. .. .. .. .. .. .. .. .150 a. ascular occlusion. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .150 B. compartment syndrome... .. .. .. .. .. .. .. .. .. .. ...154 c. irreducible Fracture... .. .. .. .. .. .. .. .. .. .. .. .. .. ...158 D. Nerve impairment.. . . ..162 E. infection... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...162 II. Complications Manifesting at a Later Date... .. ...169 F. complete physeal arrest ... .. .. .. .. .. .. .. .. .. .. ...169 G. Nonunion. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .170 h. Malunion.. . . ..176 i. ischemic Necrosis... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...180 J. overgrowth ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...183 K. synostosis. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .184 l. heterotopic ossification ... .. .. .. .. .. .. .. .. .. .. ...187 M. refracture ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...191 N. loss of Motion... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...194 o. pathologic Fracture... .. .. .. .. .. .. .. .. .. .. .. .. .. ...194 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .196 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .196

part ii

physeal Fractures: anatomic sites chapter 9

phalanges of the hand

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .201 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .203 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...203 Evaluation .. . . .208 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...215 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .222 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .225 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .225

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contents

chapter 10 Distal radius

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .227 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .229 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...232 Evaluation .. . . ..235 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...237 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .258 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .263 A. Stress Injury: Gymnast’s Wrist. .. .. .. .. .. .. .. .. .. .. .263 anatomy . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .263 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .266 Epidemiology .. . . .266 Evaluation .. . . .268 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .268 complications.. . . ..269 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .269 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .269

chapter 11 Distal tibia

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .274 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .276 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...276 Evaluation .. . . ..279 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...295 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .303 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .307 A. Medial Malleolus. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .311 anatomy . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .311 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .311 Epidemiology .. . . .311 Evaluation .. . . ..312 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...319 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .324 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .333 B. Lateral Plafond. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .338 anatomy . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .338 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .339 Epidemiology .. . . ..339 Evaluation .. . . .340 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...343 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .349 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .349

C. Triplane Fractures.. . . ..353 history .. . . ..353 anatomy . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .355 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .357 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...362 Evaluation .. . . ..362 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...371 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .380 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .383 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .384

chapter 12 Distal Fibula

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .389 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .390 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .390 Evaluation .. . . ..392 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...396 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .396 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .397 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .397

chapter 13 Metacarpal

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .399 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .401 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...401 Evaluation .. . . .402 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .405 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .405 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .407 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .410

chapter 14

phalanges of the Foot

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .411 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .414 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...414 Evaluation .. . . ..415 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...415 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .415 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .418

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chapter 15 Distal humerus

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .422 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .425 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...426 Evaluation .. . . ..428 Fracture types by age. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .434 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...437 A. Lateral Condyle... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .440 anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 440 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 440 Epidemiology .. . . 443 Evaluation .. . . 443 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 448 complications.. . . ..456 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .479 B. Intercondylar. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .479 anatomy . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .479 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 486 Epidemiology .. . . 486 Evaluation .. . . 487 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 487 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .493 C. Medial Condyle. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .493 anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .493 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .494 Epidemiology .. . . .494 Evaluation .. . . .494 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...503 complications.. . . ..507 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .509 D. Separation of the Distal Humeral Epiphysis... .. . .509 anatomy . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .509 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .511 Epidemiology .. . . ..511 Evaluation .. . . ..512 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...512 complications.. . . ..513 E. Fishtail Deformity... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...513 anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .513 Epidemiology .. . . ..514 Evaluation .. . . ..517 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...517 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .517 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .518

chapter 16 Distal ulna

anatomy and Growth.. . . ..525 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .527 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...527 Evaluation... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...527 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...531 complications.. . . ..534 author’s perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .542 references.. . . .546

chapter 17 proximal humerus

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .549 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .553 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...553 Evaluation .. . . ..553 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...559 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .575 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...578 A. Birth Fractures . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .581 anatomy . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .581 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .581 Epidemiology .. . . ..581 Evaluation .. . . ..581 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...582 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .582 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .584 B. Humerus Varus. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .584 anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .584 Epidemiology .. . . ..585 Evaluation .. . . .586 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .586 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .589 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...589 C. Stress Injury (Little Leaguer’s Shoulder) ... .. .. .. ...589 anatomy . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .589 Epidemiology .. . . ..590 Evaluation .. . . ..590 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...590 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .591 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...591 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .591

