|Year : 2014 | Volume
| Issue : 1 | Page : 73-77
Surgical treatment for Salter-Harris type III fracture of the medial femoral condyle: A prospective study
Ramji Lal Sahu
Department of Orthopedics, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India
|Date of Web Publication||6-Jun-2014|
Ramji Lal Sahu
11284, Laj building no 1, Doriwalan, New Rohtak Road, Karol Bagh, New Delhi
Source of Support: None, Conflict of Interest: None
Background: Salter-Harris type III fracture involves the medial or lateral condyle of femur. The fracture line usually exits through - the inter-condylar notch. These fractures are not common but have a high rate of complications and only very few cases have been reported. Objective: The aim of the surgery is to minimize the complications of epiphyseal injury by early fracture Fixation. Design: A 28 months prospective follow-up study. Setting: Unicentric study, operating on a total of 22 patients during a period of 5 years. Materials and Methods: From July 2005 to July 2010, 22 patients (16 males and 6 females) were recruited from Emergency and outpatient department having closed and open Salter-Harris types III fracture of the medial femoral condyle of the distal femur. All patients were operated under general or spinal anesthesia. The mean follow-up period was 28 months. Results: All children achieved union in a mean time of 10 weeks (range from 6 to 16 weeks) depending on the type of fracture pattern. Full weight bearing was possible in a mean time of 8.8 weeks. Mean duration of hospital stay was 9.8 days. The mean follow-up period was 28 months (17-48 months). Complications were recorded in 3 (13.64%) patients and included 2 Cases of insignificant limb shortening of 1 cm and 1.5 cm and 1 case of significant shortening of 2 cm. The results were excellent in 86.36 and good in 13.64% patients. Conclusion: Early anatomical reduction and fixation with screws provide satisfactory results and minimal complications.
Keywords: Medial femoral condyle fracture, Children, Anatomical fixation, Salter-Harris types III fracture
|How to cite this article:|
Sahu RL. Surgical treatment for Salter-Harris type III fracture of the medial femoral condyle: A prospective study. J Orthop Traumatol Rehabil 2014;7:73-7
|How to cite this URL:|
Sahu RL. Surgical treatment for Salter-Harris type III fracture of the medial femoral condyle: A prospective study. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 Mar 22];7:73-7. Available from: http://www.jotr.in/text.asp?2014/7/1/73/134024
| Introduction|| |
Salter-Harris Type III is a physeal separation with a fracture through the epiphysis into the joint with joint incongruity when the fracture is displaced.  Intra-articular discontinuity can lead to early degenerative arthritis and physeal discontinuity can disturb longitudinal growth. , Treatment for distal femoral physeal fractures varies according to severity of injury.  Displaced SH I or SH II fractures are treated with closed reduction and splinting with hip spica.  SH III and SH IV injuries usually require anatomic reduction, which cannot be obtained with closed reduction and are very often unstable.  Operative treatment is required because even slight residual displacement can result in formation of a bone bar that causes limb-length discrepancy and angular deformity. , Salter-Harris III fractures of the distal femur are often concealed by the overlying patella, they can be difficult to recognize on plain x-rays.  Eid A M, Hafez M A'  described traumatic injuries of the distal femoral physis. He stated that these injuries after fixation need to be followed until skeletal maturity. The purpose of this study was to minimize the complications of epiphyseal injury by early fracture fixation. I prepared this paper in consideration of its contribution to the literature.
