Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis

Abstract

Purpose: Growth disturbance of the distal femur is the most common complication after distal femoral growth plate fracture. The purpose of our study was to pool data from the literature to determine the incidence of growth disturbance in relation to the Salter-Harris (SH) classification. Additionally, we evaluated the potential influence of fracture displacement and treatment method.

Methods: A structured PubMed search was performed to identify all reports on distal femoral growth plate fractures published in the English language literature, from 1950 to 2007. Reference lists from identified articles and bibliographies from standard pediatric fracture texts were also scrutinized. For a study to be included in this review, it needed to have at least 10 patients with a minimum of 1 year follow-up and be published in the English language. A total of 16 articles met the criteria for inclusion, which accounted for 564 fractures.

Results: Of the 564 fractures, 291 (52%) had a growth disturbance. Growth disturbance occurred in 36% of SH 1 fractures, 58% in SH 2, 49% in SH 3, and 64% in SH 4 fractures. In studies with patient-level data, there was growth disturbance in 65% of fractures with displacement and 31% of the fractures with no displacement had growth disturbance. The odds of a displaced fracture having growth arrest was 4 times greater than that of a nondisplaced fracture having a growth arrest. (P = 0.0015) In the studies with patient-level data, 58% (70/121) of fractures treated without fixation developed a growth disturbance, with 37% (45/121) being a clinically significant disturbance. Of the patients treated with fixation, including those who were initially treated without but lost reduction, 63% (19/30) developed a growth disturbance, with 27% (8/30) being clinically significant. Significant growth disturbance was defined as a leg length discrepancy equal to or greater than 1.5 cm and/or 5 degrees of varus or valgus deformity. SH 4 fractures had the greatest incidence of developing a leg length discrepancy greater than 1.5 cm (9/37). Twenty-two percent (112/506) of all distal femoral growth plate fractures developed a leg length discrepancy of greater than 1.5 cm.

Conclusion and significance: Fifty-two percent of distal femoral growth plate fractures had some form of growth disturbance. Twenty-two percent (112/506) of all distal femoral growth plate fractures developed a leg length discrepancy of greater than 1.5 cm. SH 1 fractures had the lowest incidence of growth disturbance (36%), whereas SH 4 fractures had the highest rate of growth disturbance at 64%. Although there is a greater incidence of growth disturbance in patients who were treated with fixation (58% versus 63%), there was a decreased incidence of significant growth disturbance (37% versus 27%).