Twitter Facebook E-newsletters

Find Health Topic: A B C D E F G H I J K L M N O P Q R S Font Size 

T U V W X Y Z

October 2011

Questions and Answers about

Growth Plate Injuries

This booklet contains general information

about growth plate injuries. It describes what

the growth plate is, how injuries occur, and

how they are treated. At the end is a list of

additional resources. If you have further

questions after reading this booklet, you may

wish to discuss them with your doctor.

What Is the Growth Plate?

Who Gets Growth Plate Injuries?

What Causes Growth Plate Injuries?

How Are Growth Plate Fractures

Diagnosed?

What Are the Different Types of Growth

Plate Injuries?

What Kind of Doctor Treats Growth

Plate Injuries?

How Are Growth Plate Injuries

Treated?

Will the Affected Limb of a Child With a

Growth Plate Injury Still Grow?

What Are Researchers Trying To Learn

About Growth Plate Injuries?

Where Can People Find More

Information About Growth Plate

Injuries?

Key Words

Information Boxes

Signs That Require a Visit to the

Doctor

The Salter-Harris Classification of

Growth Plate Injuries

What Is the Growth Plate?

The growth plate, also known as the

epiphyseal plate or physis, is the area of

growing tissue near the ends of the long bones

in children and adolescents. Each long bone

has at least two growth plates: one at each

end. The growth plate determines the future

Share

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

1 of 13 06/09/14 1:44 PM
length and shape of the mature bone. When

growth is complete—sometime during

adolescence—the growth plates close and are

replaced by solid bone.

Because the growth plates are the weakest

areas of the growing skeleton—even weaker

than the nearby ligaments and tendons that

connect bones to other bones and

muscles—they are vulnerable to injury. Injuries

to the growth plate are called fractures.

Who Gets Growth Plate Injuries?

Growth plate injuries can occur in growing

children and adolescents. In a child, a serious

injury to a joint is more likely to damage a

growth plate than the ligaments that stabilize

the joint. Trauma that would cause a sprain in

an adult might cause a growth plate fracture in

a child.

Growth plate fractures occur twice as often in

boys as in girls, because girls’ bodies mature

at an earlier age than boys. As a result, their

bones finish growing sooner, and their growth

plates are replaced by stronger, solid bone.

One-third of all growth plate injuries occur in

competitive sports such as football, basketball,

or gymnastics, while about 20 percent of

growth plate fractures occur as a result of

recreational activities such as biking, sledding,

skiing, or skateboarding.

Fractures can result from a single traumatic

event, such as a fall or automobile accident, or

from chronic stress and overuse. Most growth

plate fractures occur in the long bones of the

fingers (phalanges) and the outer bone of the

forearm (radius). They are also common in the

lower bones of the leg (the tibia and fibula).

What Causes Growth Plate Injuries?

Growth plate injuries can be caused by an

event such as a fall or blow to the limb, or they

can result from overuse. For example, a

gymnast who practices for hours on the

uneven bars, a long-distance runner, and a

baseball pitcher perfecting his curve ball can

all have growth plate injuries.

Although many growth plate injuries are

caused by accidents that occur during play or

athletic activity, growth plates are also

susceptible to other disorders, such as bone

infection, that can alter their normal growth and

development. Other possible causes of growth

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

2 of 13 06/09/14 1:44 PM
plate injuries include the following:

Child abuse. More than 1 million

children each year are the victims of

substantiated child abuse or neglect.

The second most common injury

among abused children is a fracture,

and growth plate injuries are prevalent

because the growth plate is the

weakest part of the bone.

Injury from extreme cold (for

example, frostbite). Exposure to

extreme cold can damage the growth

plate in children and result in short,

stubby fingers or premature

degenerative arthritis (breakdown of

the joint cartilage).

Radiation and medications.

Research has suggested that

chemotherapy given for childhood

cancers may negatively affect bone

growth. Prolonged use of steroids for

inflammatory conditions such as

juvenile idiopathic arthritis can also

harm bone growth.

Neurological disorders. Children with

certain neurological disorders that

result in sensory deficit or muscular

imbalance are prone to growth plate

fractures, especially at the ankle and

knee. Children who are born with

insensitivity to pain can have similar

types of injuries.

