Epiphyseal injuries involve disruptions to the growth plate of long bones. The growth plate is responsible for longitudinal bone growth and consists of zones of cartilage cells. Various mechanisms can cause injuries, including fractures, tumors, infections, and repetitive stress. Injuries are classified using systems like Poland or Salter-Harris which describe the location and extent of the fracture. MRI is a useful imaging modality for evaluating epiphyseal injuries due to its ability to detect microfractures and provide diagnostic quality. Understanding epiphyseal anatomy and injury classifications is important for proper diagnosis and treatment.

1. Epiphyseal injury
Moderator: Dr B. shaikh nazeer.

2. Introduction
• The growth plate, also known as epiphyseal/physeal plate or physis.
Ephyseal injury is a disruption in the cartilaginous physis of long bones that
may involve epiphyseal and/or metaphyseal bone. Mostly involves the
ossification centre even sometimes may involve only its cartilaginous
portion making radiographic diagnosis difficuly.
It is a fairly common injury with a propensity for lifelong diminution of
productivity and quality of life. it is therefore imperative for today’s surgeon
to have adequate knowledge and skill in order to diagnose this condition
early and institute appropriate treatment expeditiously.

3. Introduction
• The paediatric skeleton differs from that of an adult in that
the bones are more elastic and they contain growth plates
(physes).
• Physeal injuries affect the growth plates of children and
adolescents. A basic understanding of the anatomy and
physiology of the physis is mandatory in order that injuries to
the growth plate can be managed effectively

4. • A child’s long bone consists of two
epiphyses, two physes (or growth
plates), two metaphyses and a diaphysis.
• The periosteum is the envelope around
the bone; It is very thick in the young
child and contributes to the growth in
the width of the bone.
• The physis is responsible for longitudinal
growth. With the completion of growth
at skeletal maturity, the physis
disappears and the periosteum becomes
a thin fibrous layer.

5. • Physeal injury in comparison to long bone fractures.
1. Physeal injury may disturb growth causing progressive shortening or
angular deformity.
2. Bone remodeling doesn’t remodel displaced fractures that traverse
physis and articular surface at right angle to the axis of movement of joint.
3. Rate of healing is extremely rapid.
4. Non- union may occur when there is a soft tissue(periosteum or tendon)
interposed between fragments.

6. • Epiphysis: is the portion of the long bone which develop from secondary
centre of ossification.
• growth in length
• formation of joints
• acts as an attachment for muscles and tendons.
• At birth epiphysis consists of a completely cartilaginous structure
chrondroepiphysis. A secondary centre of ossification form for each of these
chrondoepiphysis which gradually enlarge as chrondroosseous epiphysis.
• External surface- covered by either by articular cartilade or perichondrium.
Muscles fibres, tendons and ligaments may attach directly to perichrondrium
which is directly contiguous with underlying hyaline cartilage.
• These perichrondrium bends with periosteum which contribute to
biomechanical strength of eliphyseal/metaphyseal junction.

7. • Epiphyseal cartilage: plate like,thin layer of cartilage which separates the
growing diaphysis from epiphysis. Responsible for the growth of a long
bone. Cell continuously proliferates.
• Epiphyseal line: The peripheral margin of the epiphyseal cartilage.
Diaphysis: Portion of a long bone between the two cartilaginous ends.
Ossifies from primary centre of ossification develops first early fetal life in
the hyaline cartilage model of future bone.
• Metaphysis: Part of diaphysis immediately adjacent to the epiphyseal
carlilage

8. PHYSEAL HISTOLOGY
• The physis is divided into four zones:
• The germinal zone,
• the proliferative zone,
• the hypertrophic zone,
• and the zone of endochondral ossification.

10. 1. Germinal layers(Resting/Undifferrentiated cartilage cells)
located adjacent to the bone plate
supplies developing cartilage cells for all new growth
injury ---- cessation of growth.
2. Proliferative zone.
No germinal layer
Actively growing cartilage cells
abundant cartilage matrix.

11. 3. Zone of hypertrophy or vacuolization
chondrocytes become swollen & vacuolated in the process of maturation before
ossification
decrease in amount of intracellular matrix
weakest zone in physis
4. Zone of provisional calcification:
Longitudinal bars of dying condrocytes become calcified
Strength enhanced by calcification
Physeal/metaphyseal junction has many small undulations.

