145
Complications
Contents
Epidemiology of Complications . .. .. .. .. .. .. .. .. .. .. .. .145 Age.... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...146 Gender.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .147 Fracture.Site. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .147 Fracture.Type. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .148 Note.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .149 List of Complications ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...150 I. Complications Occurring
At or Near the Time of Fracture. .. .. .. .. .. .. .. .. .. .. .. .150 A. Vascular 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 . Upper.Extremity.Physes.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .169 . Lower.Extremity.Physes.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .169 G. Nonunion. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .170 H. Malunion . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .176 I. Ischemic Necrosis. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .180 J. Overgrowth. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .183 . Relative.Overgrowth. ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...183 . True.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
Chapter 8
A complication, as defined here, is a difficulty or problem resulting from the physeal fracture. A wide variety of complications can occur following physeal fracture. The literature review documented in this chapter is concerned with an overview of possible complications and the epidemiology of complications.
Complications specific to each anatomic site are dis- cussed in their respective chapters, 9 through 29. Only a few articles give a general discussion of physeal frac- ture complications [1–3].
Most complications following physeal fracture discussed in this chapter are uncommon or rare. By far the most common is premature growth arrest, which may be complete or partial. Complete physeal arrest is discussed in Section F of this chapter. Partial growth arrest is more complex in both diagnosis and management, and is discussed in Part III.
Epidemiology of Complications
In the Olmsted County study [2] (Chapter 4), there were 951 fractures in 850 patients. Of the 850 patients, 753 (88.6%) were managed successfully without com- plication. Ninety-seven patients (11.4%) had one or more complications. Since each patient may have had more than one complication, there were more compli- cations (132) than patients with complications (97).
For this study, a complication was defined as a pre- mature growth arrest, angulation deformity, length discrepancy, or functional impairment (Table 8.1).
Premature growth arrest comprised 61 of the 132
complications (46.2%). Most growth arrests occurred
at an older age, did not result in significant angular
deformity or length discrepancy, and therefore re-
quired no treatment, and some arrests were discov-
ered and treated before additional complications oc-
curred. The rate of functional impairment was highest
in the distal humerus, both in terms of total distal hu-
meral fractures (3 of 37 or 8%) and of total distal hu-
meral complications (3 of 8 or 37.5%). Although the
distal tibia had 30% of all complications, only 1 of 104
(1%) distal tibia fractures had functional impairment.
Age
The number of fractures followed by a complication at each age (Table 8.2) creates a bar graph (Fig. 8.1) similar to the total number of fractures at each age (Fig. 4.2). However, the percentage of complications at each age group was different, being higher at the extremes of age (ages 0–5 and 14–19 years, Table 8.2).
The complication rate for fractures occurring in mid- dle years, from ages 6 to 13 years, was 4–9%, while in the beginning and end of growth was greater; from ages 0 to 5 years it was 11–29% and from ages 14 to 19 years it was 9–100% (except for the absence of com- plications at ages 3 and 8 years).
Table 8.1. The.type,.number,.and.percentage.of.complications.by.site.in.Olmsted.County,.Minnesota,.1979–1988.[2]
Fx GA AD LD FI Total Percent
Distal.tibia 104 23 7 9 1 40 30 3
Distal.radius 170 11 10 5 2 28 21 2
Phalanges.(fingers) 356 10 11 2 3 26 19 7
Distal.humerus 37 1 4 0 3 8 6 1
Metacarpal 61 3 2 1 0 6 4 5
Distal.femur 13 3 0 2 0 5 3 8
Proximal.tibia 8 3 1 1 0 5 3 8
Distal.ulna 27 2 0 2 0 4 3 0
Proximal.humerus 18 1 2 0 0 3 2 3
Distal.fibula 68 2 1 0 0 3 2 3
Metatarsal 13 1 0 1 0 2 1 5
Proximal.radius 6 0 1 0 0 1 0 8
Proximal.femur 1 1 0 0 0 1 0 8
Phalanges.(toes) 55 0 0 0 0 0 –
Proximal.ulna 4 0 0 0 0 0 –
Clavicle,.medial 4 0 0 0 0 0 –
Clavicle,.lateral 2 0 0 0 0 0 –
Pelvis 2 0 0 0 0 0 –
Proximal.fibula 1 0 0 0 0 0 –
Innominate 1 0 0 0 0 0 –
ToTal 951 61 39 23 9 132 100 1
Fx.fractures.(number.for.that.site),.GA.growth.arrest,.AD.angular.deformity,.LD.length.discrepancy,.FI.functional.impairment
Fig. 8.1
Patients. (97). with. any. compli- cation,.by.age,.Olmsted.Coun- ty,.Minnesota,.1978–1988.[2]
147 Complications Chapter 8
Gender
There were 65 boys (Table 8.3) and 32 girls (Table 8.4) with complications. Thus, the ratio of boys:girls with complications was 2:1, the same as the ratio of frac- tures in boys:girls. The percentage of complications among boys (65 of 637 or 10.2%) and girls (32 of 314 or 10.2%) was the same. Interestingly, for girls, the age distribution for complications (Fig. 8.2) was similar to the age distribution of total complications (Fig. 8.1), whereas boys had more complications at the lower and higher ages (Fig. 8.3) making the percentages of complications higher at the extremes of age (Ta- ble 8.3). For boys, the percentage of complications at each age was in the double digits for ages 0–6 years and 14–19 years and in the single digits for ages 7–
13 years (except for the absence of complications at ages 3 and 8 years).
Fracture Site
The most frequent site of complication was the distal tibia: 28 of 97 patients (29%, Table 8.5), and 40 of 132 complications (30%, Table 8.1). The distal tibia, along with the distal radius and hand phalanges accounted for over 70% of patients with complications (Table 8.5) and over 70% of the total complications (Table 8.1). A major reason this was the greater number of fractures at these three sites (compare with Table 4.12).
When the prevalence of complications at each site is considered separately, the proximal femur is the most likely site to be associated with a complication (Table 8.6). The distal femur and the proximal and
Table 8.2. Number.and.percentage.of.complications.by.age.
in.Olmsted.County,.Minnesota,.1979–1988.[2]
Age
(years) Total number of fractures
Number of fractures with any complication
Percent fracture with any complication
0 7 1 14 0
1 7 2 29 0
2 5 1 20 0
3 10 0 0
4 12 2 17 0
5 19 2 11 0
6 24 2 8 3
7 28 2 7 1
8 23 0 0
9 64 3 4 7
10 97 6 6 2
11 122 12 9 8
12 132 13 9 8
13 114 10 8 8
14 129 18 14 0
15 94 15 16 0
16 44 4 9 1
17 12 2 17 0
18 5 1 20 0
19 1 1 100 0
20 1 0 0
21 1 0 0
ToTal 951 97 10 2
Fig. 8.2
Female. patients. (32). with. any.
complication,.by.age,.Olmsted.
County,.Minnesota,.1978–1988.
[2]
Table 8.4. Number.and.percentage.of.complications.for.girls.
by.age.in.Olmsted.County,.Minnesota,.1979–1988.[2]
Age (years) Total number of fractures
Number of compli
cations
Percent complications
0 3 0 0
1 3 0 0
2 1 0 0
3 5 0 0
4 4 0 0
5 10 1 10 0
6 11 0 0
7 13 1 7 7
8 15 0 0
9 33 0 0
10 46 5 11 0
11 61 11 18 0
12 58 8 14 0
13 25 3 12 0
14 19 2 11 0
15 4 1 25 0
16 1 0 0
20 1 0 0
21 1 0 0
ToTal 314 32 10 2
Fig. 8.3
Male. patients. (65). with. any.
complication,.by.age,.Olmsted.
County,. Minnesota,. 1978-1988.
