Growth Disturbances

Growth Disturbances in Pediatric Orthopaedics: Modern Study Review

High-Yield Summary

Growth disturbances following physeal injuries remain a critical concern in pediatric orthopaedics due to their potential to cause limb length discrepancies and angular deformities. The distal femur is the most vulnerable site, with a high incidence of growth arrest, especially in younger children. Early recognition, classification, and appropriate management of physeal bars are essential to optimize long-term function and minimize deformity. Contemporary treatment balances physeal bar resection, guided growth, and corrective osteotomies based on growth potential and deformity severity.

Key Diagnostic Findings

Anatomy

• Distal Femoral Physis: Largest contributor to lower limb growth (~70% of femoral length), with an undulating morphology that predisposes to partial and uneven growth plate injury.
• Common Sites of Growth Arrest: Distal femur > distal tibia > proximal tibia > distal radius > distal humerus.

Clinical Presentation

• History of physeal injury (often Salter-Harris III or IV fractures).
• Progressive limb length discrepancy or angular deformity developing months after injury.
• Possible joint stiffness or pain if deformity affects joint mechanics.

Imaging

• Plain Radiographs: Initial assessment; may show physeal bar as a bony bridge across the growth plate.
• MRI: Gold standard for early detection and precise localization of physeal bars and assessment of bar size and vascularity.
• CT Scan: Useful for surgical planning, especially to delineate bar morphology.

Classification Systems

– Peripheral Arrest: Typically post-fracture; leads to angular deformity.

• Central Arrest: Associated with vascular injury, infection, or thermal injury; leads to growth retardation and epiphyseal changes.

Current Gold Standard Treatment

Non-operative Indications

• Small physeal bars (<50% of physeal area) with minimal deformity and limited growth remaining.
• Observation with serial clinical and radiographic follow-up when deformity is mild and not progressive.

Operative Indications and Treatment

• Physeal Bar Resection: Indicated if bar involves <50% of the physis and ?2 years of growth remain.
• Goal: Restore growth potential and prevent deformity progression.
• Requires interposition material (e.g., fat graft) to prevent reformation.
• Physeal Closure (Epiphysiodesis): Considered if bar is large or resection is not feasible, especially if significant growth remains and deformity is predictable.
• Corrective Osteotomy: For established angular deformities or limb length discrepancies not amenable to bar resection.
• Guided Growth Techniques: Temporary hemiepiphysiodesis for angular correction in growing children.

Modern Complications & Outcomes

Complications

Outcomes

• Early diagnosis and timely intervention improve functional outcomes and reduce deformity severity.
• Physeal bar resection has good success rates when performed within appropriate indications.
• Long-term follow-up is essential to monitor for late deformities or growth disturbances.
• Multimodal treatment (resection, guided growth, osteotomy) tailored to individual growth potential and deformity yields best functional results.

Classic Clinical Notes

Growth Disturbances

Complications – Growth Disturbances

• Growth arrest is particularly common in the distal femur—related to forces required to break it, and the morphology of the growth plate—with its undulating morphology, the damage is not uniform across the physeal cartilage. 83% of kids under 11 with a distal femoral physeal injury have a growth disturbance.
• The distal femur is the most common location of growth arrest, followed by distal tibia, proximal tibia, radius, humerus.

Bright classification of physeal arrest:

• I – peripheral
• II – central
• III – combined

• The peripheral arrests tend to cause angular deformity.
• The central arrest tend to slow growth and show a tenting of the epiphyseal plate with cupping of the epiphysis by the metaphysis. Central arrest is more common with vascular injury, infection, or thermal injury. Peripheral arrest is more likely with fracture.

Certain injuries are typical: Salter III medial malleolus, Salter IV distal tibia, or any distal femur fracture.

Important factors to consider:

• Size of epiphyseal plate
• Rate of growth
• Growth remaining
• Size of bar

General recommendations:

• If bar is less than 50% of the growth plate, and there is two or more years of growth remaining, then resect.
• If not resectable, consider shutting down the rest of the physis.
• Always take into account what the anticipated growth will be if you leave the bar—both in terms of length and angulation. Then consider what will be the anticipated consequences of resecting it, or closing the physis.
• Be prepared to follow for angular deformity which does not correct and requires osteotomy.

Last Updated on January 25, 2026 by orthonet