849
Management: General
Premature partial physeal arrest results in bone short- ening relative to its contralateral member and may be accompanied by angular deformity. The magnitude of these abnormalities is determined by the age at which the bar formed, the velocity of growth of the physis involved, and the size and the location of the bar within the physis. These abnormalities may be managed in many ways [1–16].
Treatment Alternatives Observation
Most, if not all, cases of untreated premature partial physeal closure will progress to premature complete physeal closure (Fig. 13.7f–i). Observation is appro- priate for teenagers nearing maturity who have no or minimal length discrepancy or angular deformity. It
Contents
Treatment Alternatives ... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . .849 Observation... .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. .849 Shoe.Lift.. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .849 Surgical.Arrest.of.Normal.Physeal.Cartilage. . ... ... ... ... ... ... .849 Osteotomy.. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .849 Bone.Lengthening. . ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .850 Bone.Shortening.. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .850 Excision.of.the.Physeal.Bar... .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. ..850 Physeal.Distraction.. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .850 Transplantation.of.Physeal.Cartilage.... . .. . .. . .. . .. . .. . .. . .. . .. . ...850 Combinations.of.the.Above.. ... ... ... ... ... ... ... ... ... ... ... ... ... ... .850 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 32
is also appropriate, at least for a short time in a child of any age with a small bar, when there is no or mini- mal length discrepancy or angular deformity. Small bars may break loose (Chapter 36). No scientific anal- ysis of the actual size of a bar which might break loose has been done. One author [1] estimated it at “less than 7% of the growth plate.”
Shoe Lift
This is applicable when a lower extremity bar is cen- tral causing no angular deformity and the leg-length discrepancy is expected to be minor at maturity (e.g., 2.5 cm or less). This nonoperative treatment was ef- fectively used as the only treatment for many large discrepancies for centuries before the advent of mod- ern surgery. Today, it is commonly used while the cor- rective results of epiphyseodesis of the longer bones are being achieved, or while awaiting bone shortening or lengthening at maturity.
Surgical Arrest of Normal Physeal Cartilage 1. Arrest the remaining growth of the injured physis.
This may be considered in an older child to prevent or stop progression of angular or intraarticular deformity. It is best applied when limb-length in- equality is minor (lower extremity) or of relatively little functional consequence (upper extremity).
2. Arrest the physis of the adjacent companion bone (in the case of the forearm and lower leg).
3. Arrest the corresponding physis or physes of the con- tralateral bone or bones.
4. Arrest additional physes on the contralateral limb (e.g., both the distal femur and the proximal tibia on the opposite extremity of a proximal tibial bar).
Osteotomy
Opening wedge, closing wedge, or arcuate osteotomy are used to correct angular deformity [4, 12, 13, 16]. If there is no accompanying treatment for the bar, the
850 Chapter 32 Management: General
angular deformity will recur. Osteotomy may be re- peated several times as the deformity recurs. Delay- ing the osteotomy until near maturity is preferable if the angular deformity is mild or slowly progressive.
Some final relative shortening of the involved bone should be expected.
Bone Lengthening
The involved or contiguous bone may be surgically lengthened to achieve limb length equality and sym- metry. Lengthening of the femur or tibia, or repeated lengthenings, may be considered for discrepancies of 4–5 cm or more. Many techniques, devices, and regimens are available, including physeal distraction (Chapter 34).
Bone Shortening
In general, bone shortening procedures on the longer bone are deferred until maturity, when the precise amount can be shortened. In younger children, phy- seal arrest of the longer bone has a lower morbidity, and complication rate than bone shortening. The maximum amount of safe shortening varies with each bone. In the upper extremity no reason has been pro- posed to shorten a humerus. In the lower extremity, indications for femoral shortening are for discrepan- cies exceeding 3 cm. Up to 7.5 cm can be shortened at one procedure [5]. Tibial shortenings of more than 1 cm have generally been avoided for fear of anterior tibialis muscle weakness (footdrop) and compartment syndrome. Menelaus et al. [5] do not ascribe to these fears. Surgical shortening of the normal contralateral or companion bone (fibula or ulna) carries little mor- bidity. Surgical shortening of the ulna to equal a shorter radius is easily accomplished. However, if the radius is too long, surgical shortening of the radius is more problematic than lengthening the ulna. Many techniques, devices, and regimens are available.
