Growth Plate Fractures Part 2
In Part 1, we learned the anatomy of the growth plate, a fibrous cartilage center from which bone grows in the adolescent. After learning about the fracture types in our first article, which type do you think this athlete has? This is the case of a 14-year old male. Presented to my office with a not-so-common climbing related injury, this is the perfect learning situation for athletes, their coaches, and our families alike.
How common are these fractures? They aren’t! 15-30% of the fractures that occur in adolescents/children, they are relatively rare. Most commonly, if a growth plate fracture were to occur, it would most likely be a male and in athletes between the age of 15-17 (males) and 13-15 (females). The closer the athlete to this age range, the more susceptible they are to this injury. Over 15 for a female or 17 for a male? Lucky you, your growth plates are most likely closed and you are not susceptible to this injury in almost all cases.
What Happened to this Athlete?
This athlete didn’t have a fall or any major trauma. His parents said he began talking more and more about finger pain until they finally took him in to see his MD. After begin sent to his orthopedic surgeon, this young climber was told to stop climbing, at least for a few years and was sent home with the diagnosis of growth plate fractures in both 3rd knuckles. Let’s discuss diagnosis, treatment and rehab for this unlucky young climber.
First, which fracture type (from Part 1) do you think he has? And I say HE because this injury occurs 2:1 in males as they reach skeletal maturity later and are often climbing harder at that time. To refresh your memory, for the fracture types, here are our options…
A type 2 fracture of the metaphysics and growth plate itself….
A type 3 fracture of the growth plate and the epiphysis or end of the bone…
OR would it be Type 4: The bone above and below the growth plate fractured.
Well, which is it?! Any doctor worth their beans would tell you they need to see a second and/or a third view to be able to tell what type of a fracture this truly is.
The biggest issue that is visible is the displacement of the bone (metaphysis) down into the cartilaginous space of the growth plate. This fracture definitely includes two regions, the metaphysis and the physis or the growth plate itself. The injury could possibly include the epiphysis as well however (and much to your unhappiness) we will not be able to tell on this view alone.
What we CAN see from this view, is that the joint space itself appears to be smooth and relatively unaffected. There appear to be no floating bodies (of the bony debris variety) in the joint space. If the patient has locking or clicking after recovery, we might recommend a follow-up examination with his doctor to rule them out.
Most likely a Type 2 fracture this could also be a Type 4 if we visualize derangement (or changes) to the bone in the second film on the joint’s side of the growth plate. We will post the second view as soon as it arrives so we can discuss treatment at length!
Other Possible Diagnoses:
Keep in mind that without x-ray, this injury can also be confused with other common climbing injuries. Don’t freak out if you are reading this and are a young adolescent with joint pain… Your medical doctor will this rare injury out as he or she does their exam.
More Common Injuries Include the Following:
-Joint Mice (cartilage floaters)
There is a long list that we go to first before we diagnose with a growth plate fracture. More commonly, there could be an injury to the joint capsule itself, or the tissue that encompasses the fluid between the joints (much like a plastic bag around the two bones that make up the joint), similar symptoms to this fracture could exist. Pain from a capsular sprain would be more regional and the athlete would feel pain along the joint line instead of on the bony portion of the joint.
Joints that are jammed will also have joint pain regardless of if a fracture is present or not. Hot swollen joints can be the symptom of tissues that need to heal including the surface of the joint itself and the structures between the bones. Tendonitis and other overuse injuries can also give pinpoint joint pain at the point where the tendon crosses over any bony bumps (tubercles) or at the region where the tendon attaches at the bone. The most common stress fractures in runners are where the tendons attach and tug on the bone. This is something to think about.
Overuse leads to inflammation and swelling. Regardless of if an injury is present, your body is telling you one is on the way if you do not listen to it. You can choose to listen to it before a fracture occurs (in the case of chronic acquired overuse fractures such as stress fractures) or you can train through it to see if it goes away…A smart climber has head the saying that there are bold climbers and there are old climbers, but there are no bold old climbers. ;-)
Care for a Growth Plate Fracture:
This is where your family doctor comes in. If a fracture is visualized on your X-Ray, then more testing and/or a specialty pediatric orthopedic doctor will become involved to ensure the best outcome for your youth. They might do advanced imaging depending on the fracture to ensure proper blood flow continues in the area of injury. If this is the case, your child will likely heal with little to no side effects if immobilized and allowed to heal.
Prevention and the Patient History:
This growth plate fracture in question could have slowly occurred over time. Called a repetitive stress injury, it could have began months prior to when it finally became a fracture. As with other stress fractures, first there is a bone reaction and then the region begins to fail. The parents of this athlete say he had been training aggressively and was currently focusing on systems wall workouts.