12. Blood supply
To physis
Epiphyseal vessels ( supply germinal layer)
Metaphyseal vessels (supply central ¾ of physis)
Periosteal vessels.
Vessels entering Epiphysis:
Directly from periosteum
Indirectly through adjacent capsular attachment
Epiphyseal vessels terminate as loops in the resting cells of epiphyseal
plate while metaphyseal vessels extend only as far as the zone of
endochrondral ossification.
Thus epiphyseal circulation is responsible for nutriation of proliferative
cells of growth plate. Any damage to epiphyseal circulation may cause AVN
of epiphyseal closure in growth plate.
Metaphyseal ischemia is transient while epiphyseal ischemia is usually
permanent.

16. Types of epiphysis
• Pressure epiphysis: develop inline of weight transmission at the articular
ends of long bones. Protect epiphysis cartilage from stress and strain.
• Traction epiphysis: sites of attachment of certain muscles which exerts a
pulling actions. Tuberosities of humerus
• Atavstic epiphysis: Independent skeletal bone and fused with other bone.
Coronoid process of scapula.
• Aberrant epiphysis: 2nd to 5th metacarpal bone develop an epiphysis at its
proximal end.

17. Physeal Biomechanics
• Proliferation of chondrocytes in the epiphyseal plate is responsible for growth
in length of a long bone. In diaphyseal side of the plate the chondrocytes
hypertrophy and the matrix become calcified and the cells die.
• Osteoblast lay down a layer of primary bone on the calcified cartilage matrix.
• Physiologic stress ---- compression and tension
• The mechanical modulation of epiphyseal growth is often referred to as the
‘Hueter-Volkmann Law’.
• “The ‘Hueter-Volkmann Law’ proposes that growth is retarded by
increased mechanical compression, and accelerated by reduced loading in
comparison with normal values”

18. PHYSEAL INJURIES
• Etiology of Physeal Injuries.
Can be injured in many ways,the most frequent mechanism of injury is fracture.
Most commonly, fracture injury is direct, with the fracture pattern involving the
physis itself.
Occasionally, physeal injury from trauma is indirect and associated with a fracture
elsewhere in the limb segment, either as a result of ischemia or perhaps
compression.
Infections : osteomyelitis or septic arthritis :further complicated by joint disruption
resulting from associated epiphyseal destruction, articular cartilage damage, and
capsular adhesions, particularly in the hip and shoulder.

19. PHYSEAL INJURIES
Both malignant and benign tumors and tumor-
like disorders can disrupt normal physeal
architecture, resulting in direct physeal
destruction.
Tumor
enchondromata, and unicameral bone cysts.
Valgus deformity of the distal femur
associated with the presence of an
enchondroma of the distal lateral femur
involving the lateral physis.

20. The patient's leg was caught
under heavy pipes rolling off a
rack, resulting in stripping of the
soft tissues from the distal thigh,
open comminuted fracture of
the distal femur, and popliteal
artery injury
Physeal injury from vascular insult
In follow-up, after arterial and soft tissue
reconstruction, the patient has physeal growth
arrests of the distal femur and proximal tibia.

21. PHYSEAL INJURIES
Stress injury of the distal radius and ulna in both wrists of a
competitive gymnast. There was no history of specific injury.
The wrists were tender to touch. Note distal radial and ulnar
physeal widening and irregularity
Repetitive Stress:

22. PHYSEAL INJURIES
• Radiation: therapeutic irradiation diagnostic x-rays.
a dose as low as 400R can produce growth retardation.
• Metabolic abnormality: vitamin A intoxication, vit c deficiency,
chronic renal failure.
• Heat injury: physeal damage in severe burns not well understood.
physeal cartilage more sensitive to irradiation and cold than the
articular cartilage.

23. PHYSEAL INJURIES
• COLD BITE (frost bite)
• Physeal closure becomes evident 6-12months after cold exposure,
probably resulting from direct injury to vulnerable chondrocytes or
ischemic vascular changes due to arterial spasm.
• On x-ray charestistic : physis disappears completely, short and small
phalynx, epiphysis often have v shape.
• very few children require surgery: arthrodesis,angular osteotomy,
soft tissue arthroplasty.

24. Classification of Physeal Fractures
Poland type I: epiphyseal separation without metaphyseal fragment, or
extension into the epiphysis
Poland type II: physeal fracture line extends into the metaphysis.
Poland type III: fracture extends from the articular surface to the physis
and continues peripherally through the physis.
Poland type IV: T-condylar fracture of the epiphysis and physis.