| Materials and Methods|| |
This prospective study was carried out at Orthopaedics department of M. M. Medical College from June 2005 to June 2010. It was approved by institutional medical ethics committee. A total of 22 children with Salter-Harris Type III Fracture of the Medial Femoral Condyle admitted to our institute were included in present study. A written informed consent was obtained from all the patients; they were explained about treatment plan, cost of operation and hospital stay after surgery and complications of anesthesia. Open reduction is indicated for displaced Salter-Harris type III or IV fractures, for all other types in which satisfactory alignment cannot be obtained by closed means or when associated injuries mandate it (i.e., a "floating knee" or ligament injury). Open reduction was used in all of our patients. They were followed up after surgery, were clinically and radio logically assessed for fracture healing and joint movements. According to the radiographic and clinical criteria of fracture healing, , the results are graded as excellent when the fractures unites within 10 weeks without any complication, good when union occur within 16 weeks with treatable complications like superficial infection and knee stiffness and poor when union occur before or after 16 weeks with one or more permanent complications like infection (osteomyelitis), non-union, limb shortening and permanent knee stiffness. Delayed union was recorded when the fracture united between two to four months while non-union was noted when union had not occurred after four to six months of treatment. The mean follow-up period was 28 months (17 to 48 months). Patients with Salter-Harris Type III Fracture of the Medial Femoral Condyle with age between 6 to 16 years presented within a week of the injury and did not have any previous surgical treatment for the fracture were included in the study. Malnourished patients and pathological fractures and fracture non-union were excluded from the study. Examination of patients was done thoroughly at the time of admission to exclude other injuries. In majority of the patients open anatomical reduction and percutaneous or internal fixation of the medial Femoral Condyle of distal femur was performed immediately on emergency basis after the injury. Patients who were unfit for surgery due to associated injuries to vital organs, hemodynamic instability, active infection at injury site and pyrexia were operated at a delayed setting. Routine anteroposterior, lateral and oblique radiograph were taken of all the patients. Valgus stress radiograph made with the patients under general anesthesia, demonstrating distraction at the fracture site through medial aspect of the distal femoral epiphyseal plate, with the lateral tibia condyle rotated on its femoral articulation. The radiographs are compatible with the diagnosis of Salter Harris type III fracture of the distal femoral epiphysis. Magnetic resonance imaging of the knee joints were also done of the entire patient for the confirmation of the ligamentous injury. Criteria of instability-Surgical fixation are required when there is at least 2mm of fracture fragment displacement and/or step off. In undisplaced fractures - Percutaneous fixation was applied to the medial condyle with one partially threaded percutaneous cannulated cancellous screw. Screws were driven across fracture, parallel to the physis. In displaced fractures, the patients underwent open reduction and internal fixation operation in emergency department.
Internal fixation was used to allow early mobilization and rehabilitation of both the physeal separation and the ligamentous injury. A tourniquet around the proximal thigh was used for temporary hemostasis if it is placed proximally enough to avoid binding the thigh muscles under the inflated tourniquet. For open reduction and internal fixation of a Salter-Harris type III or IV separation, an anteromedial or anterolateral longitudinal incision was used. The anterior physeal and articular margins of the fracture are exposed. If the fracture is non-displaced, percutaneous cannulated screw fixation is indicated. In displaced fractures, arthrotomy allows inspection of the articular surface of the epiphysis. Reduction is checked by noting the apposition of the articular surfaces, the physeal line anteriorly and the fracture pattern and can be confirmed with image intensifier. Provisional stabilization is obtained with Kirschner guide wires. When reduction is accomplished, screws are directed transversely across the epiphysis in Salter-Harris type III separations. If crossing the physis with fixation is unavoidable, smooth pins or wires should be used. Fixation pins usually are introduced through stab wounds adjacent to the incision. The pins are cut off beneath the skin. After reduction and fixation are checked by intraoperative radiographs. The knee joint is thoroughly irrigated and inspected for other fractures and ligament disruption. After surgery, the reduction is protected by a long leg or hip spica cast. Associated collateral ligament was present in some patients which were repaired at the time of open reduction.
Post reduction care
Treatment criteria for non-surgical verses surgical management of medial femoral condyle fractures has been taught and is well accepted to be based on the amount of fracture fragment displacement. Surgical fixation is required when there is at least 2mm of fracture fragment displacement and/or step off.Ambulation on crutches usually was possible within a few days. At 1 st week after reduction, the patient returned for radiographs taken through the cast. If displacement had occurred, it was not too late to obtain reduction by re-manipulation by open method. If reduction was maintained, straight-leg exercises had begun four times daily. At 4 weeks after injury, the patient returned for radiographs. If sub-periosteal new bone formation was present adjacent to the metaphysis, the cast bivalve and the posterior portion may then be removed twice daily for active muscle-strengthening and range-of-motion exercises, done both supine and prone. The splint may be reapplied for ambulation with crutches. Partial weight bearing was gradually increased. At 6 to 8 weeks after injury and at regular intervals thereafter, the patient returned for reexamination to evaluate healing, range of knee motion and the strength of thigh muscles. When range of motion and thigh muscle strength were fully recovered, the patient returned to normal activities. At 6 months after injury, alignment, leg length, angular deformities and gait were evaluated with comparative radiographs of the lower extremities. If alignment, leg length and gait were within normal limits, the patient was dismissed from routine care but was counseled to return for evaluation of growth 12 and 24 months after injury.
| Results|| |
There were 22 cases in this study, 16 patients were males and six patients were females. There were 13 cases that had injuries in the right side of knees and 9 cases in the left side of knees.