Excision of the Physeal Bar See Chapter 33.
Physeal Distraction See Chapter 34.
Transplantation of Physeal Cartilage See Chapter 35.
Combinations of the Above
It is unusual for a patient to be treated optimally with only one of the above modalities. Even when successful bar excision allows several centimeters of longitudinal growth, some other modality, such as a shoe-lift, surgical closure of normal physeal tissue, or osteotomy to correct angular deformity, is often needed. The choice of management will depend on the size and location of the bone bar, the physis in- volved, and the age of the patient. These factors are interrelated and must be considered in concert.
Size and Location of the Bone Bar
Small bars, e.g., less than 10% of the area of the physis, may be observed for a few weeks for spontaneous res- olution (Chapter 36). The observation period needs to be closely controlled to avoid unwanted additional length discrepancy or angular deformity. If either of these occurs, observation should give way to more specific treatment. Bars of >50% of the total physis are less likely to respond well to bar excision and consid- eration should be given to alternative methods, even if they include multiple procedures. There has been some success from excision of bars >50% in the distal femur in very young children. Bars in the center of the physis with normal perichondral rings respond better to bar excision than peripherally located bars with loss of a portion of the perichondral ring.
Physis Involved
Symmetric equal length of lower extremity bones is required to avoid pelvic obliquity and spine deformi- ty. Physes which provide the most longitudinal growth (the distal femur and proximal and distal tibia) need close observation. In the upper extremity, length dis- crepancy of up to 6 cm is well tolerated functionally.
Thus in the upper extremity, bars of the distal radius and ulna receive the most attention in an effort to maintain relative equal length and wrist alignment.
Age of Patient
A young child with many years of growth remaining has the greatest chance to develop both length dis- crepancy and angular deformity, and in some in- stances articular incongruity, e.g., fishtail deformity of the distal humerus. A bone bar in a girl with skel-
851 Management: General Chapter 32
etal age greater than 12 years, or a boy greater than 14 years may be observed for a time. Most of these children have so little growth remaining that the bar will cause minimal additional length discrepancy or angular deformity. In this situation it is prudent to assess body height and skeletal maturity to document any discrepancy with chronologic age. If a child’s physical characteristics or skeletal age are less mature than the chronologic age, or if the parents and older siblings matured late, more active treatment should be considered.
Additional Considerations
The duration of the bone bar may be unknown. For example, a bar may be first discovered years following fracture. The bar could have developed at any time during that interval. The amount of relative shorten- ing and angular deformity along with growth arrest lines will help to give some information concerning the duration of the bar.
Osteotomy is the only sure way to correct angular deformity. Some angular deformities of up to 20° have been noted to correct by growth and remodeling fol- lowing bar excision [3]. However, most deformities will not correct this much and some do not correct at all. Osteotomy may be performed at the time of bar excision, or later (if necessary). Thus, the surgeon is presented with a decision when excising a bar associ- ated with angular deformity. Reasons for delaying the osteotomy are multiple: 1) the deformity may correct spontaneously, obviating osteotomy; 2) the deformity may correct partially, making the osteotomy a less troublesome operation; 3) the deformity may recur following osteotomy in an immature child, necessi- tating a second osteotomy; and 4) osteotomies are most effective when performed at or near the maxi- mal focus of deformity. This is usually at the site of the bar. Thus, the most effective osteotomy is as close to the bar as possible. An osteotomy at this location could easily negatively affect the bar excision, as well as the blood supply to the remaining physis. The rea- sons for combining bar excision and osteotomy are that it involves one operation rather than two, and that the patient may not return for follow-up. The age of the patient influences this decision since mid to older age children will have less time to correct the deformity due to limited remaining growth.
Staples applied temporarily to the convex side of a physis with a bar may prevent the angular deformity from progressing, but will not improve the deformity in the presence of the bar. Applying staples to the con-
vex side of the angled physis in combination with bar excision also makes little sense since the goal of bar excision is to re-establish growth.