25. Salter & Harris Classification of
Epiphyseal plate injuries
• Salter-Harris Classifications are a straightforward and reliable way to
diagnose and treat growth plate fractures.
• There are five types of classifications that are listed by the location of the
fracture.
• This is the most widely used method for classification today since its
conception in the 1960s.
• The importance of this classification system is to accurately diagnose a
fracture so the correct method of treatment can be performed swiftly to
decrease the chances of growth disturbances and angular growth
deformities.
• The epiphyseal plate is the weakest area in children’s anatomy, weaker
than their associated ligaments and tendons, causing fractures to occur in
the growth plate when trauma occurs

26. Salter & Harris Classification of
Epiphyseal plate injuries

29. Type I
Slipped Capital Femoral Epiphysis

30. Type II

31. Type III

32. Type IV

33. Type V

34. Investigation

35. Advantages of MRI
• Dr. Cardinal suggests using MRI over other modalities for a follow up
exam. MRI beats other modalities in diagnostic quality (especially
diagnosing microfractures
• Kleinman. Shah, Kritsaneepaiboon, and Murray (2009) used MRI images of
several patients’ knees to demonstrate the value of MRI exams.
• The MRI’s on these patients were done because the clinical findings still
persisted despite normal plain films.
• Due to the higher level of diagnostic quality “in some cases, the findings
may be noted only on MRI”

36. Sagittal image showing type II
fracture line (solid arrow).
Posterior physical widening and
periosteal (arrowhead) and capsular
(open arrow) disruption are evident.
Findings pointing to hyperextension
injury.

37. 14yr. old boy who presented with hyperextension injury to left knee
AP radiograph reveals only a subtle oblique metaphyseal fracture
extending to medial cortex. (arrow)
B. Coronal image confirms Salter-Harris II fracture with adjacent periosteal
elevation (open arrow). Lateral physis is widened with increased fluid
(curved arrow). Bone bruise in medial tibial epiphysis and joint effusion

38. • Principle of Management:
1. closed reduction attempts, GA or sedation
2. reduction maneuver consists of traction followed
manipulation.
3 >10 days after fracture.
4. Anatomical reduction in III & IV
5. avoid Internal fixationi

39. Distal femoral physeal injury
• Distal femoral physeal injury represent 7% of all lower limb extremity physeal
fracture
• Categorized into two group newborn and adolescent.
• Salter Harris classification alone has not been accurate in predicting the overall
outcome thus mechanism of injury and degree of initial evaluation.
• CLINICAL FEATURES
• H/O initial trauma, more energy required to produce fracture in juvenile than adult.
• On physical examination: acute distress secondary to pain in knee, unable to walk
• displaced- knee swollen, tense
• non displaced: less pain, may able to ambulate
• knee is flexed position and deformity with extension of distal or valgus.
• Ecchymotic areas give information of deforming force

40. Distal femoral physeal injury
• Radiograph Finding:
• AP and lateral images of knee and entire femur.
• oblique view and stress view.
• CT help to define amount of displacement
• MRI

41. • Salter and colleagues stated that when excessive manipulation appears to
be necessary to achieve acceptable reduction, it is better to maintain
growth potential and perform corrective osteotomy at a later date than to
overstress the physis and cause more damage.
• The goal is to gain anatomical reduction with stable fixation(>10)
• Younger children acceptable alignment Upto 20 degrees of angular in
sagittal plane, less than 5 degree of varus or valgus angulation and no
rotational deformity.

42. • Salter harris type I: newborn by immobilization without attempt at
reduction.
• Older child with complete physeal separation closed reduction.
• In hyperextension fracture - immobilization with hip spica or long-leg cast
with knee flexed (60’). Followed by gradual extension of knee in 3 to 4
weeks.
• Salter harris type I: 60 to 70% displaced at the time of initial evaluations
• nondisplaced or minimally displaced – closed reduction and external
immobilization. When metaphyseal fragment is on lateral side, the distal
fragment is in valgus and can be reduced with a varus- producing
maneuver to overcorect the deformity. Long knee cast with 20 to 30’ knee
flexion.

43. • Displaced: closed reduction with percutanious fixation to fix the
metaphyseal fragment
• young child – kirschner wire
• Adolecent -- cannulated screws (4.0- or 6.5mm screws) percutaniously.
• Although litreture suggest in 10 to 15% need internal fixations
• Failed closed reduction require open reduction in 5% of case. This
irreducuble type II caused by interposed periosteum on the tension side of
fracture or less often, muscle interposition and this require open
reduction followed by internal fixation.

