Whenever you hear of a child suffering from an injury, automatically your mind wanders to the topic of growth plates. We always wonder if the growth plate is affected; the concern is legitimate and needs to be thoroughly evaluated upon presentation to the doctor. When dealing with lower extremity injuries the Podiatrist will x-ray and clinically evaluate the injury to determine if the area in and around the growth plate is affected but the actual “plate” unaffected, or if the injury has directly disrupted the growth plate itself. The treatment plan changes from initial management to the possibility of surgical management and the choice of fixation (pins/screws etc) that can be utilized depending on the extent of growth plate involvement.
When understanding a pediatric injury versus the same injury in an adult, there are some important concepts to understand. The first is that in kids, the bones are very malleable meaning that the tendons and ligaments surrounding the bones, helping with normal motion are stronger than the actual bones themselves. Therefore, in a pediatric patient injury is likely to lead to bone injury versus in an adult where the bones are stronger, ligament damage is more likely. Secondly, treating injuries or fractures in the pediatric patient is much more complicated because of the presence of the growth plate.
Growth plates in the lower extremity, when visualized on x-ray, indicate that the growth of the individual is still possible. When evaluating bones on x-ray, there are specific “zones” that can be identified to signify growth, disruption of growth, and healthy bone. What you may not know is that when born, the bones are very soft and malleable and only harden (ossify) and change completely into the solid bone in a child’s mid to late teens and sometimes not until their early twenties. What this indicates is that injury anywhere in the body, before ossification takes place, can affect growing bone with the possibility of disrupting growth, causing abnormal/irregular growth, and even has the potential to halt growth altogether.
In an adult, the growth plate has closed, growth has ceased and treatment of a fracture can be initiated without fear of interrupting growing bone. If pins, screws, or plates are needed for fixing the adult fracture, they can be applied without reservations or worries of disrupting growth. However, in pediatric patients, certain types of fixation must be avoided and others used carefully and in specific ways so as to protect the growth plate and allow for normal growth to continue.
When the growth plate is unaffected fracture management is tricky, but can be more easily handled and the growth plate more easily avoided during treatment. When fracture across the growth plate is created by the initial injury the goal of fracture management becomes more complicated as the growth plate cannot be avoided during treatment. It must be addressed with reduction and fixation bringing the edges of the fractured growth plate into close proximity with one another. Doing so decreases the risk of interrupted or halted growth in the affected bone with the hope that restoration of normal growth occurs.
Pediatric fractures can be tricky, but they can be treated in such a way as to minimize disruption to normal growth patterns. It is important to seek treatment immediately if a fracture is suspected, but refrain from pondering the worst-case scenario until your child has been evaluated!