[2]
Table 8.3. Number. and. percentage. of. complications. for.
boys.by.age.in.Olmsted.County,.Minnesota,.1979–1988.[2]
Age (years) Total number of fractures
Number of compli
cations
Percent complications
0 4 1 25 0
1 4 2 50 0
2 4 1 25 0
3 5 0 0
4 8 2 25 0
5 9 1 11 0
6 13 2 15 0
7 15 1 6 7
8 8 0 0
9 31 3 9 7
10 51 1 2 0
11 61 1 1 6
12 74 5 6 8
13 89 7 7 9
14 110 16 15 0
15 90 14 16 0
16 43 4 9 3
17 12 2 17 0
18 5 1 20 0
19 1 1 100 0
ToTal 637 65 10 2
149 Complications Chapter 8
distal tibia, when injured, also have high propensity for a complication. Obviously, the small numbers of fracture at some sites obviates statistical significance.
However, it can be stated that even though hand pha- langes are the most frequent site of fracture (Ta- ble 4.12), and are prominent in both Table 8.1 and Table 8.5, only a small percentage (5.9%) develop a complication (Table 8.6). This contrasts with the high percentages of knee and ankle physeal fractures which develop complications (Table 8.6).
Since the distal tibia appears prominently in all three tables (Tables 8.1, 8.5, 8.6), it may be stated that this is the most troublesome site for a complication, considering both frequency of the fracture and the likelihood of complication.
Fracture Type
Although type 2 fracture accounted for 55 of the 97 (57%) complications (Fig. 8.4), this corresponds close- ly with the fact that it accounts for 54% of all fractures (Table 4.12). There was a good correlation of the type of fracture and the percentage of that fracture type developing a complication (Table 8.7), with type 1 having the lowest (5.4%) and type 6 the highest (100%) complication rates. There was a gradual increase of percentage of types 3, 4, and 5 developing a complica- tion, as expected. This further supports the validity of the Peterson classification (Chapter 3).
Table 8.5. Percentage.of.patients.with.complications.by.site.
in.Olmsted.County,.Minnesota,.1979–1988.[2]
Number of compli
cations
Percent complications
Distal.tibia 28 28 9
Phalanges.(fingers) 21 21 6
Distal.radius 20 20 6
Distal.humerus 6 6 2
Distal.femur 5 5 2
Metacarpal 4 4 1
Distal.fibula 3 3 1
Proximal.tibia 3 3 1
Distal.ulna 2 2 1
Proximal.humerus 2 2 1
Metatarsal 1 1 0
Proximal.radius 1 1 0
Proximal.femur 1 1 0
Phalanges.(toes) 0 0
Proximal.ulna 0 0
Clavicle,.medial 0 0
Clavicle,.lateral 0 0
Pelvis 0 0
Proximal.fibula 0 0
Innominate 0 0
ToTal 97 100 0
Table 8.6. Percentage.of.complications.by.sitea.in.Olmsted.County,.Minnesota,.1979–1988.[2]
Number of fractures Number of complications Percent complications
Proximal.femur 1 1 100
Distal.femur 13 5 38 5
Proximal.tibia 8 3 37 5
Distal.tibia 104 28 26 9
Proximal.radius 6 1 16 7
Distal.humerus 37 6 16 2
Distal.radius 170 20 11 8
Proximal.humerus 18 2 11 1
Metatarsal 13 1 7 7
Distal.ulna 27 2 7 4
Metacarpal 61 4 6 6
Phalanges.(fingers) 356 21 5 9
Distal.fibula 68 3 4 4
ToTal 97
a.Sites.without.a.complication.not.included
Note
The data in these tables are from the only population- based study [2] and do not reflect the referral practice, where complications represented a much greater pro- portion of the total. Indeed, complications were often the indication for referral. Most of the complications illustrated as examples in this text are therefore from the referral practice. Since the time period covered by the Olmsted County study was only 10 years, addi- tional complications could occur in these patients in subsequent years, particularly young children who were seen toward the end of the study period.
List of Complications
In this chapter a wide scope of complications is considered. These are divided into: (I) those which occur at or near the time of fracture, and thus include
difficulties in diagnosis or treatment, and (II) those manifesting later, and thus represent troublesome or negative outcomes. The following order of these com- plications is based on these two features and not on the incidence or severity of the complications.
I. Complications occurring at or near the time of fracture
A. Vascular occlusion B. Compartment syndrome C. Irreducible fracture D. Nerve impairment E. Infection
II. Complications manifesting later F. Complete physeal arrest G. Nonunion
H. Malunion I. Ischemic necrosis J. Overgrowth K. Synostosis
L. Heterotopic ossification M. Refracture
N. Loss of motion O. Pathologic fracture
I. Complications Occurring At or Near the Time of Fracture A. Vascular Occlusion
Vascular occlusion is most likely to occur when major vessels are in close proximity to the physis and par- ticularly when they are tightly constrained by soft tis- sue structures major. Other factors contributing to vascular occlusion are soft tissue swelling and the ap- plication of a tight dressing or cast after reduction.
The proximal tibia (Chapter 20) most closely fits these anatomic criteria and is the most commonly reported site for vascular occlusion (Figs. 20.8, 20.12, 20.23).
Most are type 2 or 3 fractures. One type 5 fracture resulting in occlusion has been reported [8].
Arterial and venous occlusion can occur by direct pressure (stenosis producing thrombosis), laceration, or transection [4, 6] from fracture fragments. Stretch-
Fig. 8.4
Occurrence.of.any.complication.by.fracture.type,.Olm- sted.County,.Minnesota,.1978-1988.[2].(Peterson.clas- sification)
Table 8.7. Percentage.of.complications.by.type.of.fracture.in.Olmsted.County,.Minnesota,.1979–1988.[2].(Peterson.Classifica- tion)
Type 1 2 3 4 5 6 Total
Number.of.fractures 147 510 126 104 62 2 951
Number.of.complications.(patients) . . 8 . 55 . 10 . 12 10 2 . 97
Percent.complications.of.each.type . . 5 4 . 10 8 . . 7 9 . 11 5 16 1 100 0 . . –
151 Complications Chapter 8
ing the artery may exceed the elastic limit of the inti- ma. A layer of platelets and fibrin form on the intimal tear. The resulting thrombus may lead to total occlu- sion in a few hours or may be delayed several hours [7]. In some instances the intimal layer of artery is se- lectively torn. In this instance the intimal layer may roll or turn under itself and occlude the artery.
Vascular occlusion of a major vessel is obviously an emergency since a delay of a few hours will result in tissue necrosis which in turn might require amputa- tion (Fig. 8A.1) [5–7]. One difficulty in raising the suspicion of the treating physician is that although there may have been considerable displacement at the moment of fracture sufficient to lacerate or occlude
Fig. 8A.1
Vascular.occlusion,.proximal.tibial.type.3.fracture .This.13.year.3.month.old.boy.sustained.a.severe.hyperextension.
.injury.of.the.right.knee.when.he.fell.from.a.hay.bale.elevator.while.his.foot.was.caught.in.the.elevator .Upon.presenta- tion.in.the.emergency.room,.the.leg.below.the.knee.was.cyanotic,.cold,.anesthetic,.paralyzed,.and.pulseless,.but.with.
delayed.capillary.filling .Witnesses.to.the.injury.estimate.the.knee.was.hyperextended.90° .a.AP.and.lateral.roentgeno- graphs. two. hours. post. injury. show. type.3. fractures. of. both. the. proximal. tibial. and. fibular. physes . The. proximal.