44. • Salter harris type III: less common open reduction and internal fixation,
fracture must be anatomically reduced to preserve the articular anatomy
and reduce the likelihood of growth arrest.
• Anteromedial or anterolateral incision, followed by percutaneous fixation
of the epiphysis(canulated cancellous screw) preferably 2 screw.
• Long knee cast immobilization for 6 weeks with knee 20 to 30’ flexion
• Salter harris type IV:
• All type – long leg cast continued for 6 to 8 weeks
• Prognosis - depends on age , fracture displacement, reduction, types
• juvenile (<11). Growth problem
• Complication Acute late

45. Proximal tibial physeal fracture
• Fracture to proximal tibial physis are rare and account for 0.5 to 3% in
children. This rareness reflects the lack of collateral ligamentous
attachments to the proximal tibial epiphysis, which allow valgus or varus
forces to be transmitted through these ligaments to their attachment on
the distal femoral physis, fibular head and tibial metaphysis.
Anatomy: the proximal tibia ossific nucleus forms at 2 months of age,
with secondary ossification of tibial tuberosity 10 and 14 years. It unites
with proximal tibial physis at 15 years
radiolographic investigation of patients 12 to 20 years of age hve shown
that the proximal tibial physis appears to fuse posteriorly, followed by
anterior fusion.

46. Proximal tibial physeal fracture
• Mechanism of injury: both direct and direct to the knee result in
fracture of proximal tibial physeal. Indirect blow to a hyperentended
knee when the lower part of the leg is in fixed position.
• Varus and valgus, even rarely flexion type indirect trauma.
• The patients are typically older (16 years), an age when the anterior
proximal tibial physis remain open but the proximal physis is closed.
• Clinical presentations: knee effusion held in flexion position.
• knee extension painful and restricted to hamstring spasm.
• hyperextension injury the knee may be flexed in only 10 degree, while
in flextion type the knee is more flexed at the time of evaluations.

47. Proximal tibial physeal fracture
• Management:
• Closed reduction:
• Non operative indication: Nondisplaced and Minimally displaced fracture.
• Reduction is performend by anteriorly directed translation of the
metaphysis fragment while traction is applied to the leg with the thigh
stabilized by assistant . To obtain reduction knee to be in flexion.
• Cast immobilized for 4 to 6 weeks with knee not more than 60 degree
flexion. After weeks latter cast be removed to reduce the amount of knee
flexion to 20 to 30 degree of flexion.
• Radiograph :weekly for initial 2 weeks to ensure fracture reduction
maintained. Mild displacement is acceptable.

48. Proximal tibial physeal fracture
• Indication for operative treatment :
1. Failed closed reduction in type I & II
2. Failure to maintain reduction in long leg cast,less than 60’ of flexion
3. All displaced type III & IV
4. Presence of arterial complication.
Unstable physeal fractue which cannot be maintained with external
immobilization, smooth pins should be placed in crossed fashion, crossed
distal to physis. Cast immobilization for 6 to 8 weeks.
Displaced type II: pin or screw fixation needed to stabilized mhyseal
fragments thus preventing violation of physis.
Open reduction with Intrnal fixation required for displaced type III & IV.

49. Distal fibula and tibial fracture
• Distal tibia and fibula fracture are relatively common, second to distal
radius fractures as the most common in physeal fracture in children.
• The horizontal orientation of the physis and the strong ligamentous
attachment distal to the physis make the physis more vanerable to injury.
occurs between 10 and 15 years of age more in boys than girls.
clinical presentation: h/o twisting of ankle. Pain at the time of initial trauma,
pain on weight bearing, predominant area of swelling.

50. Distal fibula and tibial fracture
• Isolated nondisplaced distal fibular salter harris type I – short leg walking
cast or fracture boot for 4 weeks.
• Displaced fracture- closed reduction and short leg Non weight bearing cast
for 4 to 6 weeks.
• Salter harris type II treated with a short leg non weight bearing cast for 4
to 6 weeks and it heals without complications.
• Salter harris type I distal tibial fracture: rare in children and
account for 15% of all distal tibiofibular fracture in children.
• Closed reduction followed by long leg cast for 4 weeks for displaced
at the time of initial injury. After 4 weeks short leg cast for
additional 2 weeks. Complication of premature physeal arrest with
subsiquent limb length discrepency reported in 3% of cases.

51. Distal fibula and tibial fracture
• Salter harris type II distal tibial fracture : most common distal tibial
fracture in children. Account for 40% of all ankle fracture.
• Nondisplaced fracture required well moulded long leg cast for 3
weeks latter can be modified for short leg cast for another 2 weeks.
• Displaced fracture require gentle closed reduction with long cast for
4 weeks followed by 2 weeks of short leg cast.
• Salter harris type III distal tibial fracture : 20 % of all distal
tibiofibular fracture in children at an aveage age of 11 to 12 years.
• Nondisplaced fracture require 4 weeks in a long leg cast followed by
4 weeks in short leg cast. The initial plaster must be applied with
foot in 5 to 10 degree of eversion.
• Displaced fracture of more than 2mm should be reduced in
operation room by either closed or open reduction followed by
screw fixation.

52. Distal fibula and tibial fracture
• Salter harris type IV distal tibial fracture: open reduction and internal
fixation required because these fracture are displaced and fracture line
extends into the joints. These fracture likely to be associated for early
degenerative arthritis and growth arrest.
• Postoperatively short leg cast for 6 weeks adviced.
• Complications :
• premature closure of the physis: germinal layer of physis lead to
asymmetric or symmetric growth arrest. Average shortening of 1.6 to 1.1
reported in type III & IV.
• delayed union or non union: rare in young children, in adolecent if
non union exists then open procedure to debride fibrous tissue at fracture
site, followed by autologous bone graft and internal fixator.

53. Management according to Type:

54. • Type I Salter-Harris fractures occur when there is a
complete separation of the entire physis and the surrounding
bone is not involved.
• commonly seen when considering growth plate injuries and
tends to occur more frequently in younger children.
• Physis being radiolucent.
• Simple closed reduction and immobilization is needed
because healing is rapid in children and the risks after
immobilization of complications is extremely low

55. • Type II fractures are the most commonly diagnosed
and “are usually easily identified on routine
radiographs).
• The fracture exists along the physis and continues up
through a small section of the metaphysis.
• triangle-like and the periosteum is torn on the
opposite side to where the metaphysis is fractured,
but it is still intact on the adjacent side.
• The intact periosteum makes it easier to perform a
closed reduction without on over-reduction.

56. • INCOMPLETE REDUCTION
• YOUNG PATIENTS OLDER CHILDREN
• Acceptable. Get more accurate reduction
over manipulation not adviced
if can’t be reduced
Distal tibia fracture
Tendon, nerve and vascular
structure impingement
surgery

57. INTERNAL FIXATION BY
PINS OR SCREWS
SMALL METAPHYSEAL
FRAGMENTS
SMALL DIAMETER
SMOOTH PINS FROM
EPIPHYSIS ACROSS
PHYSIS AND INTO
MAIN METAPHYSIS
USE BIODEGRADEABLE
PINS
REMOVE AFTER 3
WEEKS
FALLOW UP AFTER >=6
MONTHS TO LOOK
FOR PERSISTANT OF
GROWTH
FROM METAPHYSIS TO
METAPHYSIS
AVOIDING PHYSIS

58. Surgery is usually required to ensure
the bones are properly aligned and then
kept immobilized for optimal recovery
The prospect of recovery is positive as
long as the vascular supply to the bones
remains intact
• Type III fractures run along the joint surface and persist deep
into the epiphyseal plate.
• fracture is uncommon when they are diagnosed, it is usually found
in the distal tibia of an adolescent whose growth plate is nearly
finished.

59. ANATOMIC
REDUCTION
OF ARTICULAR
SURFACE
AVOID
DEGENARATIVE
ARTHROSIS
OF PHYSEAL
CARTILAGE
DECREASE
CHANCE OF
GROWTH ARREST

60. • Type IV fractures start above the growth plate
(in the metaphysis) and cut all the way through
the epiphysis.
• “These fractures are usually caused by axial
loading or shear stress, comminution is common”
• Damages the joint cartilage normal growth of the
individual may be impaired.
• Surgery is required in order to properly re-align
the joint surface, if not aligned correctly growth
problem occurs
• “Close follow-up to monitor for bone-length
discrepancies and angular deformities is
essential”.