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chapter 18 Distal Femur

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .595 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .598 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...598 Evaluation .. . . 603 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 608 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .627 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .634 A. Birth Fractures. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .634 anatomy . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .634 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .634 Epidemiology .. . . .634 Evaluation .. . . ..635 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...639 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .640 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .640 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .640

chapter 19 Metatarsals

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 643 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 644 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...647 Evaluation .. . . ..647 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...647 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .647 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .650

chapter 20 proximal tibia

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .651 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .655 Epidemiology .. . . ..659 Evaluation .. . . ..659 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...661 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .681 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 686 A. Stress Injury... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 686 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .691

chapter 21 proximal radius

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .695 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 696 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 696 Evaluation .. . . .699 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .700 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .718 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .731

chapter 22 proximal ulna

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .733 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .736 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...737 Evaluation .. . . ..739 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...744 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .745 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...745 A. Stress Injury... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...745 anatomy . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .745 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .746 Epidemiology .. . . ..746 Evaluation .. . . ..746 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...746 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .747 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .747

chapter 23 proximal clavicle

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .749 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .750 Epidemiology .. . . ..750 Evaluation .. . . ..750 Management. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .751 complications.. . . ..753 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...753 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .753

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Xiii contents

chapter 24

pelvis: triradiate cartilage

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .755 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .756 Epidemiology .. . . ..756 Evaluation .. . . ..757 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...759 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .765 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...766 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .767

chapter 25 Distal clavicle

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .769 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .769 Epidemiology .. . . ..769 Evaluation .. . . ..770 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...770 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .772 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .772

chapter 26 proximal Femur

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .773 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .776 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...777 Evaluation .. . . ..778 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...778 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .785 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...786 A. Birth Fractures. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .786 anatomy . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .786 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .786 Epidemiology .. . . ..786 Evaluation .. . . ..787 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...788 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .788 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...788 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .789

chapter 27 proximal Fibula

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .791 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .792 Epidemiology... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...793 Evaluation .. . . ..793 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...793 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .793 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .795

chapter 28

spine (ertebral physeal Endplate)

anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .797 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .799 Epidemiology .. . . ..799 Evaluation .. . . ..799 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...802 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .802 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...802 A. Cervical Spine... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...802 anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .802 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .802 Epidemiology .. . . ..802 Evaluation .. . . ..802 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .803 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .803 B. Thoracolumbar Spine.. . . .803 anatomy and Growth . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .803 classification . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .803 Epidemiology .. . . .804 Evaluation .. . . .804 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .804 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .804 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .804

chapter 29 ribs

references.. . . ..807

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XiX contents

part iii

partial physeal arrest

chapter 30 Etiology

anatomy . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .811 Epidemiology .. . . ..813 influence of Gender . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .813 influence of age . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .813 influence of site . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .813 influence of Fracture type .. . . ..814 influence of treatment .. . . ..815 incomplete partial physeal Bar . .. .. .. .. .. .. .. .. .. .. .817 prevention . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .820 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .822

chapter 31 assessment

clinical Examination ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...825 imaging studies . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .825 limb length Measurements .. . . ..827 Bar analysis: location, area, and contour. .. .. .. .. .833 classification of Bars ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...842 state of Maturity . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .844 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .845 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .845

chapter 32

Management: General

treatment alternatives . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .849 size and location of the Bone Bar .. . . ..850 physis involved ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...850 age of patient .. . . ..850 additional considerations .. . . ..851 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...851 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .851

chapter 33

physeal Bar Excision

history .. . . ..853 Experimental studies in animals . .. .. .. .. .. .. .. .. .. .854 indications in humans ... .. .. .. .. .. .. .. .. .. .. .. .. .. ...855

surgical technique ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...855 interposition Materials .. . . .860 postoperative care ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .863 results: the literature ... .. .. .. .. .. .. .. .. .. .. .. .. .. . .863 Follow-up. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .872 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .876 results: the Mayo clinic Experience. .. .. .. .. .. .. .. .877 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .882 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .882

chapter 34

physeal Distraction

introduction . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .885 procedure ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .886 Distraction of a physis with a Bar. .. .. .. .. .. .. .. .. .. .887 physeal Distraction

with concurrent Bar Excision . .. .. .. .. .. .. .. .. .. .. .. .888 physeal Distraction Followed by Bar Excision . .. .. .888 Bar Excision Followed by physeal Distraction . .. .. .888 complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .888 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .890 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .890

chapter 35

physeal cartilage transplantation

introduction . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .893 autograft transplantation of the End

of a Bone . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .893 autograft transplantation of a Block

of Bone containing the physis .. . . .894 autograft transplantation of the physis alone . .. .894 allograft transplantation . .. .. .. .. .. .. .. .. .. .. .. .. .. .895 transplantation of cultured cartilage cells . .. .. .. .896 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .896 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .896

chapter 36

spontaneous resolution

introduction . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 899 Forme Fruste Bar ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .902 author’s perspective ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .904 references . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .906

subject index. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .907