Working Diagnosis:
Non-displaced Salter-Harris type II fracture of the right distal femur.

Treatment:
1. He was placed in a long leg cast with non-weight bearing status, on crutches. Repeat radiographs at two weeks showed no displacement of the fracture.
2. After four weeks, the cast was removed and repeat radiographs demonstrated partial interval resolution of the fracture line. He had minimal tenderness over the distal femur and his thigh swelling had resolved. He was instructed to continue with his non-weight bearing status but was changed into a long drop-lock brace open from 0-60 degrees.
3. Two weeks later, he had improved motion and was pain free. The drop lock brace was discontinued and he was advanced to partial weight bearing. He began physical therapy for range of motion and light strengthening exercises.
4. At 9 weeks post initiation of treatment, repeat radiographs showed complete resolution of the fracture line and he was full weight bearing without pain. He was slowly advanced to full jogging, running, and a graduated return to soccer program. He returned to full soccer activities after 4 weeks.

Outcome:
Total time to return to play from initiation of treatment was 13 weeks. He is doing well, playing soccer without restrictions.

Author's Comments:
Injury often occurs at the “weakest link” which in the pediatric skeletally immature patient often involves the physis instead of ligaments or tendons. Salter-Harris type II fractures are the most common type of physeal fracture and most commonly occur prior to or at the beginning of a growth spurt. Distal femoral physeal fractures are exceedingly rare and account for only 7% of fractures in the lower extremities [1]. Non-displaced or minimally displaced Salter-Harris type I and II fractures can be treated with cast immobilization. Almost all Salter-Harris III and IV fractures require open reduction and internal fixation [2]. It is important to keep physeal fractures in one's differential even in the older teenager.

Editor's Comments:
Distal femoral physis fractures are frequently the result of motor vehicle accidents or collision sports (especially football). (1,3,5) Although Salter Harris I and II fractures are generally felt to be benign injuries, the rate of complication in the distal femur is alarmingly high.(1-5) In Salter Harris II fractures with evidence of displacement or comminution of the metaphysis, there is a 70% rate of growth plate arrest with resultant leg length discrepancy, significant valgus or varus deformity, and/or significant range of motion loss. (4) A 2009 meta-analysis showed that the complication rate for all Salter Harris II distal femur fractures (defined as a growth disturbance that resulted in a leg length discrepancy > 1.5 cm) was 25.7%. (2) Clinicians caring for athletes with Salter Harris II fracture of the distal femur should counsel patients and families of the complications risks and should consider following the patient until the distal femoral physis closes, which occurs between ages 14 and 16 in girls and ages 16 and 18 in boys. (1,6)

References:
1. Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007 Sep; 27(6):703-8.
2. Basener CJ, Mehlman CT, DiPasquale TG. Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis. J Orthop Trauma. 2009 Oct;23(9):663-7.
3. Beaty JH, Kumar A. Fractures about the knee in children. J Bone Joint Surg Am. 1994;76(12):1870Y1880.
4. Ilharreborde B, Raquillet C, Morel E, Fitoussi F, Bensahel H, Penneçot GF, Mazda K. Long-term prognosis of Salter-Harris type 2 injuries of the distal femoral physis. J Pediatr Orthop B. 2006 Nov;15(6):433-8.
5. Peterson HA, Madhok R, Benson JT, et al. Physeal fractures: Part 1. epidemiology in Olmsted County, Minnesota, 1979Y1988. J Pediatr Orthop. 1994;14(4):423Y430.
6. Pritchett JW. Longitudinal growth and growth-plate activity in the lower extremity. Clin Orthop. 1992;275:274Y279.

References:
1. Sautu, BC, Gereige, RS. Knee conditions. Pediatrics in Review. 2014;35(9): 359-370.
2. Wall, EJ, May, MM. Growth plate fractures of the distal femur. Journal of Pediatric Orthopaedics. 2012;32:S40-S46.

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