.metaphysis. could. have. been. displaced. more. at. the. time. of. injury .b. AP. and. lateral. following. closed. reduction. in. . the.emergency.room.and.a.cast.applied.and.“split.full.length ”.The.toes.remained.cold.and.dusky.but.less.so.than.they.
had.been .The.circulation.was.considered.“good.enough.to.permit.observation.overnight ”.Five.percent.alcohol.and.
Papavine.gr.ii.in.1000.cc.saline.was.given.intravenously .Foot.color.improved;.pain,.sensation,.and.motion.did.not .The.
following.day.1%.Xylocaine.lumbar.sympathetic.and.sciatic.nerve.blocks.were.performed.resulting.in.mild.improve- ment.in.color .(Continuation see next page)
Fig. 8A.1 (continued)
153 Complications Chapter 8
the adjacent vessels, the fracture fragments may have partially reduced during transport or positioning the limb for roentgenography. Thus, the initial roentgen- ograph may show only minor displacement [7, 8].
Management of significantly displaced physeal fractures requires close monitoring of pulses both pre and post reduction. Any limb that remains pulseless after reduction deserves further evaluation such as arteriography [4, 6–9] or MR arteriography. Vascular injury documented on arteriography requires throm- bectomy or surgical repair despite adequate collateral circulation which may keep the foot pink and warm [6].
The use of sympathectomy [5, 9] as the primary treatment to improve circulation has not met with uniform success (Fig. 8A.1). Its use as adjunctive treatment will depend on the situation and, perhaps more practically, on the opinion of the vascular sur- geon. Likewise, fasciotomy will not improve blood flow through an occluded or lacerated vessel, but may be appropriate for accompanying compartment syn- drome.
In many situations physeal fractures will have some inherent stability following reduction, allowing minimal or no external support. This is particularly appropriate if the patient is admitted to the hospital
Fig. 8A.1 (continued)
c.Two.days.after.injury.AP.and.lateral.views.showed.slight.increase.in.forward.displacement.of.the.epiphysis .The.pop- liteal.artery.was.explored,.found.to.be.“badly.damaged,”.containing.a.firm.thrombus .Attempted.thrombectomy.and.
arteriotomy.were.unsuccessful.and.a.1/4.inch.Teflon.vascular.prosthesis.was.placed.between.the.ends.of.the.distal.
femoral.artery.from.distal.to.the.adductor.canal.to.immediately.proximal.to.the.bifurcation .Blood.flow.was.only.par- tially.improved.despite.blood.transfusions.and.IV.heparin .The.following.day.right.lumbar.sympathetic.ganglionecto- my.and.nerve.trunk.resection.were.performed .Four.days.later.a.below.knee.amputation.was.performed.5.inches.be- low.the.knee .The.stump.was.packed.and.subsequently.become.infected,.requiring.multiple.dressing.changes,.partial.
closure,.and.final.closure .d.Four.months.post.injury.(age.13.years.7.months).osteomyelitis.of.both.the.tibia.and.fibula.
is.well.established .Abscess.drainage,.sequestrectomies,.and.scar.revisions.followed .e.Thirty-three.months.post.injury.
(age.16.years.1.month).the.physes.are.closed .Ten.operations.for.“cellulitis”.followed .f.AP.and.lateral.views.at.age.
32.years.9.months.(19.years.6.months.post.injury) .The.patient.had.ongoing.prosthesis.problems
for observation. The other obvious reason for mini- mal or no external support is when internal fixation has been used to stabilize the fracture. In some situa- tions external fixation may be used to provide both stability and unencumbered observation.
Because so many of these factors are present at the proximal tibia and because this fracture is uncom- monly encountered by residents and emergency room staff, it was my directive that any patient with a prox- imal tibial growth plate fracture, regardless of the amount of displacement visualized on the initial ra- diograph, be admitted to the hospital for observation with little or no external support (e.g., a loosely fitted knee immobilization splint). Persistent significant pain following reduction requires evaluation, not in- creasing analgesic medication (Fig. 20.12A).
B. Compartment Syndrome
Compartment syndromes are conditions in which increased tissue pressure within a confined space compromises circulation, function, and ultimately the viability of the contents within the space. The two prerequisites for compartment syndrome are an envelope limiting the space available and swelling within the envelope. The envelope is usually the fascia surrounding muscle groups, but may also be tight skin, or external dressings such as casts, splints, or dressings. Common causes for tissue swelling within compartments include fractures (including physeal fractures), contusions, crush injuries, post ischemic reperfusion swelling, burns, drug injec- tions, and swelling secondary to surgical insult such
proximal tibial osteotomy. Some cases of cast tight- ness, ischemia during Bryant’s traction, and Volk- mann’s contracture following elbow fracture are more related to the treatment than the underlying condi- tion.
The recorded sites of compartment syndrome fol- lowing physeal fractures are fractures of the distal radius (Fig. 8B.1) [11, 13, 14, 19], proximal tibial tu- berosity [10, 15–18], distal tibia [12, 15], and proximal tibial epiphysis [9]. The types of fracture reported are type 2 [9, 14, 15, 17, 19], type 3 [11–13, 15], and type 5 [17, 18]. The youngest patient recorded is a 4-week-old girl with a distal tibial type 2 physeal injury [12].
The clinical picture is one of progressive swelling and increasing pain. Examination elicits tenseness, tenderness, diminished joint motion, diminished sensation, but usually normal arterial pulses.
The diagnosis of compartment syndrome may be difficult in children, particularly neonates. The patient may be unable to give a history or follow commands to cooperate with the examination. Mea- surement of intracompartmental pressures become essential.
The key to proper management is early diagnosis.
The first 24–36 hours of the syndrome are crucial in preventing permanent disability. Complete tissue ischemia of more than 8 hours is associated with myonecrosis. After undergoing necrosis, skeletal muscle becomes fibrotic and ultimately develops a fixed contracture. Concomitant nerve ischemia con- tributes to motor dysfunction and can cause sensibil- ity loss or chronic pain. The final outcome can be a dysfunctional, deformed limb with a fixed ischemic contracture.
Fig. 8B.1 Ñ
Compartment.syndrome,.distal.radius.type.3.fracture .An.11.year.8.month.old.boy.fell.injuring.his.left.wrist .a.The.ra- dial.epiphysis.is.displaced.dorsally .b.AP.and.lateral.following.closed.reduction.the.same.day .Anesthesia.was.obtained.
by.injection.of.procaine.into.the.fracture.hematoma.through.the.dorsum.of.the.wrist .A.long.arm.cast.was.applied .The.
following.morning.there.was.pain,.numbness,.swelling,.and.pallor.of.the.fingers .The.cast.was.split.dorsally,.with.im- provement.of.sensation .That.evening.the.cast.was.removed.and.replaced.by.a.volar.aluminum.splint .Persistent.dimin- ished.sensation.and.motion.were.accompanied.by.increasing.pain .c.On.the.fourth.post.injury.day.the.patient.was.
transferred.to.us .The.hand.and.forearm.were.tensely.swollen .Note.blisters.on.the.thenar.eminence.and.wrist .Finger.
motion.was.limited.and.two-point.discrimination.was.>10.mm .The.patient’s.temperature.was.38°C,.the.leukocyte.
count. was. 15,700/mm3. with. >1%. polymorphonuclear. cells . The. ESR. was. 38.mm . A. deep. infection. was. suspected . . d.Decompression.was.accomplished.by.a.multicurved.incision.on.the.volar.aspect.of.the.wrist .Forearm.muscles.bulged.
out.of.the.incision,.but.were.viable .Pus.was.not.encountered.and.cultures.were.subsequently.negative .After.release.
of.the.tourniquet.all.digits.became.pink.and.warm .Postoperatively,.the.pain.was.much.decreased .The.wound.was.
dressed.and.left.open .Three.days.post.incision.the.fasciotomy.was.extended.proximally.because.of.persistent.wrist.
and.forearm.swelling .(Continuation see next page)
155 Complications Chapter 8
Fig. 8B1
Fig. 8B.1 (continued)
157 Complications Chapter 8
Fig. 8B.1 (continued)
e.Seven.days.after.incision.(11.days.after.injury).instabil- ity.of.the.epiphysis.resulted.in.Kirschner.wire.fixation . All. previous. cultures. showed. no. growth .f. Persistent.
forearm. muscle. swelling. precluded. primary. wound.
closure .Split.thickness.skin.grafting.was.used.to.close.
the.wound .Total.hospitalization.was.20.days .The.radi- al.and.radial.median.nerve.hypesthesia.improved.slow- ly .g. Ten. months. following. injury. there. is. premature.
closure.of.the.radial.side.of.the.distal.radial.physis.and.
mild.relative.overgrowth.of.the.ulna .h.Photographs.of.
both.hands.and.forearms.11.months.post.injury .There.
is.limited.thumb.abduction,.grip.weakness,.and.fore- arm.muscle.atrophy .i.Physeal.bar.excision.11.months.
post. injury. (age. 12.years. 7.months). with. insertion. of.
cranioplast . The. distal. radius. grew. 11.mm. before. the.
bar. recurred . The. distal. ulna. physis. was. surgically.
closed.at.age.14.years.1.month .j.Scanograms.of.fore- arms.at.age.20.years.7.months.(8.years.11.months.post.
injury) .All.physes.are.closed .The.normal.right.radius.
(right).is.4 1.cm.longer.than.the.left.(left),.the.right.ulna.
3 9.cm. longer. than. the. left . Note:. The. compartment.
syndrome. in. this. case. is. only. one. of. several. possible.
causes. of. the. premature. partial. physeal. closure . The.
others.are.the.fracture.with.displacement,.the.hema- toma. block,. the. instability. during. several. operative.
procedures. for. treatment. of. the. compartment. syn- drome,. the. placement. of. a. Kirschner. wire. across. the.
physis,.or.a.combination.of.these.factors .More.details.
of. the. case. are. provided. in. reference. 13 . (Reprinted.
from.Hernandez.and.Peterson.[13],.with.permission)
When a compartment syndrome in a child is sus- pected, there should be a low threshold for measuring compartment pressures. Early surgical decompres- sion is the only recommended treatment for an estab- lished compartment syndrome, and is the only way to prevent or limit morbidity. A compartment syndrome may play a role in subsequent premature physeal clo- sure [13].
C. Irreducible Fracture
Most physeal fractures, even many of those with sig- nificant displacement, can be reduced by closed re- duction. On occasion, however, a tissue structure, such as periosteum, tendon, digit extensor hood, joint capsule, vessel, nerve, muscle, cartilage, or bone is impinged between the fragments. When this oc- curs there is a “rubbery” or “springy” resistance or
“muffled crepitation,” which impedes maneuvers to manipulate the fragments into proper alignment [23, 26, 43].
Repetitive manipulation may be injurious to the impinging tissue or to the physis. Diminished circu- lation of an extremity which occurs after reduction [24] is likely due to interposed vascular tissue. In these instances surgical exposure is required to extri- cate the interposed tissue or the entrapped bone.
Maintenance of reduction by internal fixation ap- pears to be a surgeon’s choice rather than site depen- dent. Cases found to be stable after extrication of the impinged tissue and reduction have been successfully managed without internal fixation [20, 22, 30, 40, 43, 45]. A review of the English literature reveals that all documented cases are single case reports except for one article recording three cases [24]. The most com- mon site of fracture may be hand phalanges (Table 9.7)
[21, 28, 30, 31, 45], followed by the proximal tibia (Fig. 8C.1) [20, 25, 35, 37, 42, 43], the distal tibia (Fig. 8C.2) [24, 27, 38], distal radius [29, 32, 34, 44], distal ulna (Fig. 16.8) [22, 23, 29], and one case each of the distal humerus [36] and distal fibula [40].
The most common entrapped tissue is the perios- teum [20, 27, 32, 35, 37, 42, 43]. It has been most noted in the proximal tibia [20, 35, 37, 42, 43] and distal ra- dius [32]. One article in the German literature [38]
recorded 15 cases of periosteum entrapment: nine in the distal tibia, four in the distal fibula, and two in the proximal tibia. All were type 2 fractures except for 1 type 3 fracture at each site.
Other entrapped tissue will be related to the spe- cific site. Tendon entrapment is mostly likely in the hand and wrist: finger flexor tendons in the proximal phalanx [26], and wrist and hand flexor and extensor tendons in the distal radius and ulna [23, 29, 41]. En- trapment of muscle (pes anserinus) has been recorded in the proximal tibia [42, 43], joint capsule in the dis- tal humerus [36], bone in the distal fibula [40], carti- lage (ring of Ranvier) in the proximal tibia [35], ligament (medial collateral) in the proximal tibia [25], fibrous tissue in the hand proximal phalanx [31], and volar plate in the hand middle phalanx [30]. En- trapment of both vessels and nerves has been recorded in the distal tibia (anterior tibial vessels and nerve) [24].
The youngest case reported is 2 months of age [36].
All cases reported have been type 2 fractures ex- cept for two type 3 fractures of the hand middle pha- lanx (the proximal interphalangeal joint) and one type 5 fracture of the proximal tibia [37]. In one un- usual case [28], a type 3 physeal fracture of a finger middle phalanx occurred during an unsuccessful at- tempt at reducing a proximal interphalangeal joint dislocation.
Fig. 8C.1 Ñ
Irreducible.proximal.tibia.type.2.fracture .This.14.year.10.month.old.boy.injured.his.left.knee.playing.football .a.The.
proximal.tibial.epiphysis.is.displaced.anterior.and.laterally .b.The.fracture.was.reduced.under.general.anesthesia .The.
AP.view.(left).confirms.a.type.2.fracture.(lateral.metaphyseal.fragment).with.incomplete.reduction .The.distal.femoral.
physis.is.normal.on.all.views .A.long.leg.nonweightbearing.cast.was.worn.six.weeks .He.returned.to.competitive.foot- ball,.hockey,.baseball,.and.track,.but.was.impeded.by.left.genu.valgus.(his.“knees.hit.together”.when.running).and.
knee. “stiffness”. after. running .c. A. standing. AP. roentgenograph. 1.year. 5.months. after. the. fracture. (age. 16.years.
3.months),.showed.genu.valgum.7°.on.the.right,.and.17°.on.the.left .The.left.proximal.tibial.and.distal.femoral.physes.
are.closed .The.left.femur.is.5.mm.and.the.left.tibia.is.11.mm.shorter.than.the.right .Note.open.physes.right.knee .A.left.
proximal.tibial.closing.wedge.osteotomy.was.performed .The.tibial.wedge.removed.measured.13° .Surgical.physeal.
arrest.was.performed.on.the.proximal.right.tibia .d.Standing.AP.4.months.postoperative.(age.16.years.7.months).shows.
the. osteotomy. healed . The. patient. denied. pain. or. instability. and. had. returned. to. full. activity. with. normal. gait . . (Continuation see next page)
159 Complications Chapter 8
Fig. 8C.1
Fig. 8C.1 (continued)
e.Scanogram,.age.19.years.8.months.(4.years.10.months.post.fracture) .The.patient.is.normally.active,.including.playing.
college.division.1A.hockey,.and.is.asymptomatic .The.left.leg.is.2 4.cm.shorter.than.the.right.and.has.mild.genu.valgum . Since.the.proximal.tibia.has.mild.varus.the.genu.valgus.may.be.due.to.earlier.closure.of.the.lateral.portion.of.the.distal.
femoral.physis .Note:.The.incomplete.reduction,.premature.physeal.closure,.abnormal.appearing.medial.physis.(d),.
and.valgus.deformity.are.all.suggestive.of.interposed.tissue,.probably.periosteum .Will.the.residual.mild.genu.valgum.
predispose.to.generative.arthrosis.in.the.future?