[Table 1] All the patients were of Salter-Harris Type III Fracture of the Medial Femoral Condyle with age between 6 to 16 years. There were 6 cases of fall from height, 8 cases of sports injuries, 7 cases of road traffic accident and 1 case was due to fall into the pit. There were 18 cases with displacement of medial condyle and in 4 cases had no displacement of medial condyle. Out of 22 cases, 4 cases were closed undisplaced, 16 cases were closed displaced and 2 cases were open displaced epiphyseal injuries of salter-harris III of knee joints. All the cases were fixed with cannulated cancellous screws. Out of 22 cases, 4 cases were treated with close reduction and percutaneous screw fixation. Whereas 18 cases were treated with open reduction and internal fixation with screws. This is an intra-articular injury of a weight bearing joint that cannot be left for conservative treatment because slight movement of knee joint may displace the fracture fragment. All children achieved union in a mean time of 10 weeks (range from 6 to 16 weeks) depending on the type of fracture pattern. Full weight bearing was possible in a mean time of 8.8 weeks. Mean duration of hospital stay was 9.8 days. The mean follow-up period was 28 months (17-48 months). The clinical results of our study were rated on the basis of the radiographic and clinical criteria of union, nonunion , delayed union or malunion. The patients were followed according to their clinical and radiological status. There were 19 patients who had union in 90 to 150 days with a mean of 110.68. Union was achieved in 3 patients in 95-109 days with a mean of 103.38. At final follow-up, clinical and radiographic examination revealed that all the fractures had healed without angulations, deformity (varus and valgus) or visible articular incongruity. At the end of the six weeks, knees extensions were full, flexion was 0-150 º and the patients started to walk with full weight. In his last control at the end of the one year, the knees regained full extension and 160° flexion. In 2 cases there is insignificant limb shortening of 1 cm and 1.5 cm and in third case there is 2 cm limb shortening, determined by clinical measurement of the involved limb four years after injury. Inspite of epiphyseal injuries, there were 3 cases of anterior cruciate ligament laxity and one case of anterior cruciate ligament instability. Union was achieved in 100% of patients. The results were excellent in 86.36% and good in 13.64% patients [Table 2] and [Table 3] [Figure 1], [Figure 2], [Figure 3].
|Figure 1: Anteroposterior and lateral radiograph of the left knee: Salter-Harris types III fracture of the medial physis and epiphysis showing posterior displacement of medial condyle (a). Lateral view of the left knee in CT scan: Salter-Harris type III fracture of the medial physis and epiphysis showing posterior displacement of|
medial condyle (b)
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|Figure 2: Intra-operative radiograph of the left knee: Salter-Harris type III fracture of the medial physis and epiphysis showing posterior displacement of medial condyle (a-b)|
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|Figure 3: Post-operative Anteroposterior and lateral radiograph of the left knee showing anatomical reduction and fixation with cannulated cancellous screws|
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|Table 2: Details of 22 children with salter-harris type III fracture of the medial femoral condyle (n = 22)|
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|Table 3: Out come of results salter-harris type III fracture of the medial femoral condyle (n = 22)|
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| Discussion|| |
Fractures involving the distal femoral epiphysis are rare. They account for between 1 and 6% of all epiphyseal injuries that they constitute only 15% of all fractures in children. The growth zone of the distal femur is responsible for 70 % of bone growth of the femur and for 40% of longitudinal growth of the lower extremity. , Physeal closure and cessation of growth typically occurs at an age between 14 and 16 years in girls and between 16 and 18 years in boys. , Distal femoral epiphyseal fractures are uncommon but have a high incidence rate of complications  and are responsible for 1-6% of all physeal injuries and less than 1% of fractures in children.  Motor vehicle accidents and sports-related injuries are reported as the most common causes.  In my study, there were 6 cases of fall from height, 8 cases sports injuries, 7 cases road traffic accident and 1 case was due to fall into the dig. The Salter-Harris classification continues to be the most widely used classification system for physeal fractures.  