Genetics. The growth plates are

where many inherited disorders that

affect the musculoskeletal system

appear. Scientists are just beginning to

understand the genes and gene

mutations involved in skeletal

formation, growth, and development.

This new information is raising hopes

for improving treatment for children

who are born with poorly formed or

improperly functioning growth plates.

Metabolic disease. Disease states

such as kidney failure and hormone

disorders can affect the growth plates

and their function. The bone growth of

children with long-term conditions of

this kind may be negatively affected.

Signs That Require a Visit

to the Doctor

inability to continue play

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

3 of 13 06/09/14 1:44 PM
because of pain following

an acute or sudden injury

decreased ability to play

over the long term because

of persistent pain following

a previous injury

visible malformation of the

child’s arms or legs

severe pain from acute

injuries that prevent the

use of an arm or leg.

Adapted from A Guide to Safety for Young

Athletes with permission of the American

Academy of Orthopaedic Surgeons.

How Are Growth Plate Fractures

Diagnosed?

A child who has persistent pain, or pain that

affects athletic performance or the ability to

move and put pressure on a limb, should never

be allowed or expected to “work through the

pain.” Whether an injury is acute or due to

overuse, it should be evaluated by a doctor,

because some injuries, if left untreated, can

cause permanent damage and interfere with

proper growth of the involved limb.

The doctor will begin the diagnostic process by

asking about the injury and how it occurred

and by examining the child. The doctor will

then use x rays to determine if there is a

fracture, and if so, the type of fracture. Often

the doctor will x ray not only the injured limb

but the opposite limb as well. Because growth

plates have not yet hardened into solid bone,

neither the structures themselves nor injuries

to them show up on x rays. Instead, growth

plates appear as gaps between the shaft of a

long bone, called the metaphysis, and the end

of the bone, called the epiphysis. By

comparing x rays of the injured limb to those of

the noninjured limb, doctors can look for

differences that indicate an injury.

Very often the x ray is negative, because the

growth plate line is already there, and the

fracture is undisplaced (the two ends of the

broken bone are not separated). The doctor

can still diagnose a growth plate fracture on

clinical grounds because of tenderness of the

plate. Children do get ligament strains if their

growth plates are open, and they often have

undisplaced growth plate fractures.

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

4 of 13 06/09/14 1:44 PM
Other tests doctors may use to diagnose a

growth plate injury include magnetic resonance

imaging (MRI), computed tomography (CT),

and ultrasound.

Because these tests enable doctors to see the

growth plate and areas of other soft tissue,

they can be useful not only in detecting the

presence of an injury, but also in determining

the type and extent of the injury.

What Are the Different Types of

Growth Plate Injuries?

Since the 1960s, the Salter-Harris

classification, which divides most growth plate

fractures into five categories based on the type

of damage, has been the standard. The

categories are as follows:

Adapted from Disorders and Injuries of the Musculoskeletal

System, 3rd Edition. Robert B. Salter, Baltimore, Williams

and Wilkins, 1999. Used with the author’s permission.

Type I

Fracture through the growth plate. The

epiphysis is completely separated from the end

of the bone or the metaphysis, through the

deep layer of the growth plate. The growth

plate remains attached to the epiphysis. The

doctor has to put the fracture back into place if

it is significantly displaced. Type I injuries

generally require a cast to protect the plate as

it heals. Unless there is damage to the blood

supply to the growth plate, the likelihood that

the bone will grow normally is excellent.

Type II

Fracture through the growth plate and

metaphysis. This is the most common type of

growth plate fracture. It runs through the

growth plate and the metaphysis, but the

epiphysis is not involved in the injury. Like type

I fractures, type II fractures may need to be put

back into place and immobilized. However, the

growth plate fracture heals a great deal,

especially in younger children. If it is not too

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

5 of 13 06/09/14 1:44 PM
displaced, the doctor may not need to put it

back into position. In this case, it will

strengthen with time.

Type III

Fracture through growth plate and

epiphysis. This fracture occurs only rarely,

usually at the lower end of the tibia, one of the

long bones of the lower leg. It happens when a

fracture runs completely through the epiphysis

and separates part of the epiphysis and growth

plate from the metaphysis. Surgery is

sometimes necessary to restore the joint

surface to normal. The outlook or prognosis for

growth is good if the blood supply to the

separated portion of the epiphysis is still intact

and if the joint surface heals in a normal

position.

Type IV

Fracture through growth plate,

metaphysis, and epiphysis. This fracture

runs through the epiphysis, across the growth

plate, and into the metaphysis. Surgery is

frequently needed to restore the joint surface

to normal and to perfectly align the growth

plate. Unless perfect alignment is achieved

and maintained during healing, prognosis for

growth is poor, and angulation (bending) of the

bone may occur. This injury occurs most

commonly at the end of the humerus (the

upper arm bone) near the elbow.

Type V

Compression fracture through growth

plate. This uncommon injury occurs when the

end of the bone is crushed and the growth

plate is compressed. It is most likely to occur at

the knee or ankle. Prognosis is poor, since

premature stunting of growth is almost

inevitable.

A newer classification, called the Peterson

classification, adds a type VI fracture, in which

a portion of the epiphysis, growth plate, and

metaphysis is missing. This usually occurs with

open wounds or compound fractures, and

often involves lawnmowers, farm machinery,

snowmobiles, or gunshot wounds. All type VI

fractures require surgery, and most will require

later reconstructive or corrective surgery. Bone

growth is almost always stunted.

What Kind of Doctor Treats Growth

Plate Injuries?

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

6 of 13 06/09/14 1:44 PM
For all but the simplest injuries, your child’s

doctor will probably refer him or her to an

orthopaedic surgeon (a doctor who specializes

in bone and joint problems in children and

adults) for treatment. Some problems may

require the services of a pediatric orthopaedic

surgeon, who specializes in injuries and

musculoskeletal disorders in children.

How Are Growth Plate Injuries

Treated?

Treatment for growth plate injuries depends on

the type of injury. In all cases, treatment should

be started as soon as possible after injury and

will generally involve a mix of the following:

Immobilization

The affected limb is often put in a cast or

splint, and the child is told to limit any activity

that puts pressure on the injured area.

Manipulation or Surgery

If the fracture is displaced (meaning the ends

of the injured bones no longer meet as they

should), the doctor will have to put the bones

or joints back in their correct positions, either

by using his or her hands (called manipulation)

or by performing surgery. Sometimes the

doctor needs to fix the break and hold the

growth plate in place with screws or wire. After

the procedure, the bone will be set in place

(immobilized) so it can heal without moving.

This is usually done with a cast that encloses

the injured growth plate and the joints on both

sides of it. The cast is left in place until the

injury heals, which can take anywhere from a

few weeks to 2 or more months for serious

injuries. The need for manipulation or surgery

depends on the location and extent of the

injury, its effect on nearby nerves and blood

vessels, and the child’s age.

Strengthening and Range-of-Motion

Exercises

These are exercises designed to strengthen

the muscles that support the injured area of

the bone and to improve or maintain the joint’s

ability to move in the way that it should. Your

child’s doctor may recommend these after the

fracture has healed. A physical therapist can

work with your child and his or her doctor to

design an appropriate exercise plan.

Long-Term Followup

Long-term followup is usually necessary to

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

7 of 13 06/09/14 1:44 PM
monitor the child’s recuperation and growth.

Evaluation includes x rays of matching limbs at

3- to 6-month intervals for at least 2 years.

Some fractures require periodic evaluations

until the child’s bones have finished growing.

Sometimes a growth arrest line (a line on the x

ray where the bone stopped growing

temporarily) may appear as a marker of the

injury. Continued bone growth away from that

line may mean there will not be a long-term

problem, and the doctor may decide to stop

following the patient.

Will the Affected Limb of a Child

With a Growth Plate Injury Still

Grow?

About 85 percent of growth plate fractures heal

without any lasting effect. Whether an arrest of

growth occurs depends on the treatment

provided, and the following factors, in

descending order of importance:

Severity of the injury. If the injury

causes the blood supply to the

epiphysis to be cut off, growth can be

stunted. If the growth plate is shifted,

shattered, or crushed, the growth plate

may close prematurely, forming a bony

bridge or “bar.” The risk of growth

arrest is higher in this setting. An open

injury in which the skin is broken

carries the risk of infection, which could

destroy the growth plate.

Age of the child. In a younger child,

the bones have a great deal of growing

to do; therefore, growth arrest can be

more serious, and closer surveillance is

needed. It is also true, however, that

younger bones have a greater ability to

heal.

Which growth plate is injured. Some

growth plates, such as those in the

region of the knee, are more involved

in extensive bone growth than others.

Type of fracture. Of the six fracture

types described earlier, types IV, V, and

VI are the most serious.

The most frequent complication of a growth

plate fracture is premature arrest of bone

growth. The affected bone grows less than it

would have without the injury, and the resulting

limb could be shorter than the opposite,

uninjured limb. If only part of the growth plate

is injured, growth may be lopsided and the limb

may become crooked.

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

8 of 13 06/09/14 1:44 PM
Growth plate injuries at the knee have the

greatest risk of complications. Nerve and blood

vessel damage occurs most frequently there.

Injuries to the knee have a much higher

incidence of premature growth arrest and

crooked growth.

What Are Researchers Trying to

Learn About Growth Plate Injuries?

Researchers supported by the National

Institutes of Health continue to seek better

ways to diagnose and treat growth plate

injuries and to improve patient outcomes.

Examples of such work include:

Use of therapies to enhance the body’s

production of chondrocytes. These

cells are essential to growth at the

ends of the bones.

Research on drugs that protect the

growth plate during radiation treatment.

Identifying radiologic predictors for

premature closure of the growth plate

following fractures. By predicting the

injuries most likely to result in arrested

growth, doctors could opt to treat them

differently and more aggressively.

Research on cancer drugs to

determine which ones are likely to

affect the growth plates.

Further investigating the mechanisms

responsible for cartilage and

growth-plate defects.

Development of methods to regenerate

musculoskeletal tissue by using

principles of tissue engineering.

NIAMS currently funds Core Centers for

Musculoskeletal Disorders at major medical

centers. These centers provide the resources

for established, currently funded investigators

who are often from different disciplines, to

adopt a multidisciplinary approach to common

research problems in musculoskeletal

disorders.

The centers foster research to better

understand the mechanisms of bone repair

and regeneration, including fracture healing

and development of techniques for growth

plate repair.

Where Can People Find More

Information About Growth Plate

Injuries?

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

9 of 13 06/09/14 1:44 PM
National Institute of Arthritis and

Musculoskeletal and Skin Diseases

(NIAMS)

Information Clearinghouse

National Institutes of Health

1 AMS Circle

Bethesda, MD 20892-0001

Phone: 301-495-4484

Toll Free: 877-22-NIAMS (877-226-4267)

TTY: 301-565-2966

Fax: 301-718-6366

Email: NIAMSinfo@mail.nih.gov

Website: http://www.niams.nih.gov

Other Resources

American Academy of Orthopaedic

Surgeons (AAOS)

Website: http://www.aaos.org

American Academy of Pediatrics

(AAP)

Website: http://www.aap.org

American Orthopaedic Society for

Sports Medicine (AOSSM)

Website: http://www.sportsmed.org

Key Words

Computed (or computerized)

tomography (CT) scan. An imaging

technique that provides doctors with a

threedimensional picture of the bone. It

also shows “slices” of the bone,

making the picture much clearer than x

rays.

Displaced fracture. A fracture in

which the two ends of the broken bone

are separated from one another.

Epiphyseal plate. The area of

developing tissue near the end of the

long bones in children and

adolescents. It is also called the physis

or growth plate.

Epiphysis. The end of a long bone,

which is initially separated by cartilage

from the shaft of the bone and

develops separately. It eventually fuses

with the shaft (diaphysis) of the bone to

form a complete bone.

Femur. The thigh bone.

Fibula. The long, thin outer bone of the

lower leg.

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

10 of 13 06/09/14 1:44 PM
Growth plate. The area of developing

tissue near the end of the long bones

in children and adolescents. Each long

bone has at least two growth plates:

one at each end. The growth plate

determines the future length and shape

of the mature bone. When growth is

complete—sometime during

adolescence—the growth plates are

replaced by solid bone. The growth

plate is also called the physis or

epiphyseal plate.

Humerus. The bone of the upper arm.

Ligaments. Tough bands of

connective tissue that connect bones.