Fig. 8C.2
Irreducible.fracture,.distal.tibia,.type.2.fracture .Twelve.
year.1.month.old.boy.injured.his.left.ankle.playing.soc- cer .Reduction.under.general.anesthesia.was.attempt- ed. four. times .a. AP. roentgenogram. in. cast. following.
second. attempted. reduction . There. is. a. displaced.
type.2.fracture.of.the.distal.tibia.(arrows).and.a.fracture.
of.the.fibular.diaphysis .Two.more.reductions.attempts.
were.also.unsuccessful .b.At.the.time.of.open.reduction.
“significant.periosteal.soft.tissue.stripping.was.found.
over.the.anteromedial.aspect.of.the.tibia.which.was.in- terposed.in.the.fracture.itself ”.In.addition,.the.metaph- yseal.(Holland).fragment.could.not.be.reduced.to.the.
metaphysis.due.to.interposed.peroneal.tendons.and.a.
free.fragment.of.bone .These.were.extricated.and.the.
fracture. reduced. and. internally. fixed. with. three.
3/32.inch.Steinmann.pins .c.Thirteen.months.post.frac- ture,.age.13.years.2.months,.the.physis.is.growing.nor- mally. (right) . A. scanogram. showed. the. left. tibia. was.
1.mm.longer.than.the.right .He.returned.to.playing.soc- cer. without. limitation. or. difficulty .(Continuation see next page)
161 Complications Chapter 8
Fig. 8C.2 (continued)
Persistence of a soft tissue structure within the fracture site predisposes to malunion (Fig. 8C.1), non- union, or, in the case of periosteum, to the formation of a physeal bar [39]. Even when the irreducibility is corrected early by surgery, premature physeal arrest is possible [22]. The outcome in most cases operated early is good (Fig. 8C.2) [20, 21, 23–26, 29, 32, 34–37, 43, 45].
On occasion, the metaphysis or the epiphyseal fragment may button-hole through the joint capsule, periosteum, or finger retinaculum, which then func- tions like a Chinese fingertrap [21, 22, 33, 34, 45].
These fractures are unreducible by closed means. This has been noted at the hand proximal phalanx [21], hand distal phalanx [45], distal ulna [22], and the dis- tal radius [34].
D. Nerve Impairment
Nerve impairment following physeal fracture is un- common and has been reported only at the distal hu- merus [47, 48, 50, 51], the distal radius [13, 46, 52, 53], and the proximal radius [48]. Fractures of the distal humerus have included the lateral condyle [47, 48, 51], the medial epicondyle [48, 51], and the lateral epicon- dyle [48]. It may occur at the knee, but when this oc- curs the vascular complications overshadow the nerve impairment.
In acute cases, the usual scenario is displacement of the epiphysis of a type 2 or 3 fracture which causes the edge of the metaphysis to stretch or impinge a nerve (Fig. 8A.1). This is common at the distal radius producing an acute carpal tunnel syndrome [13, 49, 52, 53]. The resulting neuritis or neuropraxia usually resolves soon after reduction [51, 52], or resolves with time [13].
Severance of a nerve with a resulting neuroma is rare, and has been reported only as a complication of retained metal used to internally fix a physeal frac- ture [47].
Tardy ulnar nerve palsy due to deformity from a physeal fracture at the elbow is perhaps the most like- ly presentation [48, 50, 51]. The ulnar nerve lesions may be due to: 1) compression within the limited space of the cubital tunnel, 2) traction such as occurs with valgus deformity, 3) impingement by the triceps tendon associated with varus deformity, or 4) friction from bone fragments or osteophytes in close proxim- ity to the nerve [51]. The delay between injury and nerve impairment may be days to years. The condi- tion is manifested by pain, paresthesias, and muscle weakness and wasting [51].
In the distal radius neuropraxia noted only after reduction may be due to repeated manipulations or a fixed position of wrist flexion [46].
Treatment of acute nerve impairment is usually closed reduction of the fracture and observation of the neuropraxia [13, 51, 53]. The trauma of repeated attempted reductions may promote neuropraxia.
Percutaneous fixation is often used to prevent insta- bility of fracture fragments from reinjurying the nerve [53]. Surgical decompression [49, 53] is avail- able for persistent nerve impingement and anterior nerve transposition is helpful for tardy ulnar nerve [48, 50, 51]. Tendon transfers are appropriate in some cases of permanent nerve damage [47].
E. Infection
Osteomyelitis can occur following any child’s frac- ture, whether the fracture is open or closed. Closed fractures treated closed are less likely to become in- fected than open fractures, or fractures treated by in- ternal fixation (Fig. 8E.1). In closed fractures the most plausible explanation for its occurrence is the pres- ence of bacteremia at the time of fracture. Bacteria have a better chance of multiplying in stasis of the fracture hematoma. Compere (1935) [59] noted 5 of 42 physeal fractures (11.9%) were complicated by in- fection and that all 5 had growth arrest. No other de- tails of the cases were given. There was no case of in- fection associated with the 951 cases in the Olmsted County Study [2].
Closed crush injuries of the phalanges, common in children, may include fracture of the physis which in turn may develop pyogenic granuloma of the physis [55]. This results in widening and lysis of the physis which in turn predisposes to premature physeal clo- sure and joint stiffness.
Mallet finger and the stubbed great toe in children consist of volar displacement of the metaphysis of the distal phalanx usually due to a type 2 or 3 fracture.
This is often accompanied by avulsion of the proxi- mal nail from the nailbed and is therefore an open fracture (Fig. 9.4). Infection is more likely to occur if the nail is excised. One such case resulted in osteomy- elitis of the distal phalanx treated by amputation of the finger [56]. The recommended treatment is to re- place the nail beneath the nailfold with the distal pha- lanx reduced in slight hyperextension. This helps sta- bilize the fracture making internal unnecessary [56].
Although infection is rarely recorded following a closed physeal fracture, the result can be disastrous.
Foucher [54], in 1863, gave a detailed description of a
163 Complications Chapter 8
13-year-old girl with a closed type 3 separation of the proximal humerus which developed hematogenous osteomyelitis. Both diagnoses were confirmed at the time of autopsy 6 weeks later: cause of death was sep- ticemia, perpetuated by the osteomyelitis.
Even today drastic outcomes are possible. An 10- year-old girl with closed, bilateral, type 2 fractures
of the distal radius developed bilateral hematogenous osteomyelitis, which progressed to uncontrollable septicemia (Fig. 8E.2). Death was averted by a mid- forearm amputation. This may become more com- monplace with the increasing occurrence of drug resistant organisms and decreasingly effective antibi- otics.
Fig. 8E.1
Infection,. proximal. humerus,. type.3. fracture . This.