It helps in understanding the mechanism of injury and in predicting the likelihood of complications. Salter-Harris type II fractures are the most common fracture type of the distal femoral physis. ,, Poor results are correlated with severely displaced fractures, non anatomic reduction, associated injuries and open fractures. Complications included are growth arrest, resulting in leg length discrepancy, permanent decreased range of motion and angular deformity. , In my study there were 2 insignificant cases of limb length discrepancy and one case of deformity. Salter-Harris type I fractures had the lowest incidence of growth disturbance (36%), whereas Salter-Harris type IV fractures had the highest rate of growth disturbance at 64%.  Recently, Taggart et al,  reported that the use of point-of-care ultrasonography in the emergency department setting could correctly diagnose Salter-Harris fractures. Findings of periosteal fluid at the level of the metaphysis and widening of the physis allowed for the diagnosis of a fracture.  In my study, I treated all the cases on emergency bases and all the fractures were reduced anatomically and fixed properly as soon as possible. Because this is an intra-articular injury of a weight bearing joint it is essential that anatomic position must be maintained for the preservation of blood supply of fracture fragment. If there is any displacement, anatomic reduction must be obtained because of the high probability of growth arrest, bony bar formation and angulations in these fractures. Lin  concluded that the sliding plate allows longitudinal bone growth, without blocking the distal femur growth plate if it is appropriately placed. Although these findings cannot be directly extrapolated to treatment of distal femoral epiphyseal fractures in children, they form a useful basis for future studies. A total of 3 out of 22 patients were irregular in their follow-up visits. The results were excellent in 86.36% and good in 13.64% patients. Statically analysis was limited to calculation of percentage of patients who had unions, malunion, delayed unions, or non unions and Excellent, Good and poor outcomes. The limitations of this study are small number of the cases Observational studies have value. However the conclusions need to based on the observations in the series of treated patients. Obviously there will not be any control group as treatment is offered to all patients.
| References|| |
|1.||Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg Am 1963;45:587-622. |
|2.||Riseborough. EJ, Barrett IR, Shapiro F. Growth disturbances following distal femoral physeal fracture-separations. J Bone Joint Surg Am 1983;65:885-93. |
|3.||Zionts LE. Fractures around the knee in children. J Am Acad Orthop Surg 2002;110:345-55. |
|4.||Brone LA, Wroble RR. Salter-Harris type III fracture of the medial femoral condyle associated with an anterior cruciate ligament tear - report of three cases and review of the literature. Am J Sports Med 1998;26:581-7. |
|5.||Eid AM, Hafez MA. Traumatic injuries of the distal femoral physis. Injury 2002;33:251-5. |
|6.||Brumback RJ, Toal TR Jr, Murphy-Zane MS. Immediate weight bearing after treatment of a comminuted fracture of femoral shaft with a statically locked intramedullary nail. J Bone Joint Surg (Am) 1999;81:1538-44. |
|7.||Sahu RL, Sikdar J. Fracture union in closed interlocking nail in femoral fracture. J Nepal Med Assoc 2010;49:228-31. |
|8.||Anderson M, Messner MB, Green WT. Distribution of lengths of the normal femur and tibia in children from one to eighteen years of age. J Bone Joint Surg Am 1964;46:1197-202. |
|9.||Torg JS, Pavlov H, Morris VB. Salter-Harris type-III fracture of the medial femoral condyle occurring in the adolescent athlete. J Bone Joint Surg Am 1981;63:586-91. |
|10.||Pritchett JW. Longitudinal growth and growth-plate activity in the lower extremity. Clin Orthop Relat Res 1992;275:274-9. |
|11.||Peterson CA, Peterson HA. Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma 1972;12:275-81. |
|12.||Arkader A, Warner WC JR, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop 2007;27:703-8. |
|13.||Rockwood CA, Wilkins KE, Beaty JH. Rockwood and Green's Fractures in Children. 4 th ed. Vol. 3. New York, NY, USA: Lippincott-Raven; 1996. |
|14.||Beaty JH, Kumar A. Fractures about the knee in children. J Bone Joint Surg Am 1994;76:1870-80. |
|15.||Czitrom AA, Salter RB, Willis RB. Fractures involving the distal epiphyseal plate of the femur. Int Orthop 1981;4:269-77. |
|16.||Basener CJ, Mehlman CT, DiPasquale TG. Growth disturbance after distal femoral growth plate fractures in children: A meta-analysis. J Orthop Trauma 2009;23:6637. |
|17.||Taggart I, Voskoboynik N, Shah S, Liebmann O. ED point-of-care ultrasound in the diagnosis of ankle fractures in children. Am J Emerg Med 2012;30:1328.e1-3. |
|18.||Lin DS, Lian KJ, Hong JY, Ding ZQ, Zhai WL. Effects of a Sliding Plate on Morphology of the Epiphyseal Plate in Goat Distal Femur. Int J Med Sci 2012;9:178-83. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]