Imaging of physeal injury: overuse

Abstract

Context: As the intensity of youth participation in athletic activities continues to rise, the number of overuse injuries has also increased. A subset of overuse injuries involves the physis, which is extremely susceptible to injury. This paper aims to review the utility of the various imaging modalities in the diagnosis and management of physeal injuries in the skeletally immature population.

Evidence acquisition: A search for the keywords pediatric, physis, growth plate, x-ray, computed tomography, magnetic resonance imaging, and overuse injury was performed using the PubMed database. No limits were set for the years of publication. Articles were reviewed for relevance with an emphasis on the imaging of growth plate injuries.

Study design: Retrospective literature review.

Level of evidence: Level 4.

Results: Three major imaging modalities (radiographs, computed tomography, and magnetic resonance imaging) complement each other in the evaluation of pediatric patients with overuse injuries. However, magnetic resonance imaging is the only modality that offers direct visualization of the physis, and it also offers the best soft tissue contrast for evaluating the other periarticular structures for concomitant injury.

Conclusion: Imaging has an important role in the diagnosis of physeal injuries, and the information it provides has a tremendous impact on the subsequent management of these patients.

Keywords: computed tomography; magnetic resonance imaging; overuse injuries; physis.

Figure 1.

Thirteen-year-old with Salter Harris type 2 fracture. (A) Coronal computed tomography (CT) image demonstrates a Thurston Holland metaphyseal fracture fragment (arrowhead). (B) Sagittal CT image demonstrates widening of the anterior aspect of the physis (arrow).

Figure 2.

Seventeen-year-old male (bone age, 15 years) with Salter Harris type 3 fracture. (A) Coronal computed tomography and (B) coronal proton density magnetic resonance imaging demonstrate vertical fracture lines extending through the tibial epiphysis to the physis and there is a subtle step off of the articular surface (arrows).

Figure 3.

Sagittal 3-dimensional, fat-suppressed, T1-weighted, gradient-recalled images in the same patient at 3 time points (A, 12 years; B, 14 years, and C, 15 years) demonstrating centripetal closure of the femoral physis and physeal closure progressing from posterior to anterior in the proximal tibia.

Figure 4.

Ten-year-old with tibial eminence avulsion seen on (A) anterior-posterior radiograph (white arrowhead). (B) Sagittal inversion recovery and (C) fast spin echo magnetic resonance images demonstrate an additional obliquely oriented fracture line extending from the articular surface through the epiphysis to the physis (arrows), rendering this a Salter Harris 3 fracture.

Figure 5.

(A) Anterior-posterior; (B) sagittal 3-dimensional, fat-suppressed, T1-weighted, gradient-recalled; and (C) sagittal proton density images of the ankle in a 10-year-old girl with a distal tibial osseous physeal bar (white arrow) after removal of instrumentation for fracture treatment.

Figure 6.

(A) Sagittal and (B) coronal computed tomography image of a 10-year-old boy 5 months after a distal femoral fracture with an osseous bar (arrows) across the lateral half of the distal femoral physis, resulting in varus angulation at the knee noted on concurrent radiographs.

Figure 7.

Thirteen months after a distal femoral fracture with an osseous bar located centrally within the distal femoral physis. (A) Sagittal and (B) coronal 3-dimensional, fat-suppressed, T1-weighted, gradient-recalled magnetic resonance images demonstrate the bridge (white arrows) as abnormal low signal intensity crossing the central physis (white arrowheads). At the peripheral margins, the physeal cartilage is indistinguishable from the articular cartilage (white arrowheads). (C) Sagittal proton density image demonstrates that signal within the bar (white arrow) is isointense to the adjacent bone, indicating its osseous composition.

Figure 8.

Fifteen-year-old injured playing soccer. Magnetic resonance image was obtained to exclude cruciate and collateral ligament injury. (A) Coronal 3-dimensional, fat-suppressed, T1-weighted, gradient-recalled and (B) proton density images demonstrate a Salter Harris type 2 fracture (white arrows).

Figure 9.

Coronal (A) proton density and (B) 3-dimensional (3D), fat-suppressed, T1-weighted, gradient-recalled images from the patient shown in Figure 6 demonstrate physeal irregularity (solid white arrow) and a metaphyseal island of physeal cartilage (hatched arrow) in an area where the physis is closed (arrowheads). (C) Sagittal 3D, fat-suppressed, T1-weighted, gradient-recalled image from an 11-year-old boy demonstrates intrusions of physeal cartilage into the proximal tibial metaphysis (asterisks).

Figure 10.

(A and B) Sagittal 3-dimensional, fat-suppressed, T1-weighted, gradient-recalled magnetic resonance images from a 13-year-old 3 months after all epiphyseal anterior cruciate ligament reconstruction demonstrate no injury to the distal femoral physis adjacent to the epiphyseal fixation (arrowhead). Arrow in image B demonstrates a small area of physeal disturbance anteriorly in the proximal tibia.

Figure 11.

Thirteen-year-old pitcher. Oblique coronal (A) 3-dimensional, fat-suppressed, T1-weighted, gradient-recalled and (B) inversion recovery as well as (C) oblique sagittal proton density magnetic resonance images demonstrating physeal widening (arrow) and minimal edema (white arrowheads) as well as sclerosis on the metaphyseal side (black arrowheads) indicating chronicity.

Figure 12.

Sagittal 3-dimensional (3D), fat-suppressed, T1-weighted, gradient-recalled image with superimposed 3D model of the physeal bar where the red indicates the normal physis and the blue represents the bar. The 3D model has been virtually “extracted” from the planar image. The physis and bar area were calculated from the 3D model. Physis area, 2553.7 mm²; bar area, 698.6 mm²; percentage bar, 27.4%.

Figure 13.

Nine-year-old gymnast with chronic mechanical stress leading to physeal injury of distal radius where there is bone marrow edema (asterisk), periosteal new bone formation (black arrow), and physeal widening (white arrows) secondary to chronic stress.

Figure 14.

Fifteen-year-old pitcher with acute onset pain while playing baseball. (A) Oblique radiograph and (B) coronal inversion recovery magnetic resonance image demonstrate widening of the medial epicondylar physis (arrow) with adjacent apophyseal edema (asterisk).

Figure 15.

Sixteen-year-old pitcher with delayed olecranon apophyseal union. (A) Coronal inversion recovery and (B) sagittal proton density images demonstrate a stress reaction with bone marrow edema (asterisk) about an unfused olecranon apophysis (arrow). (C) Patient underwent pin fixation as seen on the lateral radiograph.

Figure 16.

Seventeen-year-old male track and field athlete with (A) anterior-posterior radiograph, (B) coronal inversion recovery, and (C) sagittal proton density images demonstrating an acute avulsion of the anterosuperior iliac spine (arrow).

Figure 17.

Twelve-year-old soccer, basketball, and lacrosse player with anterior knee pain. (A) Sagittal inversion recovery and (B) proton density images demonstrate bone marrow edema about the tibial tubercle apophysis (asterisks) and within the metaphysis, indicative of Osgood Schlatter disease. Thickening and high signal intensity of the patellar tendon (black arrow) indicates patellar tendinosis.