16.year.6.month.old.boy.fell.from.a.moving.motorcycle.
striking.his.left.shoulder .a.A.displaced.type.3.fracture.
was. reduced. under. general. anesthesia. and. the. arm.
placed.in.a.shoulder.immobilizer.splint .Five.days.later.
the.fracture.had.re-displaced .b.Six.days.post.fracture.
excellent.reduction.was.achieved.under.general.anes- thesia.on.abduction.AP.(left).and.axillary.(right).views ..
c.Roentgenographs.taken.in.a.“Statue.of.Liberty”.cast.
showed.some.loss.of.position .The.cast.was.wedged.at.
the.shoulder.level ..(Continuation see next page)
Fig. 8E.1 (continued)
165 Complications Chapter 8
Fig. 8E.1 (continued)
d.Sixteen.days.post.fracture.the.fragments.were.again.displaced .e.On.the.17th.day.post.fracture.the.cast.was.removed.
and.reduction.under.a.third.general.anesthesia.was.unsuccessful .A.short.anterior.deltopectoral.curved.incision.was.
made .A.large.hematoma.was.evacuated .The.humeral.head.was.found.stable.in.healing.callus.in.an.anterior.medial.
position .The.periosteum.and.callus.were.divided.to.achieve.reduction .The.reduction.was.unstable .A.Rush.pin.was.
passed.from.proximally.through.a.small.split.in.the.deltoid.muscle,.through.the.humeral.head.and.into.the.medullary.
cavity .A.shoulder.immobilizer.was.applied .f.One.month.post.fracture.purulent.drainage.from.the.incision.cultured.
Staphylococcus.aureus .Sedimentation.rate.was.95.mm/h .A.fourth.general.anesthetic.was.used.to.open.and.debride.
the. incision . The. wound. was. packed. open . Three. more. general. anesthetics. were. given. for. further. debridement,. . delayed.closure.of.the.wound,.and.removal.of.the.Rush.pin.(3.months.post.fracture) .g.Seven.months.post.fracture,..
age.17.years.1.month,.the.patient.was.normally.active,.asymptomatic,.and.had.full.shoulder.motion .There.was.no.sign.
of.infection .h.Four.years.post.fracture,.age.20.years.6.months,.the.shoulder.was.asymptomatic.and.clinically.normal . The.patient.was.employed.in.electrical.installation.work .He.later.became.a.sign.painter .He.was.followed.on.multiple.
occasions.in.the.clinic.through.age.40.years.with.no.mention.of.shoulder.difficulty .Note:.It.is.easy.to.speculate.the.
.result.of.this.proximal.humeral.fracture.would.have.been.equally.as.good.with.treatment.by.hanging.arm.cast,.shoul- der.immobilizer,.or.abduction.splint,.avoiding.the.infection.and.seven.general.anesthetics
Fig. 8E.2
167 Complications Chapter 8
Fig. 8E.2 (continued)
Bilateral.distal.radius.type.2.fractures,.with.bilateral.infection .A.10.year.10.month.old.girl.fell.while.skiing,.sustaining.an.
abrasion.on.her.face.and.bilateral.displaced.type.2.fractures.of.the.distal.radius .a.AP.and.lateral.roentgenographs.of.
the.left.wrist .b.AP.and.lateral.views.of.the.right.wrist .c.Reductions.were.performed.at.the.emergency.room.closest.to.
the.ski.facility.under.oral.sedation.and.short.arm.casts.applied .The.facial.abrasion.was.cleansed .No.transcutaneous.
needles.were.employed .The.patient.returned.to.her.home.and.was.seen.the.following.day.in.the.emergency.room.
with.swelling.and.drainage.about.the.right.eye,.nasal.obstruction,.and.temperature.40 0°C .Facial.roentgenographs.
were.negative.for.fracture .The.diagnosis.was.blockage.of.the.nasolacrimal.duct .Polytrim.eyedrops.were.given .The.
abrasion.was.cleansed .The.distal.radius.fractures.had.slipped.and.were.re-reduced.under.general.anesthesia .Long.
arm.casts.were.applied.and.the.patient.admitted.for.observation .The.next.morning.she.was.afebrile.and.was.dis- missed .On.the.second.post.injury.day.she.was.seen.as.an.outpatient .She.had.no.fever.and.no.eye.pain,.but.mild.“yel- low.drainage.out.of.the.right.eye ”.On.the.third.post.injury.day.there.was.pain.and.swelling.on.both.forearms .The.casts.
were.removed .The.forearms.were.swollen.and.firm.and.there.was.marked.decrease.in.sensation.of.the.median,.radial,.
and.ulnar.nerves.in.the.right.hand.and.no.motor.function.in.the.right.hand .Compartment.pressures.were.40.mm.in.the.
right.and.50.mm.in.the.left.volar.compartments .Bilateral.compartment.syndrome.was.suspected .Bilateral.forearm.
fasciotomies.and.carpal.tunnel.releases.were.performed .“Frank.purulence.was.encountered ”.The.right.pronator.qua- dratus.was.largely.necrotic.and.the.necrotic.portion.was.excised .The.fractures.were.noted.to.be.unstable .Gram.stains.
revealed.“multiple.gram.positive.cocci.consistent.with.Strep”.bilaterally .Intravenous.antibiotics.were.begun .On.the.
fourth.post.injury.day.both.open.wounds.were.further.debrided.and.irrigated.and.an.abscess.on.the.right.cheek.was.
incised.and.drained.of.12.cc.frank.brown.pus .This.incision.was.also.packed .d.On.the.sixth.post.injury.day.further.
.debridement.revealed.thrombosis.with.proximal.and.distal.spasm.of.both.radial.and.ulnar.arteries .Thrombectomies.
resulted. in. re-establishing. partial. blood. flow . The. unstable. fractures. were. pinned. with. cross. K-wires . Additional.
.debridement.was.performed.on.the.seventh.post.injury.day .Severe.respiratory.problems.resulted.in.the.use.of.high.
frequency.oscillary.ventilation,.high.dose.steroids,.and.ultimately.tracheosteomy .During.the.course.of.treatment.there.
were.several.pneumothoraces.and.ultimately.a.persistent.lung.cyst .(Continuation see next page)
Fig. 8E.2 (continued)
e.Early.in.the.morning.of.the.eighth.post.injury.day,.rising.temperature,.decreasing.respirations.and.tachycardia.caused.
the.septicemia.to.be.life.threatening .The.right.hand.was.ischemic,.the.distal.radius.and.ulna.were.nonviable,.and.there.
was.additional.myonecrosis .Right.below.elbow.amputation.was.performed .The.left.radius.osteomyelitis.was.treated.
by.multiple.debridements.and.saucerization.of.both.the.distal.radius.and.ulna .Hospitalization.was.9.weeks.and.2.days . f.Six.months.post.injury.(age.11.years.4.months),.the.left.radius.osteomyelitis.is.healing.with.premature.closure.of.the.
physis .Surgical.arrest.of.the.ulna.is.indicated.since.the.radius.is.not.a.good.candidate.for.lengthening .There.is.forearm.
muscle.atrophy.and.limited.hand.function .Physical.therapy,.occupational.therapy,.and.respiratory.therapy.continue ..
A.prosthesis.was.fitted.on.the.right.below.elbow.stump,.with.plans.for.a.functional.unit.in.the.future .Note:.This.case.
scenario.is.best.explained.on.the.basis.of.a.facial.abrasion.which.developed.a.facial.abscess.concurrent.with.bilateral.
physeal.fractures .The.ensuing.bacteremia.or.septicemia.invaded.the.fracture.hematoma.resulting.in.streptococcal.
fasciitis.with.secondary.compartment.syndrome,.which.led.to.osteomyelitis,.eventual.amputation.of.the.right.hand,.
and.distal.forearm.and.significant.anatomic.and.functional.impairment.of.the.left.hand.and.forearm .The.streptococ- cus.in.this.case.was.resistant.to.multiple.combinations.of.antibiotics .Increasing.bacterial.resistance.will.result.in.more.
cases.like.this.in.the.future
169 Complications Chapter 8
II. Complications Manifesting at a Later Date F. Complete Physeal Arrest
Premature partial arrest of a physis is a complex prob- lem and is considered in Part III. Untreated partial physeal arrest invariably progresses to premature complete arrest (Fig. 13.7).