Leg-length discrepancy of 2.5 cm or less usually causes little, if any, functional impairment or low back pain and can be left untreated, or a shoe-lift may be applied on the short side. Leg-length discrepancy anticipated to be 2.5–5 cm at maturity may be man- aged by arrest of growth of the contralateral bone if the child has sufficient growth remaining to correct the discrepancy. Bone shortening on the contralateral longer side may be considered if all physes are closed or the child is nearing maturity. The patient’s antici- pated height at maturity is a factor in all these in- stances, because short people do not readily accept being made shorter. Real or anticipated discrepancies of 5 cm or more are candidates for treatment with bone lengthening on the ipsilateral side.
Arm-length discrepancy results in functional im- pairment only when the discrepancy is extreme. Dis- crepancies of 6 cm or less are best left untreated. Sur- gical shortening of the contralateral normal upper extremity has never been reported and has no appli- cation. Lengthening of the humerus [11] and forearm (radius and ulna concurrently) is possible, but carries potential morbidity and is best done by surgeons with experience with a variety of bone lengthening tech- niques.
Author’s Perspective
All of the above treatment options have been used in the management of physeal bars and should be con- sidered in every case. However, excision of the bar, when successful, may negate the need for the other modalities and their potential morbidity. If bar exci- sion is used and is unsuccessful, all other options may still be used.
References
1. Bowen JR: Doctors can help prevent pediatric post-frac- ture growth arrest. Orthopedics Today 21:46-47, 2001 2. Broughton NS, Cole WG: The management of premature
growth plate arrest. In: Menelaus MB (ed): The Manage- ment of Limb Inequality ed. Edinburgh: Churchill Living- stone, 1991, Chapter 9, pp 121-128
3. Langenskiöld A: An operation for partial closure of an epiphyseal plate in children, and its experimental basis.
J Bone Joint Surg 57B:325-330, 1975
4. Langenskiöld A: Traumatic premature closure of the dis- tal tibial epiphyseal plate. Acta Orthop Scand 38:520-531, 1967
852 Chapter 32 Management: General 5. Menelaus MB, Doig WG, Oppenheim WL: Shortening pro-
cedures: femoral shortening, tibial shortening, and intra- pelvic shortening. In: Menelaus MB (ed): The Management of Limb Inequality ed. Edinburgh: Churchill Livingstone, 1991, Chapter 7, pp 95-107
6. Peterson HA: Management of partial physeal arrest. In:
Chapman MW (ed): Operative Orthopaedics., 2nd ed.
Philadelphia: J B Lippincott, 1993, Chapter 217, Vol 4, pp 3065-3075
7. Peterson HA: Partial growth plate arrest and its treatment.
In: Lovell WW, Winter RB (eds): Pediatric Orthopaedics, Second ed. Philadelphia: JB Lippincott Co., 1986, Chapter 25, Vol 2, pp 1083-1101
8. Peterson HA: Partial growth plate arrest and its treatment.
J Pediatr Orthop 4:246-258, 1984
9. Peterson HA: Partial growth plate arrest and its treatment.
In: Morrissy RT (ed): Lovell and Winter’s Pediatric Ortho- paedics., 3rd ed. Philadelphia: J B Lippincott, 1990, Chap- ter 33, pp 1071-1089
10. Peterson HA: Physeal injuries and growth arrest. In: Beaty JH, Kasser JR (eds): Rockwood and Wilkins’ Fractures in Children, Fifth ed. Philadelphia: Lippincott Williams and Wilkins, 2001, Chapter 5, pp 91-138
11. Peterson HA: Surgical lengthening of the humerus. Case report and review. J Pediatr Orthop 9:596-601, 1989 12. Scheffer MM, Peterson HA: Opening-wedge osteotomy for
angular deformities of long bones in children. J. Bone Joint Surg. 76A:325-334, 1994
13. Scheffer MM, Peterson HA: Opening-wedge osteotomy for angular deformities of long bones in children. Adv. Or- thop. Surg. 19:16-18, 1995
14. Spinelli RR: Treatment of evolutive and stable angular deformities following premature partial physeal arrest by contemporary realignment and lengthening. Mapfre Med 4(Supl II):245-247, 1993
15. Waters PM, Bae DS, Montgomery KD: Surgical manage- ment of posttraumatic distal radial growth arrest in ado- lescents. J Pediatr Orthop 22:717-724, 2002
16. Zehntner MK, Jakob RP, McGanity PL: Growth distur- bance of the distal radius epiphysis after trauma: Operative treatment by corrective radial osteotomy. J Pediatr Orthop 10:411-415, 1990