For those who aren’t familiar, Systems Wall workouts includes repetitive holds to strengthen core recruitment, movement patterning, and train symmetrical movement patterns. The holds can be large or small however more injuries occur in the hand, arm and shoulder with smaller holds due to the increased force needed in the region.
If his pain began early, he and his coach could have either changed the hand holds (larger/easier/closer) or decreased the volume or intensity that this athlete was training. The systems wall is just a tool and used incorrectly any tool can cause good or bad. Control, especially self-control is a big aspect in this type of injury. If the fracture occurred suddenly, nothing could be done. If it slowly appeared and the athlete felt pain and continued to climb and/or train through it with no change in volume or intensity of climbing and non modification to allow the region to heal while climbing, it makes sense that this athlete missed out on a window of opportunity.
The athlete was told to take time off but was given no finger brace. This is most likely dependent on what was visualized in the second and third view of the X-ray. In my understanding, we brace all fingers and all joints that have sustained a growth plate fracture. Saying that the athlete needs to avoid climbing until he had reached maturity in that growth plate (Age 17) is a stretch and should be better modified to be: once the athlete is done healing and has done his rehabilitation, he can begin climbing gently and to tolerance letting pain be his guide. The doctor may have seen other driven athletes who continued to injure themselves and this is why he deemed the athlete needed to quit for a few years however this athlete and his family deserve an informed decision. The likelihood that this patient can sustain another fracture in this region is higher than most as he is just entering the period of time when his growth plates fuse. They might be completely fused next year, each body is so genetically different than the next.
Positive on x-ray in both hand/finger region, the doctor in this case had never seen this exact injury before. This is common. Bilateral fractures almost never exist. This athlete is a special case.
The athlete and the family were told that the area would heal on its own. This could very well be the case if the second and third views show normal findings. If the bony bit that we see sitting in the growth plate has lost its vascularity, or the blood flow has been lost below the growth plate, this patient could be susceptible to arthritis in the future. With such a small chunk missing out of the metaphysis, hopefully this bit will float back into place and fuse back where it belongs. Only a followup X-ray taken in a few weeks would let us know this for sure.
The quick care of this area is highly recommended in all cases of growth plate fracture. Within 5 to 7 days, healing is already occurring. As this athlete has a chronic case, it might be slow than most to heal however 2 weeks of casting might begin the process effectively. The patient may need up to 6 weeks of casting before basic use such as opening doors and using a pencil are allowed. Climbing might be a few months away yet.
Above all, we need to be sure any fractured regions are aligned, blood flow is correct and any/all immobilization has began. Your basic MD is the beginning of this care followed by a orthopedic surgeon (or a pediatric orthopedic surgeon if surgery is needed). This patient was referred to another pediatric orthopedic surgeon in his area for a second opinion. Most likely his first doctor was correct but without this information in his second and third X-rays, we need to be sure that he is correctly treated as it is likely he will be using his hands at a highly trained level for years to come.
Common Treatments for Growth Plate Fractures:
1. Immobilization- In all cases, immobilization is recommended for the area to heal. The patient is also instructed to avoid using the region and to keep stresses to the area at a minimum while it heals. This can take 2 weeks to a few months depending on the severity of the injury.
2. Surgery and/or Manipulation- The affected area might need to be relocated and/or surgically fixated with small screws. The goal is to ensure proper joint and growth plate alignment and immobility until the region has healed. This might take 2 weeks after the surgery or be up to a few months depending upon the severity of the injury.
3. Physiotherapy- Stability exercises and strengthening are recommended by a local PT to reinforce the injured region and decrease risk of future injury. This could take 12-24 visits depending on the injury.
4. Follow-up(s) with your Orthopedic Surgeon- A follow-up visit is almost always needed to ensure the area is properly healing and that the patient is at maximum before being allowed to return to climbing. If the area is partially healed and the athlete chooses to climb on it, the athlete can sustain a more serious injury.
Long term Side Effects:
Growth Plates can close early in athlete cases where it has shifted or been crushed. These athletes will have less growth in the area of the injury. This is a long term effect. The age of the child, the severity of the growth plate damage, and the location of the growth plate are all factors that will limit the final outcome. If the growth plate is asymmetrically damaged, the region might become crooked or displaced as the uninjured side of the growth plate stays open and does not prematurely close.
This is an important study as 15-30% of all childhood fractures occur within the finger joint region. We worry about growth plate injuries as your medical providers as they can change the rate of bony development if a large enough injury is sustained. With proper treatment, most growth plates heal without long term complications and the young athlete is able to return to climbing without increased risk of future injury.