Metaphysis. The growing portion of a

long bone that lies between the ends of

the bones (epiphyses) and the shaft

(diaphysis).

Magnetic resonance imaging (MRI).

A procedure in which a strong magnet

is used to pass a force through the

body, resulting in a clear, detailed,

cross-sectional image. Unlike standard

x rays, it can show soft tissue as well

as bone and thus is useful in

diagnosing injuries to the growth

plates.

Neurological. Having to do with the

nervous system (made up of the brain,

spinal cord and peripheral nerves), this

system of tissues uses electrical and

chemical means to record and

distribute information within the body.

Orthopaedic surgeon. A physician

who specializes in treating (through

surgery, casting, or other means)

abnormalities of or injuries to the

bones.

Physis. The area of developing tissue

near the end of the long bones in

children and adolescents. The physis

is also called the growth plate.

Radius. The smaller of the two bones

of the forearm. It is located on the

thumb side of the arm.

Tendons. Tough but flexible bands of

tissue that connect muscles to bones.

Tibia. The larger of the two bones that

make up the lower leg. It is also

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

11 of 13 06/09/14 1:44 PM
referred to as the shin bone.

Ultrasound. A technique that allows

doctors to view the soft tissues of the

body by bouncing sound waves off the

tissue and then converting the echoes

into a picture called a sonogram.

Acknowledgments

NIAMS gratefully acknowledges the

assistance of the following individuals

in the preparation and review of the

original version of this booklet: James

S. Panagis, M.D., M.P.H., NIAMS,

NIH; R. Tracy Ballock, M.D., Case

Western Reserve University,

Cleveland, OH; Michael G. Ehrlich,

M.D., Brown University, Providence,

RI; Ryan Goodwin, M.D., Cleveland

Clinic, Cleveland, OH; and Robert B.

Salter, M.D., Hospital for Sick

Children, Toronto, Ontario, Canada, in

the preparation and review of this

booklet. NIAMS also acknowledges

the American Academy of Orthopaedic

Surgeons for the use of its publication,

Skeletal Growth and Development:

Clinical Issues and Basic Science

Advances.

The mission of the National Institute of

Arthritis and Musculoskeletal and Skin

Diseases (NIAMS), a part of the

Department of Health and Human

Services’ National Institutes of Health

(NIH), is to support research into the

causes, treatment, and prevention of

arthritis and musculoskeletal and skin

diseases; the training of basic and

clinical scientists to carry out this

research; and the dissemination of

information on research progress in

these diseases. The National Institute

of Arthritis and Musculoskeletal and

Skin Diseases Information

Clearinghouse is a public service

sponsored by the NIAMS that provides

health information and information

sources. Additional information can be

found on the NIAMS website at

www.niams.nih.gov.

For Your Information

This publication contains information

about medications used to treat the

health condition discussed here. When

this publication was developed, we

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

12 of 13 06/09/14 1:44 PM
included the most up-to-date (accurate)

information available. Occasionally,

new information on medication is

released.

For updates and for any questions

about any medications you are taking,

please contact

U.S. Food and Drug

Administration

Toll Free: 888–INFO–FDA

(888–463–6332)

Website: http://www.fda.gov

For additional information on

specific medications, visit

Drugs@FDA at

www.accessdata.fda.gov/scripts

/cder/drugsatfda. Drugs@FDA

is a searchable catalog of

FDA-approved drug products.

This publication is not copyrighted.

Readers are encouraged to duplicate

and distribute as many copies as

needed.

Additional copies of this publication are

available from:

National Institute of Arthritis

and Musculoskeletal and

Skin Diseases (NIAMS)

Information Clearinghouse

National Institutes of Health

1 AMS Circle

Bethesda, MD 20892-0001

Phone: 301-495-4484

Toll Free: 877-22-NIAMS

(877-226-4267)

TTY: 301-565-2966

Fax: 301-718-6366

Email: NIAMSinfo@mail.nih.gov

Website:

http://www.niams.nih.gov

NIH Publication No. 12-7845

Many of our publications are

available in print. Would you

like to order publications on

bone to be mailed to you?

Visit our online order form.

Questions and Answers About Growth Plate Injuries http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/defaul...

13 of 13 06/09/14 1:44 PM