Premature complete closure of a physis causes ces- sation of growth at that physis. Because the physis is completely closed, there is no progressive angular de- formity. Continuing growth of the contralateral phy- sis, or the companion bone physis (e.g., the radius or ulna), produces length inequality between the two bones involved. The amount of inequality is deter- mined by the physis injured (specifically, its contribu- tion to the growth of that bone) and the amount of growth remaining (specifically the patient’s age at the time of growth arrest).
Physeal arrest is first detected by routine roentgen- ographs or MRI. The amount of length discrepancy compared with the contralateral normal bone is best determined and monitored by scanography (Chap- ter 31). Physeal fracture with subsequent arrest could be best studied scientifically by the insertion of metal markers into the epiphyses and metaphyses, both proximal and distal to a fractured physis, and its nor- mal contralateral physis, at the time of fracture [58].
A difference in growth between the two sides would be readily appreciated. Selection criteria of fracture site, fracture type, and age of patient, have not been determined for application of this technique.
Premature complete physeal closure occurred in 37 (3.9%) of the 951 physeal fractures in the Olmsted County population based study [2]. The vast majority of these occurred in older children whose other phy- ses had little growth remaining, and no treatment was necessary. These figures could increase as the young- er patients who were seen late in the 10-year study pe- riod continue to mature. This experience is different than our referral practice which contains much high- er percentages of patients with length discrepancy and angular deformity sufficient to require surgery.
The figures noted above are far different than those of Compere [59] who in 1935 wrote “Of the fractures in children that involved the growth cartilage and were seen before deformity had occurred and were followed for more than six months with roentgen ex- aminations, 18 of 19 cases, or 95%, showed growth disturbances.” However, neither the referral history or the completeness of premature physeal closure was recorded. There is similar absence of detail in a report by Lipschultz (1937) [60] who noted premature phy-
seal arrest in 15 of 105 cases (14%). Although Bisgard (1938) [57] reported roentgenographic evidence of disturbances of growth in 50% of fractures involving epiphyseal cartilage, he noted a clinical disturbance of growth in only 6 of 49 cases (12.2%).
In older children with little growth remaining, no treatment is required; this is common. In younger children, consideration for treatment depends on the specific physis injured and the amount of length dis- crepancy calculated to be present at maturity. Treat- ment options include a shoe-lift for lower limb dis- crepancy, physeal arrest of the contralateral or companion (radius/ulna or tibia/fibula) bone, ipsilat- eral bone lengthening, contralateral bone shortening, or a combination of these. Because no physis remains, bar excision and physeal distraction are not options.
Upper Extremity Physes
Complete physeal arrest of the proximal humerus rarely results in sufficient length discrepancy to pro- duce functional impairment. If the discrepancy ex- ceeds 6 cm, bone lengthening may be considered (Fig. 17B.2) [63]. The contralateral humerus should never be surgically arrested or shortened. No such cases have been reported.
Complete arrest of the distal humerus requires no treatment. Even if this occurred in a young child, there is so little growth at the distal humerus that the length discrepancy would be little noticed, would not produce functional impairment, and would not re- quire humeral lengthening. The contralateral humer- us should never be shortened or its distal physis surgi- cally arrested.
Complete arrest of the proximal radius or ulna likewise never causes sufficient forearm length dis- crepancy to consider physeal arrest of the contralat- eral forearm. Traumatic arrest of the proximal radius at an early age could cause sufficient distal radial–ul- nar variance to consider surgical arrest of the distal ulnar physis, ulnar shortening, or even radial length- ening. Because much greater length occurs from the distal ends of these bones than from the proximal ends, post injury arrest of the distal end of either is often treated by surgical arrest of the companion bone, lengthening of the involved bone, or both.
Lower Extremity Physes
In the lower extremities, limb-length inequality
causes pelvic tilt and spine curvature, which predis-
pose to low back pain. Clinical observations and mea-
surements are often inaccurate to the extent that dif-
ferences of 1/2 inch or less are not reliable [62].
Measurement by methods of imaging are discussed in Chapter 31. A lower limb length discrepancy of one inch or less needs no active treatment [61].
Post traumatic areas of the capital femoral physis at a young age from fracture or any other cause can result in significant femoral length discrepancy. Sur- gical arrest of the contralateral capital femoral physis is not warranted because of its surgical inaccessibility and potential for avascular necrosis. It would be more appropriate to have the patient wear a shoe-lift, arrest the contralateral distal femoral physis at a later date, or lengthen the ipsilateral femur at times determined by growth charts or at maturity.
Complete premature arrest of a distal femoral phy- sis may be treated by permanent use of a shoe-lift, femoral lengthening, physeal arrest of the contralat- eral femoral physis, or contralateral femoral shorten- ing at maturity. The choice depends on the degree of calculated length discrepancy, body height at matu- rity, and the desire of the patient.
Complete arrest of the proximal or distal tibial physis may be treated similarly to the distal femur, with the addition of physeal arrest of the ipsilateral fibula if significant relative overgrowth of the fibula is likely. Surgical shortening of the contralateral tibia should never be undertaken as an elective procedure, as any significant surgical tibial shortening (e.g.,
>1 cm) will result in weakness of the anterior tibialis muscle and footdrop.
G. Nonunion
A nonunion is established when a fracture site shows no visibly progressive signs of healing roentgeno- graphically (FDA, in conjunction with the Orthopae-
dic and Rehabilitation Devices Panel). In children, nonunion of any fracture is unusual [72]. Nonunion of physeal fractures is also uncommon. There were no nonunions in the 951 cases of the Olmsted County population based study [2].
Nonunion following physeal fracture occurs most often when the fracture is not recognized, or is treated expectantly or inadequately (Fig. 13.7). However, some occur even following ORIF. Most occur follow- ing type 5 fractures (Fig. 8G.1). They can occur at any site and are most commonly reported in the distal humeral lateral condyle (Figs. 15A.11, 15A.12, 15A.13) [65–68, 70, 71, 73, 76–78]. They occur occa- sionally in the distal humerus medial condyle (Figs. 15C.1, 15C.2), the distal tibial medial malleo- lus (Figs. 11A.13, 11A.14), the thumb metacarpal (Fig. 13.7), and the proximal radius (Fig. 21.18). Non- union of a distal femur is documented in one case in which the original roentgenograph was negative [69].
The patient sustained a football “clipping injury” and undoubtedly had a “concealed” type 4 fracture (see Chapter 18).
Nonunion of the proximal olecranon epiphysis oc- curs in athletes as a “stress” fracture (Chapter 22A) from overuse of one or both upper extremities [64, 75, 80–82]. These are usually easily treated by surgical fusion of the physis. Another type of stress nonunion occurs through the entire physis of a fused or anky- losed immature joint. This has been shown to occur following an operative fusion of the hip [74], and after inflammatory or rheumatoid ankylosis of the hip [79].
Residua of nonunions in general are limitation of motion, angular deformity, delayed neuropathy, weakness, pain, and degenerative arthrosis.
Nonunion at each fracture site is discussed in more
detail in the chapter for each site.
