Intra-articular Physeal Fractures of the Distal Femur: A Frequently Missed Diagnosis in Adolescent Athletes

Abstract

Background:Intra-articular physeal fractures of the distal femur are an uncommon injury pattern, with only a few small case series reported in the literature.Purpose:To pool patients from 3 high-volume pediatric centers to better understand this injury pattern, to determine outcomes of surgical treatment, and to assess risk factors for complications.Study Design:Case series; Level of evidence, 4.Methods:A multicenter retrospective review of all patients presenting with an intra-articular physeal fracture between 2006 and 2016 was performed. Patient demographic and injury data, surgical data, and postoperative outcomes were documented. Radiographs were evaluated for fracture classification (Salter-Harris), location, and displacement. Differences between patients with and without complications were compared by use of analysis of variance or chi-square tests.Results:A total of 49 patients, with a mean age of 13.5 years (range, 7-17 years), met the inclusion criteria. The majority of fractures were Salter-Harris type III fractures (84%) involving the medial femoral condyle (88%). Football was responsible for 50% of the injuries. The initial diagnosis was missed in 39% of cases, and advanced imaging showed greater mean displacement (6 mm) compared with radiographs (3 mm). All patients underwent surgery and returned to sport with “good to excellent” results after 2 years. Complications were more common in patients with wide-open growth plates, patients with fractures involving the lateral femoral condyle, and patients who were casted (P < .05).Conclusion:Clinicians evaluating skeletally immature athletes (particularly football players) with acute knee injuries should maintain a high index of suspicion for an intra-articular physeal fracture. These fractures are frequently missed, and advanced imaging may be required to establish the diagnosis. Leg-length discrepancies and angular deformities are not uncommon, and patients should be monitored closely. Surgical outcomes are good when fractures are identified, with high rates of return to sport.

Orthopaedic case management: A balancing act

“…; Little and Milewski ; Pennock et al . ). This type of fracture in adolescent children is recognised to have a delay of diagnosis in almost 40% of cases, particularly when the fracture is minimally displaced (Pennock et al .…”

“…This type of fracture in adolescent children is recognised to have a delay of diagnosis in almost 40% of cases, particularly when the fracture is minimally displaced (Pennock et al . ). That presentation bears similarity to the foal in the report by Valk and Schumacher, where initial evaluation by the attending veterinarian, and presumably the relative comfort of the foal, did not raise fracture sufficiently as a likely diagnosis to perform radiographs of the stifle.…”

“…This type of fracture also carries an excellent prognosis in children for future athletic endeavours (Pennock et al . ).…”

“…The uncommon configuration of the physeal fracture reported by Valk and Schumacher (complex type 3 Salter-Harris fracture of the distal femur) is also uncommon in other species, including children (Berg et al 1984;Arkader et al 2007;Little and Milewski 2016;Pennock et al 2017). This type of fracture in adolescent children is recognised to have a delay of diagnosis in almost 40% of cases, particularly when the fracture is minimally displaced (Pennock et al 2017). That presentation bears similarity to the foal in the report by Valk and Schumacher, where initial evaluation by the attending veterinarian, and presumably the relative comfort of the foal, did not raise fracture sufficiently as a likely diagnosis to perform radiographs of the stifle.…”

“…Physeal fracture configurations are dependent upon many factors, including the size and age of the animal, the magnitude and direction of force that causes the injury, the particular physis involved, its shape, any pre-existing local physeal abnormalities and the associated soft tissues of the region. The uncommon configuration of the physeal fracture reported by Valk and Schumacher (complex type 3 Salter-Harris fracture of the distal femur) is also uncommon in other species, including children (Berg et al 1984;Arkader et al 2007;Little and Milewski 2016;Pennock et al 2017). This type of fracture in adolescent children is recognised to have a delay of diagnosis in almost 40% of cases, particularly when the fracture is minimally displaced (Pennock et al 2017).…”