61. • Type V fractures crushing of the epiphysis.
• Hardest fracture type to diagnosis and the most difficult to heal.
• This injury is most likely to occur in the weight-bearing joints of the
knee and ankle.
• “Crush injuries where complete disruption of the Salter Harris
Fractures epiphyseal vascular system has resulted in death of the
growth plate cartilage”
• Increased risk of pre-mature fusion.
“In the arm this may produce only a cosmetic deformity, but in the
leg any consequent inequality of length may cause considerable
disability

62. TYPE OF IMMOBILISATION
SALTER AND HARRIS
TYPE I/II
IMMOBILIZE FOR HALF THE TIME
IT WOULD TAKE A METAPHYSEAL
FRACTURE IN THE SAME BONE TO
HEEL
TYPE III/IV
IMMOBILIZE FOR SAME AMOUNT
OF TIME AS WE WOULD FOR A
PURELY METAPHYSEAL INJURY IN
THE SAME AREA
LONGER PERIOD OF
IMMOBILIZATION IN
CHRONIC ILLNESS
IMMUNOSUPRESSION
RENAL/LIVER DISEASE
MALIGNANCY

63. • Period of immobilization:
• In lower limb type I/II – Non weight bearing or toe-touch for initial
7-14 days. Latter gradually progression to full weight bearing.
• Type III/IV or internal fixation fracture
toe-touch for 3-4 weeks till K-wire is removed then cast
immobilization with full weight bearing.

64. Prognosis
• Depends on
• 1. severity of injury displaced, comminution and compounding
• 2 Age of patients – Any physeal trauma in 13/F or a 15/Male results in
significant length discrepency or angular deformity.
• 3 Anatomical site
• A. types of physeal present
• B. blood supply to the physis

65. TYPES OF PHYSIS
SMALL AND UNIPLANAR
DISTAL FIBULA
PROXIMAL RADIUS AND ULNA
SHEARING DOES NOT CAUSE MUCH DAMAGE
GROWTH ARREST/DISTURBANCE UNLIKELY
LARGE,UNDULATING,MULTIPLANAR
DISTAL FEMER
PROXIMAL TIBIA
PRONE TO ARREST EVEN WITH MILD
DISPLACEMENT
CONTRIBUTE HIGHLY TO LONGITUDINAL
GROWTH

66. BLOOD SUPPY TO PHYSIS
TYPE A
BLOOD REACHES EPIPHYSIS
AFTER CROSSING PHYSIS AND
METAPHYSIS EXTERNALLY
EX:PROXIMAL FEMER
ANY DISPLACEMENT OF
EPIPHYSIS MAY OCCLUDE
BLOOD SUPPLY
TYPE B
BLOOD REACHES VIA
MULTIPLE SOURCES
EG:MOST
EPIPHYSES
LESS
CHANCES OF
ISCHEMIA

67. 4.XRAY TYPE:
• Petersons classification type 1 has least damage to physis and
gradually the damage increases over subsequent type vi which has
greatest damage.
5 sex:
• No statistical data show any difference in outcome based on gender

68. COMPLICATIONS
1. Sepsis ---seen in compound injuries
2. Overgrowth---very rare
may be seen in capitullum fractures of lateral humeral
condyle
rarely require treatment
3. Hypoplasia of epiphysis
4. Delayed union and malunion
5. Compartment syndrome ---may be assosiated with proximal
tibial or distal radial injuries .
6. Avn---seen in proximal femoral capital epiphysis.

69. 7.PHYSIAL
ARREST
PARTIAL
ANGULAR
DEFORMITY
COMPLETE
REDUCTION IN
BONE GROWTH

70. MANAGEMENT OF COMPLETE ARREST
1. shoe lift
2. physial arret
3. ipsilateral bone lengthing
4. contralateral bone shortening
5. combination of 3 and 4

71. MANAGEMENT OF PARTIAL ARREST
1. Shoe lift –lower limb
-central bar
-no angular deformity
-leg length discrepancy less than 2.5cm
2. Arrest remaining growth of injured physis
3. Arrest remaining growth of injured physis and physis of
adjacent bone
4. Arrest remaining growth of injured physis and physis of
adjacent bone/corresponding physis of contralateral
bone

72. MANAGEMENT OF PARTIAL ARREST
5. open/closed wedge osteotomy to correct angular deformity
6. bone lengthening .
7. bone shortening of contralateral/companion bone.
8.exision of physial bar and insertion of on interposition
material.
9.breaking bone bar by physial distraction .
10.transplantation of an epiphysis and physis.