171 Complications Chapter 8
Fig. 8G.1
Distal.humerus,.lateral.condyle,.type.5,.nonunion .This.4.year.4.month.old.boy.fell.while.playing,.injuring.his.left.elbow . a.A.lateral.condyle.fracture.containing.metaphysis.(type.5).is.significantly.rotated .Right.elbow.for.comparison.(left) ...
b.The.following.day.open.reduction.was.accompanied.by.internal.fixation.with.suture .Faintly.visible.air.(dark).outlines.
the.large.cartilaginous.lateral.condylar.fragment .(Continuation see next page)
Fig. 8G.1 (continued)
c.A.posterior.plaster.splint.was.used.for.immobilization .d.Three.years.2.months.later,.age.7.years.6.months,.increasing.
cubitus.valgus.was.accompanied.by.motion.0–135°.flexion.compared.with.0–150°.on.the.right .There.was.prominence.
of.the.medial.epicondyle.with.the.elbow.in.extension.(left).and.of.the.lateral.condyle.with.the.elbow.in.flexion.(right) . The.patient.was.normally.active.and.asymptomatic .e.The.nonunion.is.well.established .f.Osteosynthesis.was.per- formed.at.age.7.years.7.months,.in.an.attempt.to.obtain.union.without.advancing.the.lateral.condyle.or.disturbing.the.
capitellar.physis .The.capitellum.was.left.in.extension.on.the.lateral.view.(right) .g.One.year.later,.age.8.years.7.months,.
the. metaphysis. was. united . The. proximal. radius. is. anterior. to. the. capitellum. (right) . The. screws. were. removed . . (Continuation see next page)
173 Complications Chapter 8
Fig. 8G.1 (continued)
Fig. 8G.1 (continued)
h.At.age.9.years.1.month.the.capitellar.physis.remained.open.but.growth.was.difficult.to.assess .The.cubitus.valgus.was.
improved.(compare.with.g) .i.Corrective.arcuate.osteotomy.corrected.the.remaining.valgus,.but.not.the.extension.of.
the.capitellum .(Continuation see next page)
175 Complications Chapter 8
Fig. 8G.1 (continued)
j.At.age.13.years.1.month.he.was.normally.active,.asymptomatic,.and.unable.to.think.of.anything.he.was.unable.to.do.
with.his.left.elbow .Carrying.angles.were.symmetrically.normal .Elbow.flexion.was.35–125° .There.was.90°.forearm.
.supination. and. pronation,. despite. asymmetric. overgrowth. of. the. radial. head .k. At. age. 15.years. 1.month,. 10.years.
7.months.post.fracture.the.patient.was.playing.organized.basketball.and.baseball .All.physes.were.closed .The.osteo- phyte.on.the.capitellum.(arrows).was.difficult.to.assess .The.projection.of.the.x-rays.did.not.allow.good.visualization.of.
the.joint.surfaces .Since.the.patient.was.asymptomatic.no.further.evaluation.or.treatment.was.recommended .Degen- erative. arthrosis. is. inevitable . The. patient. was. followed. in. other. departments. of. the. clinic. as. late. as. age. 25.years.
10.months.with.no.mention.of.elbow.symptoms .The.fishtail.deformity.in.this.case.is.due.to.the.nonunion.and.prema- ture.physeal.closure .The.final.appearance.and.result.most.likely.would.have.been.enhanced.with.more.flexion.of.the.
capitellum.at.the.time.of.first.osteosynthesis.(f)
H. Malunion
Malunion of a physeal fracture occurs when displace- ment or angulation of the epiphysis unites in an ab- normal position. In young children prior to ossifica- tion of the epiphysis, arthrography [83] or MRI may be helpful in documenting the position of the mal-
united fragments. In older children routine roentgen- ography and CT scans are usually sufficient. Mal- union is most likely to occur following a fracture which is initially undetected or one which is treated nonoperatively (Fig. 8H.1). This has resulted in favor- ing ORIF, even for undisplaced fractures, particularly for humeral lateral condyle fractures [84].
Fig. 8H.1
Malunion,.distal.tibia.type.4.fracture .An.11.year.2.month.old.boy.fell.twisting.his.left.ankle .a.AP.and.lateral.roentgeno- graphs.were.reported.normal.and.there.was.no.treatment .Upon.closer.review,.there.is.a.type.4.fracture.of.the.medial.
malleolus.(arrow) .An.oblique.view.parallel.with.the.fracture.is.necessary.to.determine.the.amount.of.separation.of.this.
fracture .Since.there.was.no.treatment,.the.fragments.are.at.risk.of.separating.further.during.ambulation.in.the.imme- diate.post.fracture.period .b.One.year.later.(age.12.years.2.months).there.is.“stiffness,.achiness,.and.synovitis.of.the.
ankle ”.Attempts.at.running.and.jumping.cause.ankle.pain.and.swelling .AP.view.of.both.ankles.standing.shows.a.mild.
left.ankle.varus,.an.abnormal.distal.articular.surface,.widening.of.the.ankle.joint.mortise,.a.narrow.band.of.union.be- tween.the.medial.malleolus.and.the.remaining.epiphysis,.and.an.open,.irregular.physis .The.left.tibia.was.1.mm.short- er.than.the.right.on.scanogram .(Continuation see next page)
177 Complications Chapter 8
Fig. 8H.1 (continued)
c.A.mortise.view.confirms.an.open.physis.and.normal.linear.longitudinal.growth.from.the.Harris.arrest.line.(closed arrows) .There.is.a.bone.fragment.distal.to.the.fibula.(open arrow) .d.Lateral.views,.both.ankles,.standing .(Continuation see next page)
Physeal fractures treated nonoperatively often malunite, but to such a minor degree that they re- model normally with growth providing the physis is intact (types 1, 2, 3). Malunion of a type 5 fracture is common and in addition to malalignment usually forms a physeal bar, which in turn causes progressive
angular deformity and length discrepancy. Malunion may occur without developing a physeal bar (Fig. 8H.1).
In this instance longitudinal growth would continue and progressive angulation deformity would not oc- cur. Malunion can occur anywhere, but is most fre- quently reported at the lateral (Figs. 15A.8, 15A.9, 15A.11, 15A.14, 15A.15, 15A.16) [76, 84, 85] and me- dial (Fig. 15C.3) [83] humeral condyles (Chapter 15A, C) [76, 84, 85]. The distal humerus has so little growth that progressive growth deformity from a physeal bar associated with a malunion has not been reported.
Established troublesome malunion can be treated
by osteotomy (Fig. 8G.1h–j). In the case of the elbow,
accompanying ulnar nerve transposition should be
considered [76].
Fig. 8H.1 (continued)
179 Complications Chapter 8
Fig. 8H.1 (continued)
e–h.Coronal.CT.scans.with.cuts.progressively.from.anterior.to.posterior.show.what.appears.to.be.nonunion.of.the.
epiphysis.(arrows).on.cuts.e.and.f,.and.union.on.cuts.g.(arrow).and.h .The.physis.is.open.on.all.views .i.Transverse.cut.CT.
scan.of.both.distal.tibial.epiphyses.shows.the.anterior.portion.of.the.epiphysis.is.more.wide.on.the.left.and.is.ununited . The.posterior.portion.is.united .There.is.an.internal.rotational.malunion.of.the.medial.malleolus .The.treatment.con- sisted.of.bilateral.physeal.arrest,.open.on.the.left,.percutaneous.on.the.right .The.loose.body.on.the.left.was.removed . j.AP.both.ankles.standing.4.years.2.months.postoperative.(age.16.years.5.months) .The.patient.is.active.in.high.school.
football,.basketball,.and.track,.but.has.discomfort.after.activities .k.Lateral.views.both.ankles.standing .The.mild.ankle.
joint.mortise.irregularity.and.the.anterior.upward.tilt.of.the.left.distal.tibial.articular.surface.are.likely.the.causes.of.the.
present.symptoms.and.predispose.the.ankle.to.degenerative.arthrosis.in.the.decades.to.come .The.patient.should.be.
counseled.accordingly.concerning.activities .Note:.At.the.time.of.bilateral.epiphyseodesis,.alternative.treatment.of.
corrective.osteotomy.of.the.epiphysis.was.considered .This.would.undoubtedly.resulted.in.a.physeal.bar.requiring.
more.surgery .It.is.unlikely.to.suspect.that.the.end.result.would.have.been.superior .This.case.was.referred.by.Dr .Mark.
Hart,.Bismark,.ND
